2024 RECOVER Guidelines: Updated treatment recommendations for CPR in dogs and cats.

OBJECTIVE: After the 2012 Reassessment Campaign on Veterinary Resuscitation (RECOVER) CPR Guidelines, this is an update of evidence-based consensus guidelines for Basic Life Support (BLS), advanced life support (ALS), and periarrest monitoring. DESIGN: These RECOVER CPR Guidelines were generated using a modified version of the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for evidence evaluation and translation of this evidence into clear and actionable clinical instructions. Prioritized clinical questions in the Population, Intervention, Comparator, and Outcome (PICO) format were used as the basis to conduct systematic literature searches by information specialists, to extract information from relevant publications, to assess this evidence for quality, and finally to translate the findings into treatment recommendations. These recommendations were reviewed by the RECOVER writing group and opened for comment by veterinary professionals for 4 weeks. SETTING: Transdisciplinary, international collaboration in university, specialty, and emergency practice. RESULTS: A total of 40 worksheets were prepared to evaluate questions across the 3 domains of BLS, ALS and Monitoring, resulting in 90 individual treatment recommendations. High-dose epinephrine is no longer recommended, and atropine, if used, is only administered once. Bag-mask ventilation is prioritized over mouth-to-nose ventilation in nonintubated animals. In addition, an algorithm for initial assessment, an updated CPR algorithm, a rhythm diagnosis tool, and an updated drug dosing table are provided. CONCLUSIONS: While the majority of the BLS and ALS recommendations remain unchanged, some noteworthy changes were made due to new evidence that emerged over the past 10 years. Indirectness of evidence remains the largest impediment to the certainty of guidelines formulation and underscores an urgent need for more studies in the target species of dogs and cats.

2024 RECOVER Guidelines: Advanced Life Support. Evidence and knowledge gap analysis with treatment recommendations for small animal CPR.

OBJECTIVE: To systematically review the evidence and devise clinical recommendations on advanced life support (ALS) in dogs and cats and to identify critical knowledge gaps. DESIGN: Standardized, systematic evaluation of literature pertinent to ALS following Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Prioritized questions were each reviewed by Evidence Evaluators, and findings were reconciled by ALS Domain Chairs and Reassessment Campaign on Veterinary Resuscitation (RECOVER) Co-Chairs to arrive at treatment recommendations commensurate to quality of evidence, risk:benefit relationship, and clinical feasibility. This process was implemented using an Evidence Profile Worksheet for each question that included an introduction, consensus on science, treatment recommendations, justification for these recommendations, and important knowledge gaps. A draft of these worksheets was distributed to veterinary professionals for comment for 4 weeks prior to finalization. SETTING: Transdisciplinary, international collaboration in university, specialty, and emergency practice. RESULTS: Seventeen questions pertaining to vascular access, vasopressors in shockable and nonshockable rhythms, anticholinergics, defibrillation, antiarrhythmics, and adjunct drug therapy as well as open-chest CPR were reviewed. Of the 33 treatment recommendations formulated, 6 recommendations addressed the management of patients with nonshockable arrest rhythms, 10 addressed shockable rhythms, and 6 provided guidance on open-chest CPR. We recommend against high-dose epinephrine even after prolonged CPR and suggest that atropine, when indicated, is used only once. In animals with a shockable rhythm in which initial defibrillation was unsuccessful, we recommend doubling the defibrillator dose once and suggest vasopressin (or epinephrine if vasopressin is not available), esmolol, lidocaine in dogs, and/or amiodarone in cats. CONCLUSIONS: These updated RECOVER ALS guidelines clarify the approach to refractory shockable rhythms and prolonged CPR. Very low quality of evidence due to absence of clinical data in dogs and cats continues to compromise the certainty with which recommendations can be made.

Retrospective evaluation of transportation and outcome of dogs on a mechanical ventilator: 9 cases.

