Journal of Veterinary Emergency and Critical Care 22(S1) 2012, pp S4–S12

Special Article doi: 10.1111/j.1476-4431.2012.00758.x

RECOVER evidence and knowledge gap

analysis on veterinary CPR.
Part 1: Evidence analysis and consensus
process: collaborative path toward small
animal CPR guidelines
Manuel Boller, Dr. med. vet., MTR, DACVECC and Daniel J. Fletcher, PhD, DVM, DACVECC

Abstract

Objective – To describe the methodology used by the Reassessment Campaign on Veterinary Resuscitation
(RECOVER) to evaluate the scientific evidence relevant to small animal CPR and to compose consensus-based
clinical CPR guidelines for dogs and cats.
Design – This report is part of a series of 7 articles on the RECOVER evidence and knowledge gap analysis
and consensus-based small animal CPR guidelines. It describes the organizational structure of RECOVER, the
evaluation process employed, consisting of standardized literature searches, the analysis of relevant articles
according to study design, species and predefined quality markers, and the drafting of clinical CPR guidelines
based on these data. Therefore, this article serves as the methodology section for the subsequent 6 RECOVER
articles.
Setting – Academia, referral practice.
Results – RECOVER is a collaborative initiative that systematically evaluated the evidence on 74 topics relevant
to small animal CPR and generated 101 clinical CPR guidelines from this analysis. All primary contributors were
veterinary specialists, approximately evenly split between academic institutions and private referral practices.
The evidence evaluation and guideline drafting processes were conducted according to a predefined sequence
of steps designed to reduce bias and increase the repeatability of the findings, including multiple levels of
review, culminating in a consensus process. Many knowledge gaps were identified that will allow prioritization
of research efforts in veterinary CPR.
Conclusions – Collaborative systematic evidence review is organizationally challenging but feasible and effec-
tive in veterinary medicine. More experience is needed to refine the process.

(J Vet Emerg Crit Care 2012; 22(S1): 4–12) doi: 10.1111/j.1476-4431.2012.00758.x

Keywords: cardiac arrest, canine, feline

Abbreviations
ACVA American College of Veterinary Anesthesia
ACVECC American College of Veterinary Emergency
From the Department of Emergency Medicine, School of Medicine, Center
for Resuscitation Science, and the Department of Clinical Studies, School of
and Critical Care
Veterinary Medicine, University of Pennsylvania, Philadelphia, PA (Boller); ALS advanced life support
College of Veterinary Medicine, Department of Clinical Sciences, Cornell BLS basic life support
University, Ithaca, NY (Fletcher).
CAB Commonwealth Agricultural Bureaux
Drs. M. Boller and D. J. Fletcher are equal first co-authors. CPA cardiopulmonary arrest
The authors declare no conflicts of interests.
CPR cardiopulmonary resuscitation
Address correspondence and reprint requests to
Dr. Manuel Boller, Center for Resuscitation Science, School of Medicine, Uni-
LOE level of evidence
versity of Pennsylvania, 125 S 31st St - Suite 1200, Philadelphia, PA 19104, PICO Population-Intervention-Comparison-
USA. Outcome
Email: mboller@vet.upenn.edu
Submitted March 30, 2012; Accepted April 2, 2012. RCT randomized controlled trial

