Guidelines for indications for the use of extracorporeal life support in refractory cardiac arrest. French Ministry of Health.

Around 50,000 cardiac arrests (CA) occur each year in France and survival remains as low as 3 to 5%. Cardiopulmonary resuscitation (CPR) includes several treatment techniques for CA that are regularly updated in French, European, and international guidelines. Extracorporeal life support (ECLS) has been suggested as a therapeutic option in refractory CA since 1976. However, the use of this technique has remained limited to hypothermic CA and to CA occurring during the perioperative period of cardiothoracic surgery, mainly because the results of the initial trials were deceptive. The ease of use of more recent miniaturized ECLS devices has permitted a wider use of the technique in cardiac surgery departments and intensive care units (ICU). Encouraging results have been published recently by several teams in France and Taiwan, in single centre retrospective and prospective cohorts. In these studies, most CA were from toxic or cardiac causes and occurred in the hospital. In these highly selected cohorts, survival with good neurological outcome has been observed in up to 20 to 30% of cases. Nevertheless, the preliminary results of the use of ECLS in out-of-hospital CA in France are very poor, with less than 1% survival being observed. It should be emphasized that the time delay to commencing ECLS in out-of-hospital CA was far greater than that previously reported in in-hospital CA. These contrasting results lead physicians who perform CPR to question the indications and contra-indications of ECLS in these conditions and the French health authorities to question the value of such costly techniques (real cost as well as use of important and highly specialized human resources). The authors shared the following concerns that require emphasis: that an uncontrolled development of ECLS in out-of-hospital CA may lead to its abandonment because of very poor favourable outcome; that ECLS may lead to the survival of patients with poor neurological recovery and the associated considerable suffering for the patient and its relatives (although further evolution to brain death has been observed in most of these surviving patients with poor neurological outcome); that nonhomogeneous criteria may be applied in France for the use of ECLS in case of refractory CA because of the lack of any published data on its indications and contra-indications.Therefore, French medical scientific societies, under the auspices of the French Ministry of Health, selected a group of experts to propose guidelines that could help physicians performing CPR for refractory CA in deciding if ECLS should be used or not. The following text reflects a consensus obtained by these experts coming from different scientific and medical background at the present time. It should be noted that the views expressed are very likely to be modified in the near future because this topic is evolving rapidly.