OBJECTIVE: To describe the transportation and clinical outcome of 9 dogs transported to a referral hospital on mechanical ventilation (MV). DESIGN: Retrospective case series (2015-2020). SETTING: University teaching hospital. ANIMALS: Nine dogs transported to a referral center on MV. INTERVENTIONS: All dogs underwent MV during vehicular transport. MEASUREMENT AND MAIN RESULTS: The medical records of 9 dogs transported on a MV to a university teaching hospital were reviewed. Data collected included signalment, reason for MV, ventilator settings, sedation protocol, monitoring in transit, distance traveled, complications, clinical outcome, and cost. All dogs transported survived transport to the referral hospital and 8 of 9 were successfully weaned from the ventilator and discharged home. CONCLUSIONS: MV during transport in this setting was practical and safe. Dogs in this study had a high survival rate compared to previous studies of dogs undergoing MV, likely due to selection of cases assessed to have a correctable underlying disease.

Treatment of a massive naproxen overdose with therapeutic plasma exchange in a dog.

In comparison with other over-the-counter anti-inflammatory drugs, naproxen has a longer half-life in dogs and can lead to severe morbidity and mortality. This report describes the successful use of membrane-based therapeutic plasma exchange after a massive ingestion of naproxen by a dog resulting in 86% reduction in plasma concentration.

A Randomized Double Blinded Placebo-Controlled Clinical Trial of a Probiotic or Metronidazole for Acute Canine Diarrhea.

Acute diarrhea is a common, often self-limiting, cause of presentation for veterinary care, yet there is a paucity of data on frequently-prescribed treatments. The purpose of this randomized, double blinded placebo-controlled clinical trial was to compare two anecdotally-recommended treatments: a probiotic combination and metronidazole. Sixty dogs without concurrent comorbidities were randomized into three treatment groups. The time to resolution of diarrheal signs was evaluated using owner surveys and fecal scoring charts. Dogs presenting with acute diarrhea achieved acceptable fecal consistency after 3.5 ± 2.2 days when receiving probiotic, 4.6 ± 2.4 days with oral metronidazole, and 4.8 ± 2.9 days with placebo; statistically significant differences were not identified between treatment groups (p = 0.17). These findings failed to provide evidence for the common use of metronidazole in this cohort of dogs with acute canine diarrhea, and a larger study population would be required to identify a statistically significant effect of probiotics.

Antiepileptic Drug Use Patterns in Suspect Epileptic Dogs Among Neurology and Emergency Specialists.

This study used a cross-sectional survey designed to inquire about antiepileptic drug (AED) use in newly diagnosed idiopathic epileptic dogs among board-certified emergency and neurology specialists. Results were obtained from 300 completed surveys by 128 board-certified neurologists and 172 board-certified emergency and critical care (ECC) specialists. Case volume was slightly different between groups, with 36% of neurologists and 18% of ECC specialists managing >50 cases of first-time canine seizure patients yearly. The initial AED of choice was similar between the groups, with 66% of neurologists and 64% of ECC specialists using phenobarbital and 16% of neurologists and 26% of ECC specialists using levetiracetam. Although most respondents gave a loading dose of phenobarbital, roughly one-fourth of neurologists did not load the drug versus 6% of ECC specialists. The total loading dose was similar between respondents (16 mg/kg) but varied in administration protocol. Approximately half of neurologists and nearly two-thirds of ECC specialists gave a higher initial dose of levetiracetam than recommended. Almost all the respondents who gave a higher initial dose of levetiracetam used 60 mg/kg IV once. Understanding the common practices in AED use may promote future discussions regarding best practices in the management of canine idiopathic epilepsy.

Clearance of plasma ivermectin with single pass lipid dialysis in 2 dogs.