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 RECOVER introduction

VECCS Veterinary Emergency and Critical Care So- of veterinarians, each tasked with answering a specific
ciety clinically oriented question on veterinary CPR. They
WS worksheet first identified the relevant literature and graded each
study according to predefined strength and quality met-
rics. As each question was asked, evaluated, and an-
Introduction swered on a structured worksheet, these reviewers were
named worksheet (WS) authors. They were recruited
Less than 6% of dogs and cats that experience cardiopul-
via email invitations distributed to all members of the
monary arrest (CPA) in the hospital survive to hospital
American College of Veterinary Emergency and Criti-
discharge.1–3 The survival rate is approximately 20% in
cal Care (ACVECC) and the American College of Vet-
humans that experience in-hospital cardiac arrest.4, 5 De-
erinary Anesthesia (ACVA). Consequently, most partic-
spite many differences between humans and dogs or
ipants were diplomates of these 2 colleges. A total of
cats, this disparity suggests that CPA outcomes could be
68 WS authors, 7 domain chairs, and 12 advisory board
considerably improved in veterinary patients. A com-
members contributed to the initiative. While most were
prehensive treatment strategy to optimize survival from
located in the United States, volunteers from Canada
small animal CPA that includes preparedness and pre-
and Europe also participated. An anonymous electronic
vention measures, basic life support (BLS) and advanced
survey of the WS authors after completion of the WS
life support (ALS), and post-cardiac arrest (PCA) care has
process (response rate = 79%) revealed roughly equal
been proposed.6 However, consensus-based guidelines
participation from members of academic institutions
for such strategies do not exist in veterinary medicine,
(48%) and private specialty practices (52%). Despite a
nor has the evidence been systematically evaluated and
significant time commitment (37 ± 17 hours/WS author;
graded to build the foundation for such guidelines.
> 2,000 hours total), the vast majority considered the im-
Current veterinary CPR recommendations have been
portance of the project well worth the effort (96%) and
derived from guidelines for humans (eg, the Ameri-
would volunteer again (94%).
can Heart Association guidelines for CPR and emer-
The evidence evaluation methodology was highly
gency cardiovascular care) or based on veterinary expert
collaborative and similar to the evidence evaluation
opinion.6–12 In addition, there appears to be disagree-
processes used by the International Liaison Commit-
ment about how to best perform CPR among veterinary
tee on Resuscitation (ILCOR), the organization that
clinicians, even among boarded emergency and critical
has conducted evidence analysis for treatment recom-
care specialists.13
mendation development in human CPR since 1992.14, 15
The Reassessment Campaign on Veterinary Resuscita-
Ties between the 2 organizations (RECOVER and
tion (RECOVER) was designed to systematically evalu-
ILCOR) already existed at the initiation of the project but
ate the evidence on the clinical practice of veterinary CPR
were further strengthened during its evolution. More-
with 2 overarching goals: first to devise clinical guide-
over, RECOVER was also endorsed and supported by
lines on how to best treat CPA in dogs and cats, and
the ACVECC and the Veterinary Emergency and Crit-
second to identify important knowledge gaps in veteri-
ical Care Society (VECCS). We are optimistic that RE-
nary CPR that need to be filled in order to improve the
COVER is a sustainable initiative because it is com-
quality of recommendations, and thus the quality of pa-
posed of a large number of specialist volunteers from
tient care in the future. This will allow construction and
private practice and academia willing to commit to fu-
implementation of educational initiatives based on the
ture projects and has obtained broad endorsement from
clinical guidelines and will further build the foundation
important organizations in the fields of veterinary and
for coordinated research initiatives in veterinary resus-
human resuscitation. This paper describes the method-
citation.
ology used to develop the RECOVER veterinary CPR
The RECOVER organization consisted entirely of vol-
guidelines.
unteers, including 2 co-chairs that provided oversight
for all major phases of project management from con-
ception and initiation to dissemination of the findings,
an advisory board composed of experts in various fields
Evidence Evaluation Process
related to CPR, and over 80 veterinarians participating
in 1 of 5 resuscitation topic domains responsible for The RECOVER evidence evaluation process included a
evidence gathering and analysis in the areas of pre- series of steps: identification of relevant topics, execution
paredness and prevention, BLS, ALS, monitoring, or of a standardized literature search, assessment of the
PCA care (Figure 1). Each domain was led by 1 or 2 identified relevant articles, and finally assessment and
domain chairs who organized and supported a group integration of the evidence.


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M. Boller & D. J. Fletcher

Figure 1: RECOVER organizational chart. RECOVER, Reassessment Campaign on Veterinary Resuscitation; ILCOR, International
Liaison Committee on Resuscitation; ACVECC, American College of Veterinary Emergency and Critical Care; JVECC, Journal of
Veterinary Emergency and Critical Care; VECCS, Veterinary Emergency and Critical Care Society; EVECCS, European Veterinary
Emergency and Critical Care Society; AVECCT, Academy of Veterinary Emergency and Critical Care Technicians; ACVA, American
College of Veterinary Anesthesia.

