Pediatric delirium and associated risk factors: a single-center prospective observational study

Delirium in the NICU: A Point Prevalence Study

OBJECTIVES

Delirium is a well-described complication of critical illness, with occurrence rates of >25% in the PICU, and associated morbidity. Infants in the NICU are likely at risk. There have been no previous screening studies to quantify delirium rates in the neonatal population. We hypothesized that delirium was prevalent in term neonates in the NICU. In this pilot study, our objective was to estimate prevalence using a validated pediatric delirium screening tool, which has not yet been tested in NICUs.

METHODS

In this point prevalence study, all term or term-corrected infants admitted to the NICU on designated study days were screened for delirium using the Cornell Assessment of Pediatric Delirium.

RESULTS

A total of 149 infants were eligible for screening over 8 study days. A total of 147 (98.6%) were successfully screened with the Cornell Assessment of Pediatric Delirium. Overall, 22.4% (n = 33) screened positive for delirium. Delirium was more commonly detected in children on invasive mechanical ventilation (67% vs 17%, P < .01) and those with underlying neurologic disorders (64% vs 13%, P < .01). A multivariate logistic regression revealed that neurologic disability and mechanical ventilation were both independently associated with a positive delirium screen (aOR: 12.3, CI: 4.5-33.6 and aOR: 9.3, CI: 2.5-34.6, respectively).

CONCLUSIONS

Our results indicate that delirium likely occurs frequently in term-equivalent infants in the NICU. Further research is necessary to establish feasibility, validity, and interrater reliability of delirium screening in this population.

Analysis of risk factor for pediatric intensive care unit delirium in children: a case-control study

OBJECTIVE

This study aimed to survey the prevalence of delirium in the pediatric intensive care unit (PICU) and explore the associated risk factors.

DESIGN

A retrospective case-control study.

SETTING

Two PICUs within a tertiary-A general hospital.

PATIENTS

Patients aged from 1 month to 7 years who stayed in either PICU for at least 1 day were included.

METHODS

A total of 639 patients admitted to PICU of a tertiary-A general hospital from December 2018 to August 2019 were enrolled. Demographic, clinical, laboratory data and length of stay in the PICU were collected. The patients were screened twice a day with the Chinese version of Cornell Assessment of Pediatric Delirium (CAPD), and were divided into the delirium group and the non-delirium group. A risk factor analysis was conducted, with ICU pediatric delirium as primary outcome, by performing a multivariable logistic regression analysis.

RESULTS

Of the 639 patients, the prevalence of ICU pediatric delirium was 31.30%. Of the 200 children with delirium across 3703 study days, 36% children were hyperactive, 41% were hypoactive, and 23% displayed the mixed type of delirium. Univariate analysis and multivariate logistic regression analysis showed that age, PRISM IV score (OR, 2.20; 95% CI, 1.42-3.41), hypoxia (OR, 2.69; 95% CI, 1.53-4.71), metabolic dis-function (OR, 3.73; 95% CI, 2.08-6.71), duration of infection (OR, 1.22; 95% CI, 1.10-1.36), and mechanical ventilation (OR, 3.78; 95% CI, 2.25-6.35) were statistically correlated with ICU pediatric delirium. The ROC curve analysis shows the combination CRP with duration of infection has good predictive performance.

CONCLUSIONS

Age, PRISM IV score, ICU retention time, metabolic dis-function, duration of infection, hypoxia, CRP and mechanical ventilation were the independent risk factors for ICU pediatric delirium. We suggest that active preventive measures should be taken to reduce the occurrence of ICU pediatric delirium.

