Maayke Hunfeld

120 Chapter 4 Introduction Nine out of 100,000 children in the Netherlands have an out-of-hospital cardiac arrest (OHCA) each year (1). Noncardiac causes are the most prevalent known causes of OHCA, in contrast with adults ((2-4). The incidence of OHCA is lower in children compared to adults (5). A few studies suggest that survival rates of children with OHCA did not significantly improve in recent years (6-8). However, some other studies concluded that survival following pediatric OHCA did indeed increase (9-12). Understanding the process of neuro-prognostication and withdrawal of life- sustaining therapies (WLST) following pediatric cardiac arrest (CA) is important. However, detailed information regarding the process of neuroprognostication (e.g., timing and basis for WLST) is often lacking. Furthermore, early after admission to the PICU, it may be difficult to predict prognosis based on the extent of the neurologic damage and the ability of the child to make a full or at least meaningful neurologic recovery. Many children survive OHCA with long-term moderate or severe disability due to hypoxic-ischemic brain injury (13). This knowledge combined with prior individual experience may bias health-care provider neuro-prognostication and decision-making regarding WLST. A previous study characterizing the epidemiology of inhospital cardiac arrest (IHCA) and OHCA in our center revealed that 30% of the children had no return of circulation (ROC) and 34% died in the PICU, as a result of brain death (BD) or WLST due to serious neurologicdamage or respiratory/circulatory failure (14). A single-center study in the United States reported that BD (47%) was the most common cause of death in children who initially survived OHCA and received post-ROC care in the PICU. When patients died with WLST for poor neurologic prognosis (34%), timing of WLST varied from 1 to 29 days (15). The aim of this study was to characterize timing and cause of death in children admitted to the PICU following ROC after OHCA. We hypothesized that the majority of hospital non-survivors, died after WLST based on neuroprognostication. Materials and methods This observational cohort study was performed at the PICU of the Erasmus MC – Sophia Children’s Hospital, a tertiary-care university children’s hospital in Rotterdam, the Netherlands. We included patients less than 18 years old with documented OHCA who were admitted to the PICU between January 2012 and December 2017 after