Asking relevant clinical questions
The first task undertaken by the domain chairs and the
advisory board was the identification of relevant clin-
ical questions for each of the 5 RECOVER domains.
As a first step, the 277 questions investigated by IL-
COR in 2010 were evaluated (http://www.ilcor.org/
en/consensus-2010/questions-2010/) and those most
relevant to veterinary medicine were modified for use
by RECOVER. Veterinary-specific topics not covered by
the ILCOR questions were then identified and added. A
total of 87 questions were composed, reviewed by the
domain chairs and the advisory board, and categorized
by priority scores. Each question was assigned to a single
reviewer who explicitly declared any conflicts of inter-
ests. To keep the scope of the work manageable, 74 high
priority questions were chosen for investigation, and the
remaining questions, all with low priority scores, were
excluded from review. However, it was recognized that
not all significant topics could be investigated at this
time, and that many questions remain to be answered in
future initiatives.
Similar to the ILCOR evidence evaluation process,15
the RECOVER questions were written in a standardized
PICO (Population-Intervention-Comparison-Outcome)
format to facilitate clear differentiation of the compo-
nents of each question and the development of the liter-
ature search strategy.16 An example ALS PICO question
is “In dogs and cats with cardiac arrest due to VF (P),
does the use of CPR before defibrillation (I) as opposed to
defibrillation first (C), improve outcome (O) (eg, ROSC,
survival)?” The strongest evidence for or against an inter-
vention would emerge from a well-controlled trial (such
as a randomized controlled trial), with the intervention
and control groups as described in the PICO question
using the same target species (dogs and/or cats with
cardiac arrest and VF). The outcome was left unspecified

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 RECOVER introduction

in the questions, but WS authors were asked to clearly and grades it according to the likelihood of biased results.
state outcome measures used in each reviewed article. For example, a well executed, prospective, randomized,
controlled interventional trial is graded a higher LOE
than a similar study without randomization. RECOVER
The search strategies
used an LOE scale that was modified from the 2010 IL-
The literature search strategy for each question was
COR evidence evaluation process in order to increase
designed to reduce reviewer bias toward preferential
the weight of data originating from studies in the target
selection of articles and to identify all relevant liter-
species (dogs and/or cats).15 Within the target species the
ature. Each WS author was required to use 2 elec-
highest level of evidence (LOE 1) was assigned to clini-
tronic databases for the literature search, MEDLINE, and
cal randomized controlled trials (RCTs), and the lowest
the Commonwealth Agricultural Bureaux (CAB) Ab-
(LOE 5) included case series and reports (Table 1). Exper-
stracts database, which offers the most comprehensive
imental laboratory studies involving dogs or cats were
indexing and abstracting of the veterinary literature.17
classified as LOE 3. If the research did not involve dogs or
While MEDLINE is a free resource usually accessed
cats, the study was categorized as LOE 6. This predom-
via PubMed (http://www.ncbi.nlm.nih.gov/pubmed),
inantly included clinical studies in humans and experi-
CAB requires a subscription. Peers in the same domain
mental studies in swine and rodents. A table concisely
or domain chairs executed CAB search requests for WS
describing the study characteristics relevant to LOE as-
authors without access. Other search engines and ap-
signment was included in the WS author instructions to
proaches were permitted to minimize the risk of exclud-
ensure consistency between WS authors (Table 2).
ing relevant articles. Reviewers were instructed to use
In addition, a series of quality items were used to as-
the “cited by” option of Scopus, Google Scholar, or Web
sess the methodological soundness of a study within a
of Science, taking a classic or landmark relevant paper as
certain LOE. Examples of general quality factors are sim-
a starting point. In addition, the citations of topic-related
ilarity of treatment and control groups at the start of the
review articles were examined for relevant publications.
study, the relevance of the study for the question asked,
Each search strategy, including database, search terms,
the clinical relevance of the effect size observed, and
and number of hits were detailed on the worksheet. In
control for confounders. The number of quality items
addition, criteria used to exclude articles from further
applicable to each study was used by the WS authors to
analysis were clearly stated as part of the search strategy.
assign a quality term (“good,” “fair,” or “poor”) to each
In order to be included in the scientific review, articles
study. The list of quality items used in RECOVER closely
needed to be peer reviewed original research published
resembled that used in the ILCOR 2010 process for LOE
in English. Abstracts and reviews were excluded from
1, 2, 4, and 515 but was adjusted to meet the needs of
analysis. It was recognized that a substantial portion of
RECOVER in LOE 3 and LOE 6. Experimental animal
knowledge, such as all research published in languages
studies (LOE 3) were considered “good” if they were
other than English, would be excluded from analysis,
randomized and had a control group, “fair” if a control
and a bias toward studies with positive outcomes would
group was included but not randomized and “poor” if
be fostered by not including abstracts.18 In the future,
uncontrolled. In clinical studies in humans (LOE 6), RCTs
more international collaboration will be important to al-
were considered “good,” nonrandomized studies with
leviate some of these limitations. Additional exclusion
concurrent controls “fair,” and those with retrospective
criteria may have been applied that were specific for
(historic) controls or large retrospective studies “poor.”
each PICO question (eg, mild therapeutic hypothermia
Uncontrolled studies were not considered in LOE 6. For
in conditions other than CPA). Only articles deemed rel-
studies in other nontarget species, such as swine and
evant by application of these criteria underwent detailed
rodents, the quality factors used for LOE 3 applied.
review. The search strategy was reviewed by the respon-
sible domain chair, commented on and revised as neces-
sary, and only when approved did further assessment of
The grid of evidence
each relevant article ensue (Figure 2).
Once LOE and quality were assessed, all relevant ar-
ticles were plotted in 1 of 3 tables, according to their
Assessment of relevant articles direction of support for the PICO question asked. The
All relevant articles were reviewed in detail and each studies could either provide supporting evidence, neu-
was assigned a level of evidence (LOE) according to cri- tral evidence, or opposing evidence. In addition, each
teria defined a priori. The LOE categorization provided study was marked according to the outcome measures
a mechanism for building an overview of the overall used (eg, blood pressure, ROSC, survival to hospital dis-
strength of the evidence supporting and opposing the charge, and others) (Figure 3). This provided a graph-
PICO question. The LOE is a characteristic of the study ical overview of the strength of the evidence for the