OBJECTIVE: To describe the use of single pass lipid dialysis (SPLD) for treatment of ivermectin toxicosis in 2 Australian Shepherd dogs with the ABCB1-1Δ gene mutation. CASE SERIES SUMMARY: Two Australian Shepherd dogs were presented for treatment of ivermectin toxicosis. Dogs were initially treated with intravenous lipid emulsion and supportive care, without improvement of clinical signs. They both developed respiratory paralysis and required mechanical ventilation. In order to increase the clearance of circulating ivermectin, SPLD was performed using dialysate containing 5% lipid. Blood samples were obtained immediately before and after dialysis and analyzed for serum ivermectin concentration. Ivermectin reduction ratio was calculated at 29% and 39% for each dog, respectively. When compared to intrinsic total body ivermectin clearance, only the second dog had a relative improvement of plasma clearance following SPLD. Both dogs were confirmed to be homozygous for ABCB1-1Δ gene mutations. Both dogs remained ventilator dependent for several days and ultimately made a full recovery. NEW OR UNIQUE INFORMATION PROVIDED: SPLD may be an adjunctive detoxification strategy for highly lipophilic toxins such as ivermectin.

Temporary percutaneous T-fastener gastropexy and continuous decompressive gastrostomy in dogs with experimentally induced gastric dilatation.

OBJECTIVE To evaluate a percutaneous, continuous gastric decompression technique for dogs involving a temporary T-fastener gastropexy and self-retaining decompression catheter. ANIMALS 6 healthy male large-breed dogs. PROCEDURES Dogs were anesthetized and positioned in dorsal recumbency with slight left-lateral obliquity. The gastric lumen was insufflated endoscopically until tympany was evident. Three T-fasteners were placed percutaneously into the gastric lumen via the right lateral aspect of the abdomen, caudal to the 13th rib and lateral to the rectus abdominis muscle. Through the center of the T-fasteners, a 5F locking pigtail catheter was inserted into the gastric lumen and attached to a device measuring gas outflow and intragastric pressure. The stomach was insufflated to 23 mm Hg, air was allowed to passively drain from the catheter until intraluminal pressure reached 5 mm Hg for 3 cycles, and the catheter was removed. Dogs were hospitalized and monitored for 72 hours. RESULTS Mean ± SD catheter placement time was 3.3 ± 0.5 minutes. Mean intervals from catheter placement to a ≥ 50% decrease in intragastric pressure and to ≤ 6 mm Hg were 2.1 ± 1.3 minutes and 8.4 ± 5.1 minutes, respectively. After catheter removal, no gas or fluid leakage at the catheter site was visible laparoscopically or endoscopically. All dogs were clinically normal 72 hours after surgery. CONCLUSIONS AND CLINICAL RELEVANCE The described technique was performed rapidly and provided continuous gastric decompression with no evidence of postoperative leakage in healthy dogs. Investigation is warranted to evaluate its effectiveness in dogs with gastric dilatation-volvulus.

Successful treatment of severe hypokalemia in a dog with acute kidney injury caused by leptospirosis.

OBJECTIVE: To report the case management of a patient with severe hypokalemia resulting in cardiopulmonary arrest caused by infection with leptospirosis. CASE SUMMARY: A 3-year-old intact female Dachshund presented for polyuria, polydipsia, and refractory hypokalemia, which progressed to flaccid paralysis and cardiorespiratory arrest. Following successful resuscitation, the dog was apneic and managed with mechanical ventilation while volume status and electrolytes were corrected. The dog showed rapid improvement allowing for weaning from the ventilator within the first day. The dog was identified as having leptospirosis causing severe kaliuresis (fractional excretion of potassium 31%). Following discharge from hospital, the dog was managed with doxycycline, oral potassium supplementation, and spironolactone and made a full clinical recovery. NEW OR UNIQUE INFORMATION PROVIDED: This report identifies an unusually severe presentation of leptospirosis in a dog from a region where the disease is not considered common, which was successfully treated despite cardiopulmonary arrest on initial presentation.

Severe Pit Viper Envenomation with Extended Clinical Signs and Treatment Complications in a Dog.

