Background: In the last decade there has been a growing body of literature for the use of early rehabilitation and medical therapies beyond therapeutic hypothermia (TH) to improve neurodevelopmental outcomes after pediatric cardiac arrest. We report a case after cardiac arrest and describe our institutional approach to early rehabilitation and the influence of a standardized post cardiac arrest care (PCAC) medical protocol.

Case Description:
•    11-week-old, full-term female with ventricular septal defect (VSD) associated congestive heart failure (CHF) and atrial flutter (AF). 
•    Attempted cardiac catheterization for a VSD device closure
o    Procedure was aborted after two episodes of cardiac arrest due to ventricular tachycardia (VTAC) requiring CPR and defibrillation
o    Two additional episodes of VTAC in the CTICU for an approximate cumulative downtime of 35 mins
•    Initial electroencephalogram (EEG) showed a moderate degree of encephalopathy 
•    PCAC neuroprotective protocol initiated: 
o    Hypothermia 32-33 C for 48-72 hours with slow rewarming 0.2-0.4 C/hr
o    Dexmedetomidine 0.5-1 mcg/kg/hr,
o    Erythropoietin 2000 u/kg/day x five days,
o    Magnesium > 2.0
o    Avoidance of potential neurotoxic agents (benzodiazepines, morphine, ketamine etc)
o    Amantadine after 1-2 weeks at 4 mg/kg/day (was not indicated in this case)  
o    Continuous EEG through rewarming phase
•    Early rehabilitation interventions: physical, occupational and dysphagia therapy (Figure 2)

Outcomes:
•    Glasgow Coma Scale (GCS) trajectory (Figure 1). At the time of PCAC initiation, Day 1, the GCS was 4.
•    Day 3 of PCAC, she developed deconjugated gaze, head ultrasound revealed possible thalamic bleed with worsening encephalopathy on EEG. 
•    Day 5, GCS was 11 and by Day 7 was 15. Gradual escalation of rehabilitation services (Figure 2)
•    Day 7, GCS was 15 and a head MRI showed mild bilateral restricted diffusion in the occipital lobes.
•    Day 13 patient was extubated 
•    Day 26 had VSD surgical repair (3 months of age). 
•    At 4 months of age, discharged home without supplemental nutrition or oxygen. She was assessed using the Developmental Assessment of Young Children (DAYC-2).  Her General Development Index (GDI) was found to be below average (Figure 3) and she was referred for weekly outpatient rehabilitation. 
•    At 12 months of age, she demonstrated age-appropriate neurodevelopmental skills, and the GDI was found to be average (Figure 4). 
•    At 18 months of age, she was found to have regression in her language skills however overall GDI was average (Figure 5). She was referred for speech therapy. 

Conclusion:
•    To achieve optimal outcomes, early, intensive inpatient to outpatient rehabilitation including physical, occupational and dysphagia therapy in addition to a multi-facet medical neuroprotective protocol are crucial.  
•    Beyond the initial and intermediate outcomes, long term outpatient neurodevelopmental assessments should be part of every cardiac arrest patient as evident by certain disabilities like speech delay seen in this patient. 
 
References:
Neurodevelopmental outcomes after pediatric cardiac ECMO support Chrysostomou, C et al. Frontiers in Pediatrics 2013;19:1:47
Moderate Hypothermia to Treat Perinatal Asphyxial Encephalopathy Azzopardi D et al. N ENGL J Med 361; 14 October 2009
Pediatric Post-Cardiac Arrest Care A scientific statement from the American Heart Association. Circulation. 2019;140:e194–e233