Maayke Hunfeld

252 Chapter 8 such as VR and computer-based intervention programs. It is preferable to start with AAC interventions during PICU admission, with involvement of the parents, because improvement of communication reduces patients’ anxiety. Part 4. Prediction One of the goals of this PhD research was to develop an outcome prediction model in children after OHCA, especially for those who remain comatose after CA. The question was: Are we able to predict a long-term outcome within a few days after CA based on factors such as the duration of CPR, first lactate after ROC, results of neurological exam and additional tests, etc.? In the study presented in chapter 6 we showed that children with a shockable pediatric OHCA had an almost nine times higher odds of long-term good neurologic survival compared to children with a non-shockable rhythm, adjusted for confounders. The study of Meert et al., a secondary analysis of THAPCA-OH trial also showed that shockable rhythm was associated with greater 12-month survival with favorable neurobehavioral functioning, assessed with the Vineland Adaptive Behavior Scales (93). Our results might implicate that the efforts for improving outcome of pediatric OHCA should focus on early recognition and treatment of shockable OHCA at scene, and the importance of improvements in the chain of survival (e.g., bystander basic life support (BLS), public access to and use of AED and adequate emergency medical service response)(94). To proceed towards the ultimate goal of a prognostic model we need to take into account the following factors: First, outcome is determined by many factors, such pre-CA variables (SES, medical history), CA variables (witnessed CA, rhythm, bystanders BLS, quality BLS, duration of CA), and post-CA variables (post-CA care at PICU, results of ancillary tests, intensity of rehabilitation etc.). It is likely that we are not yet aware of other variables associated with a good or poor outcome, or which have not been studied in detail yet (see introduction). We do know that all these variables do influence outcome, but unfortunately evidence is often lacking and it is unknown what each variable’s predictive value is for the prognosis for each individual patient. Second, all observational research presented in this thesis was single center. Because OHCA in children is uncommon and the mortality is high (60% in our cohort), our patient samples were small. Third, in the attempt to develop a prediction model for critically ill children, one is always faced with the problem of self-fulfilling prophecy. It is unavoidable that results of tests and examinations are taken into account in the decision whether or not to continue treatment.