This manuscript describes the extended clinical abnormalities that can occur in severe snake envenomation and the clinical signs associated with antivenom hypersensitivity in a 3 yr old dog. Treatment consisted of IV fluid therapy, analgesics, a vasopressor, cardiac antiarrhythmia drugs, and polyvalent pit viper antivenom. Following initial response to treatment, relapse of clinical signs occurred. Most interesting was the recrudescence of clinical signs on day 7 that may have been caused by the release of deposited venom during surgical debridement of necrotic skin. The resulting extensive clinical signs required multiple vials of antivenom (22 vials over a 7 day period). Both F(ab')2 antivenom and antivenin (Crotalidae) polyvalent were used in this dog because of availability logistics. It is thought that this large amount of antivenom resulted in type I (anaphylaxis) and type III hypersensitivity (serum sickness) reactions. The dog made a complete clinical recovery. This description of extended, fluctuating clinical abnormalities that were associated with envenomation together with the development of hypersensitivity reactions that were presumably secondary to antivenom administration is information that can be useful for the management of patients afflicted with severe pit viper envenomation.

Use of IV lipid emulsion for treatment of ivermectin toxicosis in a cat.

Ivermectin toxicosis in cats is infrequently reported. IV lipid emulsion (ILE) is a novel treatment in veterinary medicine that has been used for amelioration of adverse effects seen with multiple lipid soluble compounds. Previously, ILE has been investigated in experimental models with rats, rabbits, pigs, and dogs, mainly for resuscitation of cardiopulmonary arrest and treatment of hypotension due to local anesthetic drug overdose. There are few case reports in veterinary medicine of using ILE for drug toxicity. Only one feline case has been reported, with IV lipids used for treatment of lidocaine toxicity. This report describes a case of ivermectin toxicosis in a 1 yr old domestic shorthair that was safely and successfully treated using ILE.

Positive impact of an emergency department protocol on time to antimicrobial administration in dogs with septic peritonitis.

OBJECTIVE: To determine whether the development of a specific antimicrobial protocol for the treatment of canine intra-abdominal sepsis would improve time to appropriate antimicrobial administration following diagnosis of bacterial peritonitis. DESIGN: Case controlled observational study. SETTING: A tertiary referral small animal teaching hospital. ANIMALS: Twenty dogs undergoing surgery for septic peritonitis prior to the deployment of the abdominal sepsis protocol served as a case control population and 40 dogs identified as having septic peritonitis after deployment of the protocol served as the study population. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Median time from diagnosis of septic peritonitis to antimicrobial administration was 6 hours (range 1-10 h) in the preprotocol group (PRE), and 1 hour (range 1-2 h) in the postprotocol group (POST) (P = 0.001). Five of 20 (25%) culture and sensitivity results yielded negative cultures in the PRE versus 6 of 34 (17.6%) in the POST. Inappropriate empirical antimicrobials were selected 3 of 20 times (15%) in the PRE and 3 of 34 times (8.8%) in the POST. The overall survival to discharge was 60% in the PRE and 70% in the POST (P = 0.425). CONCLUSIONS: The development of an emergency department antimicrobial protocol significantly decreased time to antimicrobial administration following identification of septic peritonitis in dogs.

The effect of using an impedance threshold device on hemodynamic parameters during cardiopulmonary resuscitation in dogs.

OBJECTIVE: To investigate the hemodynamic effects following the use of an impedance threshold device (ITD) in a canine model of cardiopulmonary arrest. DESIGN: Experimental, randomized crossover study. SETTING: Cardiovascular research laboratory at a university veterinary center. ANIMALS: Eight purpose bred beagle dogs. INTERVENTIONS: Dogs were anesthetized and instrumented for the measurement of right atrial pressure , systolic blood pressure, mean blood pressure, and diastolic arterial blood pressure, end-tidal CO(2) , and carotid blood flow (CBF). CBF was determined via ultrasonic flow probe placed around the carotid artery. Animals were taking part in an unassociated terminal study and following subsequent euthanasia with pentobarbital, standardized cardiopulmonary resuscitation (CPR) was performed with an impedance threshold device attached (ITD-CPR group) and without (S-CPR group). Order of treatment was randomized. MEASUREMENTS AND MAIN RESULTS: ITD group had increased CBF, coronary perfusion pressure, and a decrease in right atrial diastolic pressure. No differences in end-tidal CO(2) , diastolic arterial blood pressure, mean blood pressure, or systolic blood pressure were seen. Return of spontaneous circulation was not observed in any of the animals CONCLUSIONS: Use of the ITD resulted in favorable changes in hemodynamic parameters in dogs undergoing CPR. The ITD may be a useful adjunct during CPR in dogs and warrants clinical evaluation.

RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 4: Advanced life support.

OBJECTIVE: To systematically evaluate the evidence of the effect of advanced life support techniques on outcome in veterinary cardiopulmonary resuscitation (CPR) and to outline knowledge gaps. DESIGN: Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality, and development of consensus on conclusions for application of the concepts to clinical practice. SETTING: Academia, referral practice, and general practice RESULTS: Sixteen population, intervention, control group, outcome questions were evaluated to determine if recommendations could be made concerning drug therapy, including vasopressors, vagolytics, corticosteroids, reversal agents, buffer therapy, and correction of electrolyte disturbances. Electrical defibrillation strategies as well as other advanced interventions such as open-chest CPR, impedance threshold devices, and special considerations regarding anesthesia-related cardiopulmonary arrest (CPA) were also investigated. CONCLUSIONS: There is strong evidence supporting the use of standard-dose (0.01 mg/kg) epinephrine in CPR, as well as early electrical defibrillation for animals experiencing CPA due to ventricular fibrillation or pulseless ventricular tachycardia, preferentially using a biphasic defibrillator. For CPA due to certain causes and with the availability of advanced postcardiac arrest support, open chest CPR is preferred. Many knowledge gaps regarding other pharmacologic and advanced therapies were identified, and further studies are recommended to better systematically address these questions.

Interpretation of canine and feline blood smears by emergency room personnel.

BACKGROUND: Interpretation of blood smears is commonly used to provide rapid laboratory evaluation of animals in veterinary emergency practice, but the accuracy of results of blood smear interpretation by emergency room personnel (ERP) compared with evaluation by trained veterinary clinical pathology personnel is unknown. OBJECTIVE: The goal of this study was to compare blood smear evaluation by ERP with that of clinical pathology personnel. METHODS: All animals that had a CBC determined by a diagnostic laboratory and had blood smears evaluated by personnel at the Foster Hospital for Small Animals Emergency Room between September 2008 and July 2009 were eligible for study inclusion. ERP who evaluated blood smears completed standardized forms with estimates of the WBC and platelet counts and evaluation of RBC and WBC morphology. Results from point-of-care assessment were compared with automated or manual results reported by the veterinary diagnostic laboratory. RESULTS: One hundred and fifty-five blood smears were evaluated. There was moderate agreement (κ value, 0.63; 95% confidence interval [CI]: 0.52, 0.74) between estimated platelet counts by ERP and automated counts. Poor agreement was found between estimated WBC counts by ERP and automated counts (κ value, 0.48; 95% CI: 0.37, 0.60). Specific abnormalities with a high likelihood of clinical significance, eg, toxic change, nucleated RBCs, spherocytes, hemoparasites, and lymphoblasts, were not predictably identified by ERP. CONCLUSIONS: ERP interpretation of canine and feline blood smears should be used cautiously and should not replace evaluation by a veterinary diagnostic laboratory.

Cardiopulmonary effects of a new inspiratory impedance threshold device in acute hemorrhagic shock in dogs.

