Maayke Hunfeld

235 General discussion Part 2. Neuro-prognostication guidelines Survey Predicting the long-term outcome in children after ROC is challenging, especially in children who remain comatose after the arrest. International guidelines for neuro- prognostication are available for adults, but not for children due to lack of evidence of the predictive value of neuromonitoring modalities (26). To fill in this knowledge gap, we surveyed members of ESPNIC and EPNS (chapter 3) on current practices regarding neuro-prognostication for comatose children post-CA. Not surprisingly, we learned that practices differ between and within European PICUs. The respondents represented 23 European countries and 45 different PICUs. Only Ukraine has a national guideline for neuro-prognostication after pediatric CA, and eight PICUs (20%) have a local guideline. Regarding methods to assess neurological outcome in comatose children post-CA, neurological exam (Glasgow Coma Score (GCS) and brainstem reflexes), MRI and EEG were considered most useful, but the actual use and timing of these tests differed. The aftermath of a futile prognosis (established from <48 hours up to > 14 days) differed between respondents and countries. The majority of respondents (mainly from Western and Northern Europe) mentioned WLST, but continuation of intensive care treatment with or without restrictions was also opted for (mainly respondents from Eastern and Southern Europe). Some respondents noted that the decision whether or not to continue intensive care treatment depended on the parents’ point of view. The above findings are in line with a previous study showing that physicians from northern European countries more often decided on WLST than physicians from southern countries (27). Personal beliefs and experiences, cultural and religious aspects and local policies may play a role in these interregional European differences. Definition of a poor outcome differed among the responders. The majority considered a PCPC ≥ 4 as a poor outcome, whereas others mentioned a PCPC ≥ 3 or ≥ 5, or a difference in PCPC pre- and post-arrest of 1 or 2. This is in line with literature; in some studies a PCPC score of 1-2 is considered a good outcome, in other studies 1-3, or a difference in PCPC pre- and post-arrest < 1 or 2 (28). In our survey, we used PCPC at hospital discharge as outcome measure, because this is frequently used in studies describing outcome post-CA. It should be noted, however, that this is a very gross tool with only 6 items (see Table 1, Introduction), which does not precisely evaluate the quality of life and participation of these children. Other validated scales of neurological function after pediatric CA used in literature include the GOS (29), the King’s Outcome Scale for Childhood (Koschi) (30), the pediatric Stroke Outcome Measure (PSOM)(31), and the Functional System Score (FSS) (32). However, the scores on these scales do not precisely reflect the patient’s clinical condition. 8