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M. Boller & D. J. Fletcher

Figure 2: Worksheet and guidelines flow chart. PICO, Population-Intervention-Comparison-Outcome; RECOVER, Reassessment
Campaign on Veterinary Resuscitation; IVECCS, International Veterinary Emergency and Critical Care Symposium.

conclusion, with studies in the upper and left portions of
the table providing the strongest evidence, and studies
in the lower right providing the weakest evidence.
Summarizing and integrating the evidence
The WS authors were asked to summarize the results
of their review in a short narrative, including overall
balance between supportive, neutral, and opposing evi-
dence, the clinical relevance of that evidence for CPR in
dogs and cats, and the outcomes stated. Particular atten-
tion was given to the benefits and risks associated with
the interventions examined. Furthermore, the reviewer’s
insight into the topic allowed them to identify contradic-
tions within the cited studies. A succinct conclusion was
then written directly relating the evidence to the clini-
cal question, stating the overall answer to the question,
and commenting on any clinical recommendations for
veterinary CPR to be drawn.
Finally, the reviewers identified the major knowledge
gaps that emerged from the evidence evaluation process,
focusing on gaps that need to be addressed before the
clinical question can be answered conclusively.
After completion, the worksheet draft was reviewed
by the domain chair(s), and the worksheets edited col-
laboratively by the WS author and domain chair un-
til the evidence evaluation sheet was considered com-
plete (Figure 2). Throughout the process, Internet-based
collaborationa and reference managementb tools were
used to facilitate communication, the sharing of docu-
ments, and to allow central reference management for
all domains.
Clinical Guidelines
Completed and approved worksheets were reviewed
by the RECOVER chairs, who then drafted 101 clini-
cal CPR guidelines based on the evidence analysis. The
guidelines were designed to be succinct and clinically

