Maayke Hunfeld

237 General discussion 12–24 hours with neurological exam). Second, forty percent of the children in the WLST-Neuro group had received a sedative or opioid infusion during the neurological exam, or had been administered the last dosage within 24 hours at time of neurological exam. The possible influence of sedatives/analgesics and hypothermia on neurological exam and EEG blurs the exact differences between the BD and WLST-Neuro groups, with presumably an overlap. It could well be that if the clinicians had postponed WLST in the WLST-Neuro group (to exclude the possible influence of sedatives/analgesics, potentially also taken into account the plasma levels of analgosedative agents, and to wait until the patient had normal body temperature), more children would have declared BD. Was the decision to WLST made too early in some cases? Due to the retrospective design of our study, this is difficult to answer. As mentioned before, international evidence-based neuro-prognostication guidelines are available for adults, but not for children. Nevertheless, the fact that no differences were found in basic CPR event and post-ROC characteristics between the WLST-Neuro and BD groups is quite reassuring and suggests that the WLST decisions were justified. There is still some reason for caution, however, because 40% of the children in the WLST-Neuro group had received a sedative or opioid infusion. Although the dosages of these sedatives or opioids were within normal ranges, we cannot exclude that they have had an effect on the neurological exam, also given the children’s slower metabolism due to organ failure (for example acute kidney injury, which affects the pharmacokinetics of these drugs) and cooling. Reasons for administering sedative drugs were to prevent shivering, facilitate mechanical ventilation, and treat seizures. Clinicians should, if the patient’s condition allows it, avoid as much as possible the administration of sedatives, or otherwise regularly quantify the plasma levels. 8