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Out-of-Hospital Cardiac Arrest-Is International Agreement on Guidelines for Limits of Treatment Possible?

Out-of-hospital cardiac arrest (OHCA) in children is usually due to a progressive disease process that ultimately results in asystole or pulseless electrical activity. This causes global cerebral hypoxic-ischemic encephalopathy (HIE) with a very high mortality and neurodevelopmental morbidity in most survivors (1, 2). Survival varies with the age of the child as shown by Atkins et al (3) with infants less than 1 year having a 3.3% survival, children 1–11 years 9.1% survival, and adolescents an 8.9% survival. The study by Nagata et al (4) utilizing data from the National Japanese Utstein Registry (2007–2010) with 2,900 children 5–17 years old showed that children with cardiac causes of OHCA have a 20% survival with a Pediatric Cerebral Performance Category of 1 or 2, as compared with noncardiac causes with a survival of 6.4%. Over the last 20 years, survival has increased due to an improvement in “at scene” treatment (bystander cardiopulmonary resuscitation, cardioversion, and rapid response paramedics) and improved treatment both on route to hospital and in the PICU. A recent population study (5) in Victoria, Australia, showed that survival to hospital discharge (SHD) increased from 9.4% in 2000 to 17.7% in 2016. Although survival is increasing, many of the survivors have acquired new morbidity, usually neurodevelopmental. Moler et al (2) reported the 12-month outcome of children after OHCA as good functional status in 42 of 250 children, mod-severe problems in 16 of 250, and profound disability in 27 of 250. The primary cause of death was brain death (BD) or withdrawal of life-sustaining treatment (WLST) in ~80% of patients. Meert et al (6) confirmed the association of these patient’s 12-month outcomes to the well-known risk factors. Du Pont-Thibodeau et al (7) reviewed their admissions to PICU with OHCA (from 2005 to 2013) and reported 105 of 191 children had SHD. Forty of the 86 who died were determined to have BD, WLST occurred in 46 children: 29 Warwick Butt, FRACP, FCICM, FELSO1–4