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Table 1: Levels of evidence. LOE 1 suggests the highest, and LOE
6 the lowest level of evidence. Target species refers to dog or cat
Level Study characteristics
LOE 1 Randomized controlled trials or meta-analyses of RCTs in
target species:
Clinical studies that prospectively collect data and randomly
allocate the animals to intervention or control groups; or
meta-analyses of these studies
LOE 2 Prospective clinical studies in target species using concurrent
controls (ie, controls recruited at the same time as
experimental subjects) without randomization. These
studies can be:
1. Interventional clinical: Include animals that are allocated to
intervention or control groups concurrently, but in a
nonrandom fashion
Or
2. Observational clinical: Include cohort and case control
studies
LOE 3 Experimental laboratory study in target species:
These studies can be randomized, blinded, and controlled but
do not have to be. The study design needs to be reported
and the study will be categorized according to
methodological quality (good/fair/poor).
LOE 4 Clinical retrospective studies in target species:
The study and control groups have been selected from a
previous period in time.
LOE 5 Case series and case reports in target species:
A single group of animals exposed to the intervention (or factor
under study), but without a control group.
LOE 6 Studies, experimental or clinical, that are not directly related to
the specific target species (ie, not dogs or cats) or target
population (eg, not cardiac arrest). These could be different
species/populations, including experimental models in
nontarget species, and includes high quality studies in
humans only (such as meta-analyses, RCTs, and clinical
studies with concurrent controls, including observational
studies; these are the human equivalents to our LOE 1
and 2).
Table 2: Table to guide study allocation to different levels of
evidence (LOE). Target species refers to dogs or cats
LOE criteria present (• mandatory/◦ optional)
Target
species Clinical Randomized Controlled Concurrent
LOE 1 • • • • • tole or PEA potentially associated with increased va-
LOE 2 • • • •
LOE 3 • ◦ ◦ ◦
LOE 4 • • •
LOE 5 • •
LOE 6 ◦ ◦ ◦ ◦
applicable. Thus recommendations were made when-
ever possible, even if the evidence analysis made it clear
that the scientific basis for or against a treatment was
weak. To address this variability in the evidence base
upon which each recommendation was made, all guide-
lines were appended with (1) a Class, summarizing the

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RECOVER introduction
size of the documented treatment effect expressed as
risk:benefit ratio, and (2) a Level, summarizing the con-
fidence that this risk:benefit ratio was true based on the
amount and quality of evidence available. In addition,
the guidelines were worded in a standardized way to
reflect class and level of the recommendation.
Class and level of recommendations
The RECOVER class and level recommendation system
paralleled the system used in the 2010 AHA guidelines
for CPR and Emergency Cardiovascular Care (Table 3).19
A Class I recommendation indicated that the benefit
of an intervention far outweighed the associated risk
and suggested that the treatment or procedure should
be administered or performed. Level A then indicated
that multiple high-quality and/or high LOE studies sup-
ported this recommendation. For RECOVER, this meant
multiple high LOE or high quality studies were in sup-
port of the treatment or procedure examined and no ev-
idence of harm emerged from the evidence analysis. An
example is that CPR should be performed in 2-minute
cycles without interruption, and duration of pauses be-
tween cycles minimized (I-A).20, 21 On the other end of
the evidence spectrum, a Level C recommendation was
not supported by strong scientific data, but rather by
case reports or series, expert opinion, or clinical stan-
dards. However, despite the low weight of evidence,
a treatment or procedure could still have been recom-
mended if the potential benefit far outweighed the risk
(Class I). An example is the recommendation that post-
cardiac arrest monitoring should be sufficient to detect
impending reoccurrence of CPA (I-C).20, 22 If the benefit
of an intervention was less clear and additional research
was needed to further demonstrate the usefulness of a
treatment, the recommendation was categorized as Class
II. If the expected treatment effect was clearly visible, it
was assigned a Class IIa, while Class IIb was reserved
for treatments with less clear or conflicting evidence on
their usefulness but no substantial evidence of harm. An
example for a Class IIa recommendation is that the use
of atropine is reasonable in dogs and cats with asys-
gal tone (IIa-B).20, 23 A Class IIb recommendation is that
seizure prophylaxis with barbiturates in dogs and cats
post-cardiac arrest may be considered (IIb-B).20, 24 If at
any level of evidence an intervention was considered to
be more harmful than beneficial, it was assigned a Class
III recommendation. An example is that fast rewarming
at a rate > 1◦ C/h is not recommended in hypothermic
dogs and cats post-cardiac arrest (III-A).20, 24
Consensus
The drafted guidelines applicable to preparedness and
prevention, BLS, ALS, monitoring, and PCA care were
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M. Boller & D. J. Fletcher

Figure 3: Evidence neutral to the question on the use of vasopressin during CPR. The grid allows overall assessment of level of
evidence (LOE) and the methodological quality (good/fair/poor), as well as the endpoints examined in the studies.