Assessment and Management of Delirium in the Pediatric Intensive Care Unit: A Review

Many critically ill patients suffer from delirium which is associated with significant morbidity and mortality. There is a paucity of data about the incidence, symptoms, or treatment of delirium in the pediatric intensive care unit (PICU). Risk factors for delirium are common in the PICU including central nervous system immaturity, developmental delay, mechanical ventilation, and use of anticholinergic agents, corticosteroids, vasopressors, opioids, or benzodiazepines. Hypoactive delirium is the most common subtype in pediatric patients; however, hyperactive delirium has also been reported. Various screening tools are validated in the pediatric population, with the Cornell Assessment of Pediatric Delirium (CAPD) applicable to the largest age range and able to detect signs and symptoms consistent with both hypo- and hyperactive delirium. Treatment of delirium should always include identification and reversal of the underlying etiology, reserving pharmacologic management for those patients without symptom resolution, or with significant impact to medical care. Atypical antipsychotics (olanzapine, quetiapine, and risperidone) should be used first-line in patients requiring pharmacologic treatment owing to their apparent efficacy and low incidence of reported adverse effects. The choice of atypical antipsychotic should be based on adverse effect profile, available dosage forms, and consideration of medication interactions. Intravenous haloperidol may be a potential treatment option in patients unable to tolerate oral medications and with significant symptoms. However, given the high incidence of serious adverse effects with intravenous haloperidol, routine use should be avoided. Dexmedetomidine should be used when sedation is needed and when clinically appropriate, given the positive impact on delirium. Additional well-designed trials assessing screening and treatment of PICU delirium are needed.

Performance of Cornell Assessment of Pediatric Delirium Scale in Mechanically Ventilated Children

Accuracy of delirium diagnosis in mechanically ventilated children is often limited by their varying developmental abilities. The purpose of this study was to examine the performance of the Cornell Assessment of Pediatric Delirium (CAPD) scale in these patients. This is a single-center, prospective, observational study of patients requiring sedation and mechanical ventilation for 2 days or more. CAPD scale was implemented in our unit for delirium screening. Each CAPD assessment was accompanied by a physician assessment using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria. Sensitivity analysis was performed to determine the best cut-off score in our target population. We also evaluated ways to improve the accuracy of this scale in patients with and without developmental delay. A total of 837 paired assessments were performed. Prevalence of delirium was 19%. Overall, CAPD score ≥ 9 had sensitivity of 81.8% and specificity of 44.8%. Among typically developed patients, the sensitivity and specificity were 76.7 and 65.4%, respectively, whereas specificity was only 16.5% for developmentally delayed patients. The best cut-off value for CAPD was 9 for typically developed children and 17 for those with developmental delay (sensitivity 74.4%, specificity 63.2%). Some CAPD questions do not apply to patients with sensory and neurocognitive deficits; upon excluding those questions, the best cut-off values were 5 for typically developed and 6 for developmentally delayed children. In mechanically ventilated patients with developmental delay, CAPD ≥ 9 led to a high false-positive rate. This emphasizes the need for either a different cut-off score or development of a delirium scale specific to this patient population.

Delirium in Pediatric Intensive Care Unit: Frequency, Causes, and Interventions

Delirium is an acute neurologic dysfunction characterized by fluctuating alteration in awareness, attention, and cognition and is a result of an underlying medical condition or its treatment. It is associated with increased morbidity and mortality in the intensive care setting and may lead to long-term cognitive impairment in survivors. Pediatric delirium (PD) occurs in as many as 25% of critically ill children. The pathophysiology of delirium is complex and widespread screening of this entity is lacking. To diagnose PD, a high index of suspicion should be kept in the patients who are at high risk, and appropriate screening tools should be applied, as the symptoms of PD overlap with other commonly observed neurological phenomena in pediatric intensive care unit. How to cite this article: Dhingra S, Delirium in Pediatric Intensive Care Unit: Frequency, Causes, and Interventions. Indian J Crit Care Med 2021;25(6):620-621.

Development and validation of a postoperative delirium prediction model for pediatric patients: A prospective, observational, single-center study

Postoperative delirium is a serious complication that relates to poor outcomes. A risk prediction model could help the staff screen for children at high risk for postoperative delirium. Our study aimed to establish a postoperative delirium prediction model for pediatric patients and to verify the sensitivity and specificity of this model.Data were collected from a total of 1134 children (0-16yr) after major elective surgery between February 2020 to June 2020. Demographic and clinical data were collected to explore the risk factors. Multivariate logistic regression analysis was used to develop the model, and we assessed the predictive ability of the model by using the area under the receiver operating characteristics curve (AUROC). Further data were collected from another 100 patients in October 2020 to validate the model.Prevalence of postoperative delirium in this sample was 11.1%. The model consisted of 5 predictors, namely, age, developmental delay, type of surgery, pain, and dexmedetomidine. The AUROC was 0.889 (P < .001, 95% confidence interval (CI):0.857-0.921), with sensitivity and specificity of 0.754 and 0.867, and the Youden of 0.621. The model verification results showed the sensitivity of 0.667, the specificity of 0.955.Children undergoing surgery are at risk for developing delirium during the postoperative period, young age, developmental delay, otorhinolaryngology surgery, pain, and exposure to dexmedetomidine were associated with increased odds of delirium. Our study established a postoperative delirium prediction model for pediatric patients, which may be a base for development of strategies to prevent and treat postoperative delirium in children.

Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit

Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.

Delirium in Children Undergoing Hematopoietic Cell Transplantation: A Multi-Institutional Point Prevalence Study

Introduction: Delirium occurs frequently in adults undergoing hematopoietic cell transplantation, with significant associated morbidity. Little is known about the burden of delirium in children in the peri-transplant period. This study was designed to determine delirium rates, define risk factors (demographic and treatment related), and establish feasibility of multi-institutional bedside screening for delirium in children undergoing hematopoietic cell transplant. Methods: This is a multi-institutional point prevalence study. All subjects were prospectively screened for delirium twice daily using the Cornell Assessment of Pediatric Delirium over a 10-day period. De-identified data, including basic demographics and daily characteristics, were extracted from the electronic medical record. Results: Eleven North American institutions were included, 106 children were enrolled, and 883 hospital days were captured. Delirium screening was successfully completed on more than 98% of the study days. Forty-eight children (45%) developed delirium over the course of the 10-day study. Children were diagnosed with delirium on 161/883 study days, for an overall delirium rate of 18% per day. Higher delirium rates were noted in children <5 years old (aOR 0.41 for children over 5 years), and in association with specific medications (melatonin, steroids, and tacrolimus). Conclusion: Delirium was a frequent occurrence in our study cohort, with identifiable risk factors. Delirium screening is highly feasible in the pediatric hematopoietic cell transplant patient population. A large-scale prospective longitudinal study following children throughout their transplant course is urgently needed to fully describe the epidemiology of pediatric delirium, explore the effects of delirium on patient outcomes, and establish guidelines to prevent and treat delirium in the peri-transplant period.

Brain Injury in Extracorporeal Membrane Oxygenation: A Multidisciplinary Approach

Extracorporeal membrane oxygenation (ECMO) represents an established technique to provide temporary cardiac and/or pulmonary support. ECMO, in veno-venous, veno-arterial or in extracorporeal carbon dioxide removal modality, is associated with a high rate of brain injuries. These complications have been reported in 7 to 15% of adults and 20% of neonates, and are associated with poor survival. Thromboembolic events, loss of cerebral autoregulation, alteration of the blood-brain barrier, and hemorrhage related to anticoagulation represent the main causes of severe brain injury during ECMO. The most frequent forms of acute neurological injuries in ECMO patients are intracranial hemorrhage (2-21%), ischemic stroke (2-10%), seizures (2-6%), and hypoxic-ischemic brain injury; brain death may also occur in this population. Other frequent complications are infarction (1-8%) and cerebral edema (2-10%), as well as neuropsychological and psychiatric sequelae, including posttraumatic stress disorder.

An observational study of hypoactive delirium in the post-anesthesia recovery unit of a pediatric hospital

BACKGROUND

Hypoactive delirium is present when an awake child is unaware of his or her surroundings, is unable to focus attention, and appears quiet and withdrawn. This condition has been well-described in the intensive care setting but has not been extensively studied in the immediate post-anesthetic period.

AIM

To determine if hypoactive emergence delirium occurs in the recovery unit of a pediatric hospital, and if so, what proportion of emergence delirium is hypoactive in nature.

METHODS

We conducted an observational study using the Cornell Assessment of Pediatric Delirium in a cohort of 4424 children recovered at a tertiary pediatric hospital. The incidence of emergence delirium detected using the Pediatric Anesthetic Emergence Delirium (PAED) scale was also recorded for comparison.

