Maayke Hunfeld

86 Chapter 3 tests (at least EEG (continuous or serial) and MRI) in order to in order to optimize neuro-prognostication at this moment. The limitations and the lack of multimodal neuromonitoring studies create uncertainty in predicting outcome and the lack of evidence for many of the above mentioned modalities hampers the development of an evidence based guideline. In the vast majority of PICU practices strong supportive evidence is needed before therapy or diagnostics are applied or stopped. Each PICU cares for a relatively small number of patients with heterogeneous severe medical problems, which emphasises the need for international multicenter randomised controlled trials. Timing of determining neurological prognosis after paediatric CA remains challenging and evidence is lacking. In our survey it varied from within 48 h after CA (8%) up to beyond 14 days (10%) and 63% indicated that individual patient characteristics were also taken into account. For comatose adults post-CA the guidelines from 2015 recommended to wait with prognostication using clinical examination (with or without EEG) for at least 72 h. A bilateral absence of the N20 SSEP wave 24 to 72 h after CA or after rewarming is a predictor of poor outcome (32). In children, neuronal plasticity and capacity to recover function are poorly understood and ongoing brain development clouds neurodevelopmental prognostication. In addition, children with CA (often below the age of 10 years) may grow into their deficits as late as adolescence or young adulthood (more multitasking required on different domains)(38). This makes evaluation of outcome beyond hospital discharge and even far beyond the first years after the CA event mandatory. Research in children with acquired brain injury from other causes demonstrate that outcome should continuously be evaluated on different domains at key moments such as at the start of high school or college. However, it is obvious that collecting these long-term outcome data are logistically very challenging (30) . In our survey, PCPC at hospital discharge was used as outcome measure. However we must realise that PCPC is a very gross tool with only 6 scores. It does not evaluate precisely how these children are really doing. Other validated scales of neurological function after paediatric CA used in literature include the King’s Outcome Scale for Childhood (Koschi), the pediatric Stroke Outcome Measure (PSOM) and the Functional System Score (FSS). However, all scales do not precisely display the patient’s clinical condition. Recently an advisory statement has been published with a core outcome set for cardiac arrest (COSCA) clinical trials in adults (39). This set includes survival, neurological function and health-related quality of life. For children a similar set is mandatory and is under development.