Table 3: Class and level of recommendation. The class of each ing that all members could live with. The guidelines
recommendation describes the size of the treatment effect or the were then made accessible to the RECOVER advi-
benefit-to-risk ratio and the level is an expression of the weight
sory board and their comments were solicited and
of evidence in support of the class assignment
integrated. The documents were then posted on the
Class of recommendation RECOVER website (http://www.acvecc-recover.org/)
and the most controversial guidelines were presented
I IIa IIb III
and discussed at the IVECCS 2011 meeting during
Benefit >>> risk Benefit >> risk Benefit ≥risk Risk > benefit a 3-hour session. The members of several profes-
(should be (reasonable to (may be (should not be sional organizations (ACVECC/VECCS/European Vet-
performed) perform) considered) performed
since it is not
erinary Emergency and Critical Care Society/Academy
helpful and of Veterinary Emergency and Critical Care Techni-
may be cians/ACVA/European College of Veterinary Anaesthe-
harmful) sia and Analgesia) were invited by email to review and
Level of recommendation comment on the guidelines. The website was designed
A B C to allow blog-like commenting and discussion from any
interested registered individual for 4 weeks. Comments
(multiple (limited (very limited
populations) populations) populations)
were noted, discussed, and integrated into the consensus
Multiple high Few to no high Consensus process.
quality and/or quality and/or opinion, expert
high level of high level of opinion, Dissemination
evidence evidence standard of The Journal of Veterinary Emergency and Critical Care was
studies. studies. care.
chosen as the primary mode of dissemination of the
RECOVER evidence evaluation findings and clinical
guidelines. A writing group was formed for each do-
discussed with the respective domain chairs via phone main and an additional group for a separate clinical
conferences and reworded until consensus was reached. guidelines manuscript. The objective of each domain
Consensus was defined as either being in mutual agree- manuscript was to provide the reader with a succinct
ment on the exact wording of the guideline, or in but comprehensive overview of all evidence evaluated,
the rare case where this could not be achieved de- and thus was composed as a synopsis of the science
spite prolonged discussion, mutual agreement on word- evaluated during the RECOVER worksheet process.

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Accordingly, the knowledge gaps were also included
in these 5 articles.21–25 The WS authors were asked to
critically review the drafted manuscript sections that re-
lated to their topic prior to finalizing the articles. The
clinical CPR guidelines that emerged from all 5 domains
were bundled together in 1 article.20 The manuscript was
succinctly written, with the idea that in-depth informa-
tion could easily be gathered by consulting the science
evaluation manuscripts, and in an attempt to provide
practically useful information in an accessible format to
ease implementation in the clinical setting. To provide
concise overviews of the extensive clinical recommen-
dations, treatment algorithms for CPR, and PCA care
as well as a dosing chart for the most relevant medica-
tions were generated and are included in the guidelines
article.20
Summary
The RECOVER initiative methodology enabled an ef-
ficient, systematic review of a large body of literature,
primarily due to the contributions of a large number of
volunteer WS authors. The stated willingness of these
reviewers to participate in future initiatives combined
with the organizational infrastructure that has been de-
veloped suggest that RECOVER is a sustainable effort,
leading not only to the possibility of reevaluation of the
CPR evidence in 5 years, but even to extend the scope to
other issues relevant to resuscitation.
This initial process has also been a considerable learn-
ing experience for everyone involved and consequently
several insufficiencies were detected that need to be
remedied in the future. Instructional tools for the WS
authors must be developed to increase the efficiency and
quality of the very complex evidence review process. It
is a testament to the dedication of the WS authors that
they were able to generate high quality, comprehensive
worksheets with minimal instruction, but better support
tools such as webinars, interactive tutorials, or in-person
workshops are needed. A more extensive administrative
structure is also needed to allow the RECOVER chairs
and domain chairs to focus on the science rather than
the organization.
Despite these limitations, the evidence analysis and
grading process leading to consensus guidelines on CPR
in small animals was transparent and reproducible. It
allowed a large number of colleagues to collaboratively
review a huge body of literature in an organized fash-
ion and in a short period of time. And by doing so
they not only broke new ground in the area of veteri-
nary resuscitation, but also built a foundation for future
projects.

