Maayke Hunfeld

130 Chapter 4 15%, burst suppression (BS) 30%, BS and low voltage 5% and electrographic seizures with generalized periodic discharges 10%. Sixty-two percent had hypoxic ischemic injury on neuroimaging (MRI n=11, CT n=18, and ultrasound n=4). The time between decision making and actual WLST (of the total WLST-Neuro group) ranged from 0 to 51 days (median, 0 d; IQR, 0-1). Time between actual WLST and death ranged from 1 minute to 32 days (median, 13 min; IQR, 8-25; 8 missing). Two patients were discharged from the PICU but died in the general ward. WLST included the following: withdrawal of (non-)invasive mechanical ventilation (39/42), discontinuation of inotropic/vasoactive drugs (23/42), no escalation of existing therapy (8/42), or ECMO withdrawal (11/42). The decision to WLST was always made by the medical team. In all 42 patients, at least one pediatric intensivist was involved in the WLST decision making and in all but two, a (pediatric) neurologist. Four families (10%) initially did not accept the medical decision to withdraw life-sustaining treatment. However, after several discussions with the medical team/and or a second opinion, they all agreed. Therefore, among survivors, there were no children where the medical team decided to withdraw intensive care treatment due to poor neurologic prognosis but eventually continued treatment because parents did not agree. Discussion In this single-center observational cohort study, we found that more than half of the children who achieved ROC after OHCA died prior to hospital discharge. In the children that were admitted to PICU, the most common cause of death was WLST due to poor neurologic prognosis (WLST-Neuro 67%), whether or not combined with WLST due to refractory circulatory and/or respiratory failure or recurrent CA. In the majority of this WLST- Neuro group the decision-making took place within 72 hours after the CPR event, and in half of the patients, within 24 hours. Basic, CPR-event and post-ROC (except for number of ECMO) characteristics did not significantly differ between WLST-Neuro and BD patients. Fifty-six percent of the children who initially achieved ROC and who were subsequently admitted to the PICU died before hospital discharge. This is comparable to other studies (8, 15, 18, 19). However in our cohort, WLST after neuroprognostication was the most important cause of death (67%). In a recent study by Du Pont et al in the United States, to the best of our knowledge the only study describing timing and cause of death in the PICU after pediatric OHCA, BD was the most common cause of