Maayke Hunfeld

113 Survey neuroprognostication study by Topijan 128 patients had EEG monitoring within one day of ROSC [3]. Normal background activity was associated with good prognosis while severely abnormal EEG background (burst suppression, flat, discontinuous background patterns and early epileptic seizures) carried increased odds of death and unfavourable neurologic outcome. They concluded that addition of EEG information to clinical criteria is more predictive of outcome than clinical criteria alone [3]. After cardiac arrest ischemic cytotoxic oedema develops due to hypoxia and is followed by neuronal necrosis (apoptosis). This process is ongoing within minutes to few hours after the acute event. MRI and DW-MRI are much more sensitive than CT and provide accurate and detailed insight into the level and regions of brain tissue damage. Timing of MRI is important as shown more than 2 decades ago by Dubowitz (1998) who found that lesions present on MRI on day 3 or 4 post-CA correlated best with patient outcome versus MRI on days 1 or 2 post-CA. A normal MRI between day 3e7 post-CA was associated with a favourable outcome whereas damage in multiple brain lobes, involvement of cortical regions and basal ganglia and low apparent diffusion coefficient (ADC) values on diffusion weighted imaging (DWI) MRI were associated with poor outcome[4]. There is a need for prospective multicentre studies to better understand the variable individual susceptibilities to excitotoxicity and free radical stress, cellular metabolism and stage of brain development and the impact of specific treatment modalities. Hunfeld et al., described the differing practices in European PICUs in relation to withdrawing of life-sustaining treatment (WLST) or continuing treatment when prognosis is futile. Respondents from Western and Northern Europe more often decide to withdraw life-sustaining treatment as compared to those from the Southern and Eastern part of Europe [2]. Many ethical dilemmas arise around the decisions to withdraw life-sustaining treatment. There are very few local or national guidelines. End of life care is a process of recognising that ongoing intensive treatment is prolonging the patient’s life but may not be in the patient’s best interest. For physicians in PICU one of the most difficult decisions is limiting life-sustaining treatment (LST) and moving from cure to prioritising comfort and palliative care [5]. This study helps to raise awareness of contemporary trends in medical ethics including the awareness of patients’ autonomy (in case of paediatric populations through parents). International guidelines for reliable determination of neurological prognosis in comatose children after CA are needed to ensure patients receive optimal standards of care within European PICUs and are provided with ethically acceptable aspects of end of life care [5]. 3