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RECOVER introduction
Acknowledgment
The authors would like to thank the American College
of Veterinary Emergency and Critical Care (ACVECC)
and the Veterinary Emergency and Critical Care Soci-
ety for their financial and scientific support, as well as
Armelle deLaforcade, the ACVECC Executive Secretary
and Kathleen Liard, ACVECC Staff Assistant for their
administrative and organizational support. This work
would have been impossible without the tireless efforts
of the worksheet authors in the 5 RECOVER domains.
Their contribution to this product can not be overstated,
and their dedication to this challenging task serves as
an inspiration to the veterinary profession. Furthermore,
the domain chairs that guided these worksheets au-
thors deserve great credit. The domains were chaired
by Drs. Maureen McMichael (Preparedness and Preven-
tion), Kate Hopper (BLS), Elizabeth Rozanski and John
Rush (ALS), Benjamin Brainard (Monitoring), and Sean
Smarick and Steve Haskins (PCA care). Also, we would
like to thank the RECOVER Advisory Board for their
guidance and invaluable input during the planning and
execution of this initiative: Dennis Burkett, ACVECC
Past-President; Gary Stamp, VECCS Executive Direc-
tor; Dan Chan, JVECC Liaison; Elisa Mazaferro, Private
Practice Liaison; Vinay Nadkarni, ILCOR Liaison; Erika
Pratt, Industry Liaison; Andrea Steele, AVECCT Liai-
son; Janet Olson, Animal Rescue Liaison; Joris Robben,
EVECCS Past-President; Kenneth Drobatz, ACVECC Ex-
pert; William W. Muir, ACVECC and ACVA Expert; Erik
Hofmeister, ACVA Expert. We would also like to extend
special thanks to Dr. Joris Robben for graciously mod-
erating the RECOVER session at IVECCS 2011. Finally,
we would like to thank the many members of the veteri-
nary community who provided input on the RECOVER
guidelines at the IVECCS 2011 session and during the
open comment period via the RECOVER web site.
Footnotes
a
Basecamp, 37signals LLC, Chicago, IL.
b
Mendeley, Mendeley Inc, New York, NY.
References
1. Hofmeister EH, Brainard BM, Egger CM, et al. Prognostic indicators
for dogs and cats with cardiopulmonary arrest treated by cardiopul-
monary cerebral resuscitation at a university teaching hospital. J Am
Vet Med Assoc 2009; 235:50–57.
2. Kass PH, Haskins SC. Survival following cardiopulmonary resusci-
tation in dogs and cats. J Vet Emerg Crit Care 1992; 2:57–65.
3. Wingfield WE, Van Pelt DR. Respiratory and cardiopulmonary ar-
rest in dogs and cats: 265 cases (1986–1991). J Am Vet Med Assoc
1992; 200:1993–1996.
4. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscita-
tion of adults in the hospital: a report of 14720 cardiac arrests from
S11
M. Boller & D. J. Fletcher
the National Registry of Cardiopulmonary Resuscitation. Resusci-
tation 2003; 58:297–308.
5. Meaney PA, Nadkarni VM, Kern KB, et al. Rhythms and outcomes
of adult in-hospital cardiac arrest. Crit Care Med 2010; 38:101–
108.
6. Boller M, Boller EM, Oodegard S, et al. Small animal cardiopul-
monary resuscitation requires a continuum of care: proposal for a
chain of survival for veterinary patients. J Am Vet Med Assoc 2012;
240:540–554.
7. Cole SG, Otto CM, Hughes D. Cardiopulmonary cerebral resuscita-
tion in small animals—a clinical practice review. Part II. J Vet Emerg
Crit Care 2003; 13:13–23.
8. Cole SG, Otto CM, Hughes D. Cardiopulmonary cerebral resuscita-
