Maayke Hunfeld

238 Chapter 8 UNRESOLVED PROBLEMS 2. Neuro-prognostication guidelines for children who remain comatose after cardiac arrest are lacking. UNRESOLVED PROBLEMS 3. There are no international criteria for brain death. Unresolved problem 2. Potential solutions 2. Neuro-prognostication guideline The answer to the lack of neuro-prognostication guidelines overlaps with the possible solution of problem 1. There is an urgent need for national and international collaboration. The first step is standardization of care within PICUs across Europe, and preferably worldwide. This generates useful data that can answer relevant research questions. The ultimate aim is to establish an international, evidence-based neuro- prognostication guideline. However, even if this would become true, the question arises whether this guideline would be adhered to worldwide. Lack of financial resources and sufficient expertise to perform and interpret ancillary tests (such as neuroimaging and electrophysiology) could stand in the way. Furthermore, the consequences of a poor outcome in the individual patient – whether or not to continue intensive care treatment and whether or not to include the parent’s whishes in this decision – will remain different among countries and even between clinicians. Regarding the situation in Europe, the European Brain Council (EBC) could play a facilitating role. The EBC is a network of key players in the ‘brain area’, with a membership encompassing scientific societies, patient organizations, professional societies and industry partners. It would be very interesting, though challenging, to study the long-term outcome of pediatric comatose CA survivors in countries where WLST is uncommon. Do these countries (i.e., Eastern and Southern Europe, central Asia) have data on the long-term outcome? How do these children function, and are there any data on mortality after PICU admission? Unresolved problem 3. Potential solution 3. Brain Death An unambiguous definition of BD worldwide would facilitate accurate decision- making.