OBJECTIVE: To compare cardiovascular and respiratory effects of an inspiratory impedance threshold device (ITD) in dogs before and after induction of acute hemorrhagic shock. STUDY DESIGN: Prospective experimental randomized study. ANIMALS: Eight healthy adult dogs. METHODS: Dogs were anesthetized and maintained on spontaneous ventilation. Tidal volume (V(T)), systolic, mean and diastolic arterial blood pressure (SAP, MAP, DAP), central venous pressure (CVP), gastric P(CO2) (GBF) as an indicator of gastric perfusion, cardiac index (CI), systemic vascular resistance (SVR), oxygen delivery (DO(2)), and plasma lactate were monitored. To monitor respiratory compliance (RC) and respiratory resistance (ResR), animals were briefly placed on mechanical ventilation. Dogs were studied under 4 different conditions: (1) baseline (euvolemic state) (MAP > 60 mm Hg) with and without the ITD and (2) acute hemorrhagic shock (hypovolemic state) (target MAP of 40 mm Hg) with and without ITD. These 4 conditions were performed during one anesthetic period, allowing time for stabilization of parameters for each condition. Data were analyzed by ANOVA for repeated measure mixed models. RESULTS: No cardiovascular changes were detected between groups with and without use of ITD during euvolemic states. During acute hemorrhagic hypovolemic state, CI and DO(2) were higher with the ITD (2.9 ± 0.6 L/min/m(2)) and (326.5 ± 86.8 mL/min) compared with no ITD (1.8 ± 0.6 L/min/m(2)) and (191.3 ± 58.1 mL/min), respectively. The use of ITD during hypovolemia also increased SAP and MAP. There was an increase in ResR and decreased RC with the ITD in both euvolemic and hypovolemic states. CONCLUSION AND CLINICAL RELEVANCE: The use of an ITD in dogs during acute hemorrhagic hypovolemic shock improved cardiovascular parameters but had negative effects on RC and ResR.

Acute hyperammonemia after L-asparaginase administration in a dog.

OBJECTIVE: To describe a previously unreported and potentially fatal complication of L-asparaginase (L-asp) administration in a dog. CASE SUMMARY: A 7-year-old, 6.6 kg, female spayed Beagle presented with a 1-week history of progressive inappetance and lethargy. Diagnostic tests identified the presence of stage Vb lymphoma and liver dysfunction. The dog was treated with L-asp at 400 IU/kg, corticosteroids, and IV fluids. Within 12 hours the dog became depressed, vomited, and developed abdominal pain. Within 24 hours, the dog's mentation progressed from obtunded to comatose; subsequently the dog developed a "decerebrate posture." Blood ammonia concentrations exceeded 1,000 µmol/L (1,700 µg/dL). Treatment with broad-spectrum antimicrobials, lactulose enemas, and continuous renal replacement therapy were initiated without response and the dog suffered cardiopulmonary arrest. NEW OR UNIQUE INFORMATION PROVIDED: The purpose of this report is to describe the development of severe hyperammonemia after L-asp therapy in a dog, which has not been previously reported in the literature. Given the rapid progression and fatal outcome observed in this case, early recognition may be crucial for management and treatment of this complication.

Massive transfusion and surgical management of iatrogenic aortic laceration associated with cystocentesis in a dog.

CASE DESCRIPTION: A 4-year-old 29-kg (63.8-lb) spayed female Husky crossbred was referred for emergency treatment because of catastrophic hemorrhagic shock following attempts at cystocentesis for investigation of suspected urinary tract infection. CLINICAL FINDINGS: On arrival at the hospital, clinicopathologic assessments revealed rapidly decreasing PCV and worsening hypoproteinemia, compared with findings immediately prior to referral. The dog had severe hyperlactemia. Ultrasonography revealed the presence of free fluid in the abdomen; the fluid appeared to be blood (determined via abdominocentesis). TREATMENT AND OUTCOME: Urgent surgical exploration was undertaken. Two small lacerations in the ventral aspect of the abdominal aorta just dorsal to the bladder were identified and repaired. Multiple transfusions of packed RBCs (5 units) and fresh frozen plasma (3 units) were administered, and autotransfusion of blood (1.2 L) from the abdomen was performed. The dog recovered well from surgery and anesthesia, but developed signs of severe pain and swelling of both hind limbs, which were attributed to reperfusion injury following aortic occlusion during surgery. Treatment included administration of S-adenosylmethionine (23 mg/kg [10.5 mg/lb], PO, q 24 h) and analgesia; 5 days after surgery, the hind limb problems had resolved and treatments were discontinued. CLINICAL RELEVANCE: In the dog of this report, aortic laceration secondary to cystocentesis was successfully treated with a combination of surgery and massive transfusion; the development of reperfusion injury was an interesting and reversible complication of surgery. The possibility of damage to intra-abdominal structures should be investigated if a dog becomes acutely ill after cystocentesis.