tion in small animals—a clinical practice review. Part 1. J Vet Emerg
Crit Care 2002; 12:261–267.
9. Plunkett SJ, McMichael M. Cardiopulmonary resuscitation in small
animal medicine: an update. J Vet Int Med 2008; 22:9–25.
10. Hackett TB. Cardiopulmonary cerebral resuscitation. Vet Clin North
Am Small Anim Pract 2001; 31:1253–1264.
11. Rieser TM. Cardiopulmonary resuscitation. Clin Tech Sm Anim
Pract 2000; 15:76–81.
12. Maton B, Smarick S. 2010. AHA guidelines and veterinary medicine?
J Vet Emerg Crit Care 2012; 2:148–159.
13. Boller M, Kellett-Gregory L, Shofer FS, Rishniw M. The clinical prac-
tice of CPCR in small animals: an internet-based survey. J Vet Emerg
Crit Care (San Antonio) 2010; 20:558–570.
14. Nadkarni VM, Nolan JP, Billi JE, et al. Part 2: International col-
laboration in resuscitation science: 2010 International Consensus
on Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care Science with Treatment Recommendations. Circulation 2010;
122(16 Suppl 2):S276–S282.
15. Morley PT, Atkins DL, Billi JE, et al. Part 3: Evidence evaluation
process: 2010 International Consensus on Cardiopulmonary Resus-
citation and Emergency Cardiovascular Care Science with Treat-
ment Recommendations. Circulation 2010; 122(16 Suppl 2):S283–
S290.
S12 
C Veterinary Emergency and Critical Care Society 2012, doi: 10.1111/j.1476-4431.2012.00758.x
16. Robertson SR. Refining the clinical question: the first step in
evidence-based veterinary medicine. Vet Clin N Am Small Anim
Pract 2007; 37:419–431.
17. Murphy SA. Searching for veterinary evidence: strategies and re-
sources for locating clinical research. Vet Clin N Am Small Anim
Pract 2007; 37:433–445.
18. Counsell C. Formulating questions and locating primary studies for
inclusion in systematic reviews. Ann Intern Med 1997; 127:380–387.
19. Sayre MR, O’Connor RE, Atkins DL, et al. Part 2: evidence evaluation
and management of potential or perceived conflicts of interest: 2010
American Heart Association Guidelines for Cardiopulmonary Re-
suscitation and Emergency Cardiovascular Care. Circulation 2010;
122(18 Suppl 3):S657–S664.
20. Fletcher DJ, Boller M, Brainard BM, et al. RECOVER evidence and
knowledge gap analysis on veterinary CPR, part 7: clinical guide-
lines. J Vet Emerg Crit Care 2012; 22(Suppl 1):S102–S131.
21. Hopper K, Epstein SE, Fletcher DJ, Boller M, RECOVER basic
life support domain worksheet authors. RECOVER evidence and
knowledge gap analysis on veterinary CPR. Part 3: basic life sup-
port. J Vet Emerg Crit Care 2012; 22(Suppl 1):S26–S43.
22. Brainard BM, Boller M, Fletcher DJ. RECOVER monitoring domain
worksheet authors. RECOVER evidence and knowledge gap anal-
ysis on veterinary CPR. Part 5: monitoring. J Vet Emerg Crit Care
2012; 22(Suppl 1):S65–S84.
23. Rozanski EA, Rush JE, Buckley GJ, et al. RECOVER evidence and
knowledge gap analysis on veterinary CPR. Part 4: advanced life
support. J Vet Emerg Crit Care 2012; 22(Suppl 1):S44–S64.
24. Smarick S, Haskins SC, Boller M, et al. RECOVER post-cardiac arrest
care domain worksheet authors. RECOVER evidence and knowl-
edge gap analysis on veterinary CPR. Part 6: post-cardiac arrest
care. J Vet Emerg Crit Care 2012; 22(Suppl 1):S85–S101.
25. McMichael M, Herring J, Fletcher DJ, Boller M, RECOVER pre-
paredness and prevention domain worksheet authors. RECOVER
evidence and knowledge gap analysis on veterinary CPR. Part 2:
preparedness and prevention. J Vet Emerg Crit Care 2012; 22(Suppl
1):S13–S25.