ECC Suggested Readings
May 2025
Jamie Burkitt DVM, DACVECC
I live in Davis, California, and work at UC Davis as a faculty criticalist. I am also the Guidelines Co-Chair for the RECOVER Initiative, whose mission is to empower people to provide lifesaving care to animals through education, science, and community.
A paper that I recently liked…
Outcomes related to 10-min Apgar scores of zero in Japan
Jun Shibasaki, Takeo Mukai, Kennosuke Tsuda, Akihito Takeuchi, Tomoaki Ioroi, Hiroyuki Sano, Nanae Yutaka, Akihito Takahashi, Hisanori Sobajima, Masanori Tamura, Shigeharu Hosono, Makoto Nabetani, Osuke Iwata;
Baby Cooling Registry of Japan Collaboration Team
Paper Commentary
I selected this article because Dr. Manu Boller and I, along with many other RECOVER volunteers and subject matter experts, have been working hard to finish the RECOVER Newborn Resuscitation domain and guidelines, which should be published late this summer. During our evidence analysis I came across this article, which is relevant to newborn resuscitation and, for the newborn population, to the oft-asked question of “when do we stop?” CPR. This paper contributes some hope for positive outcomes with well-executed CPR beyond 10 minutes in term and near-term newborns.
The study design
Retrospective case series using data from the national Baby Cooling Registry of Japan from 2012 – 2016
The study background
Historically, evidence has suggested that infant human beings who are born pulseless and remain pulseless after 10 minutes of resuscitation (i.e., CPR) are unlikely to survive with a favorable neurologic outcome. However, more recent data have suggested that with timely resuscitation efforts, in combination with appropriate post-cardiopulmonary arrest management, some newborns undergoing CPR beyond 10 minutes may have a positive outcome. This study aimed to describe the survival and neurological outcomes of infants that had received > 10 minutes of CPR at birth.
Study considerations
28 of 768 infants in the Baby Cooling Registry of Japan during the study period had undergone CPR for ≥ 10 minutes. Of these 28, 3 (11%) survived beyond 18 months with favorable outcomes. Others either died by 18 months of age (9/28; 32%) or survived but with significant impairments (16/28; 57%). Of the 3 survivors with a good outcome, 1 underwent CPR for 12 minutes, 1 for 14 minutes, and 1 for 20 minutes before the first heartbeat was detected. As the cases were identified through a search through a registry of babies undergoing therapeutic hypothermia, all infants had undergone this and other supportive post-cardiac arrest measures following return of spontaneous circulation.
Takeaways
I really like this study because it shows that, at least for now, there is evidence that high-quality CPR followed by good post-CPA care can have a good outcome for some individuals. When talking to veterinary professionals about CPR, one of the most common questions we hear is “When should we stop?” and there is very little literature available to inform an evidence-based answer. However, this study suggests that the RECOVER Initiative’s general message about “when should we stop?” may be true: if there is motivation to continue (i.e., in the case of veterinary medicine, if the clients request that the team continue trying), it is reasonable to do so when there is no known irreversibly fatal condition and the CPR efforts are going well (e.g., as gauged in adult dogs and cats by ETCO2 measurement, for example). This study also suggests that high-quality outcomes are possible in ≥ 10% of infants undergoing CPR for over 10 minutes that achieve sustained return of spontaneous circulation (in this case, those that lived long enough to undergo therapeutic hypothermia).
