Maayke Hunfeld

133 Cause of death important; continuous EEG patterns at 12 hours post-CA are associated with a good outcome, whereas generalized EEG suppression and synchronous patterns with greater than or equal to 50% suppression between 6 hours and 5 days post-arrest are associated with a poor outcome (27)). Our study has several limitations. First of all, it was a retrospective single-center study. Therefore, it may not represent the post-ROC and decision-making in other hospitals in the Netherlands. Second, there was a considerable number of missing data due to the incomplete documentation of the CPR event, post-ROC care, and the decision to WLST. Additionally, as mentioned before, during 2012-2017, post-ROC care in our PICU has been slightly changed. Finally, data were extracted frommedical records. The role of parents, family, nurses or other healthcare professionals during the complex real-time decision-making process is likely not documented completely in the medical records, and therefore, may be underappreciated. Because of the uncertainty about the most accurate medical policy, not only with crucial consequences for patients and their caregivers, but also for the medical team, the hospital and health insurance companies, there is an urgent need for international collaboration with standardization of care, neurologic ancillary tests and long-term follow-up of children after CA. This way, we can get more insight in how to interpret available neuromonitoring modalities. With standardized data collection with a large patient sample size, it could finally enable us to design international guidelines that can be implemented for the individual patient. However, we must realize that even if these neuroprognostication guidelines would be available, the question rises if physicians across the world would adhere to this guideline, in view of their personal beliefs, cultural and religious aspects, different financial resources and expertise. Furthermore, an unambiguous definition of BD worldwide would facilitate accurate decision making. Besides neurologic examination including apnea testing, confirmatory tests (EEG, transcranial Doppler or CT-angiography) are required in the Netherlands to determine ‘whole’ BD (for the purpose of possible organ donation). Ancillary tests are only done when neurologic examination and apnea testing are performed reliably and completely (20). However, in The United States and United Kingdom, only neurologic examination with apnea testing is sufficient for the determination of pediatric BD. Ancillary tests can be used when parts of neurologic examination or apnea testing cannot be completed safely. Also variability exists across countries in the number of physicians required, need for repeated examination, time intervals between examination and choice of ancillary tests (28, 29). Additionally, we need to be informed about short- and long-term outcome, both physical and neuropsychologic, in OHCA survivors. Proper and precise documentation for every child is very important. Finally, recently, an advisory statement has been published with a core outcome set for cardiac arrest clinical trials in adults (30). 4