Maayke Hunfeld

262 Chapter 9 Summary The aim of this thesis was to investigate the current practice regarding neuro- prognostication and decision making in children after cardiac arrest (CA). Furthermore, we aimed to study the short- and long-term neurocognitive outcome in a homogeneous cohort of children after out-of-hospital cardiac arrest (OHCA), admitted to the pediatric intensive care unit (PICU) of the Erasmus MC Sophia Children’s Hospital in Rotterdam, the Netherlands, in a prospective longitudinal way, using repeated and validated measures. Chapter 2 gave an overview of the literature from the last 20 years on neuromonitoring modalities in comatose children after CA. Their potential prognostic value in predicting neurological outcome at an early stage was evaluated. Methods included neurological exam, routine electroencephalography (EEG) and continuous EEG (cEEG), transcranial Doppler (TCD), brain Magnetic Resonance Imaging (MRI ) and computed tomography (CT), plasma biomarkers, somatosensory evoked potentials (SSEP), and brainstem auditory evoked potentials (BAEP). Twenty- seven neuromonitoring studies met the inclusion criteria and were reviewed. We concluded that the precise role of neuromonitoring methods is still unclear, because no single test is 100% accurate yet. Thus, these neuromonitoring methods must be interpreted with extreme caution in the context of the patient’s individual clinical neurological status. In Chapter 3 the results of an international survey were presented. The aim of this survey was to describe current practices in European PICUs regarding neuro- prognostication in comatose children after CA and, in particular the methods used, their timing, and end-of-life decision making. The survey was sent to European Paediatric Neurology Society (EPNS) and European Society of Paediatric and Neonatal Intensive Care (ESPNIC) members. One-hundred-eight respondents, mainly pediatric intensivist and neurologists, representing 23 countries and 45 PICUs, (partly) completed the survey. Only one nation had a national guideline for neuro-prognostication after pediatric CA. 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. Definition of a poor outcome varied among the respondents. The aftermath of a futile prognosis (established from <48 hours up to > 14 days after CA) differed between respondents and countries, varying from withdrawal of life sustaining therapies (WLST) to continuation of intensive care treatment with or without restrictions.