Maayke Hunfeld

132 Chapter 4 or consciousness may be impaired by these drugs, one must wait to determine a prognosis. At our PICU, we still do not have guidelines for comatose, non-BD patients regarding neurological examination, MRI and EEG findings (except when EEG is isoelectric) and what it means for the prognosis for each individual patient, due to te lack of evidence of the prognostic value of these modalities. A recent statement from the American Heart Association recommends to consider multiple factors (neurologic examination, neuroimaging, EEG, plasma biomarkers etc.) when predicting outcome in children after CA (22). Could the decision to WLST have been made too early in some cases? Due to the retrospective design of our study, this is difficult to answer. As mentioned before, in contrast to adults, international evidence based neuroprognostication guidelines do not exist in children. The fact that no differences were found in basic, CPR event and post-ROC characteristics between the WLST-Neuro and BD group was quite reassuring and could implicate that the decision to WLST was accurate. However, we must remain cautious, since in the WLST-Neuro group, 40% were receiving a sedative or opioid infusion during the neurologic examination or the last dosage was administered within 24 hours at time of neurologic examination. Although the dosages of these sedatives or opioids were within normal ranges, we cannot exclude that they had an effect on the neurologic examination, also given the slower metabolism due to organ failure and cooling (TTM). Reasons for administering sedative drugs were to prevent the patient from shivering, to facilitate mechanical ventilation and for the treatment of seizures. Clinicians should, if the patient’s condition allows it, try to avoid the administration of sedatives and delay neuroprognostication. The possible influence of sedatives/analgesics and hypothermia on neurologic examination and EEG makes the exact differences between the BD and WLST-Neuro group difficult with presumably an overlap. If the treating clinicians had waited with withdrawal in the WLST-Neuro group (to exclude the possible influence of sedatives/ analgesics and to wait until the patient had normal body temperature), more children could presumably have been classified as BD. On the other hand, another possible consequence of decision making more than 72 hours after the CPR event, could mean less WLST due to change in neurologic examination and ancillary tests, spontaneous breathing, and recovery of multiple organ failure. This could lead to higher SHD numbers, but with more severe neurologically damaged children surviving long-term. For comatose adults post-CA the 2015 guidelines recommend to waiting to neuro- prognosticate using clinical examination) for at least 72 hours. A bilateral absence of the N20 SSEP wave 24-72 hours after CA or after rewarming is a predictor of poor outcome (25, 26). The prognostic role of early EEG in adults is becoming increasingly