RESULTS

There were 74 cases of emergence delirium detected during the study period using the Cornell Assessment of Pediatric Delirium (1.7%). Only 57 cases were detected using the Pediatric Anesthetic Emergence Delirium scale. The additional 17 cases detected using the Cornell Assessment of Pediatric Dlirium represent cases of hypoactive delirium. In this cohort of pediatric patients, 23% of all cases of emergence delirium were hypoactive in nature.

CONCLUSION

The significance of hypoactive delirium in this population is unknown; however, previous studies have shown that emergence delirium can result in post-operative behavior changes and may affect compliance with future episodes of care. However, hypoactive delirium is often missed without active screening. The prevalence detected in this study therefore suggests hypoactive delirium warrants further investigation.

Evaluation of QTc Interval Effects of Antipsychotic Medications for Intensive Care Unit Delirium in Pediatric Patients

OBJECTIVE

Intensive care unit delirium is an increasingly recognized problem in pediatric patients. Controversy exists regarding the safety and efficacy of antipsychotic medications for this indication. The objective of this study was to determine the incidence of and risk factors for QTc interval prolongation in pediatric patients treated with antipsychotics for ICU delirium.

METHODS

Retrospective chart review of pediatric patients admitted to the pediatric ICU or pediatric cardiac ICU and diagnosed with ICU delirium between October 1, 2014, and October 31, 2015. Patients were included if they received at least 1 dose of an antipsychotic for the treatment of delirium after a positive screen using the Cornell Assessment of Pediatric Delirium scoring tool.

RESULTS

For the 26 patients included, the median change in QTc interval on treatment was -4 msecs. Two patients (8%) had QTc interval prolongation while on antipsychotic therapy. No risk factors were identified in these 2 patients that put them at increased risk for QTc interval prolongation.

CONCLUSIONS

The incidence of QTc interval prolongation in pediatric patients who were treated with antipsychotics for ICU delirium was low. There is need for future research to determine which pediatric patients are at risk for QTc interval prolongation when antipsychotic medications are used for the treatment of ICU delirium.

Frequency and Causes of Delirium in Pediatric Intensive Care Unit: A Prospective Observational Study

Background

The number of studies evaluating delirium and its frequency in critically ill infants, children, and adolescents is increasing day by day. The primary objective of this study was to evaluate all patients hospitalized in our pediatric intensive care unit (PICU) in terms of pediatric delirium, to determine the frequency and risk factors of pediatric delirium.

Patients and methods

The patients included in this study had been hospitalized in the PICU between November 1, 2018, and August 31, 2019, and were followed up for more than 48 hours.

Results

Delirium was detected in 14 patients (9.9%) through regular evaluations. The Pediatric Index of Mortality 2 (PIM2) scores and the length of stay in the PICU were higher in patients with delirium (p = 0.03 and p = 0.01, respectively). The use of respiratory support, sedation-analgesia, vasoactive and corticosteroid treatments, and physical restraints were higher in patients with delirium and were statistically significant (p <0.05). Following admission to the PICU, psychosocial interventions were implemented for 76.1% of the whole cohort. Delirium developed in only five (4.5%) of the 108 patients who underwent psychosocial interventions, while it was detected in nine (26.5%) of the 34 patients who did not receive psychosocial interventions (p = 0.001). The psychosocial intervention was associated with a lower likelihood of delirium (odds ratio [OR], 0.237; p = 0.044). An increasing number of days in the PICU was independently associated with increasing odds of delirium (OR, 1.095; p = 0.037 for each day).

Conclusions

We observed that the risk factors associated with delirium were similar to previous studies. Additionally, psychosocial intervention before delirium symptoms developed was associated with a lower risk of developing delirium. However, multicenter randomized controlled trials are needed on this subject.

How to cite this article

Yontem A, Yildizdas D, Horoz OO, et al. Frequency and Causes of Delirium in Pediatric Intensive Care Unit: A Prospective Observational Study. Indian J Crit Care Med 2021;25(6):715-719.

The LiberAction Project: Implementation of a Pediatric Liberation Bundle to Screen Delirium, Reduce Benzodiazepine Sedation, and Provide Early Mobilization in a Human Resource-Limited Pediatric Intensive Care Unit

Background: Delirium, bed immobilization, and heavy sedation are among the major contributors of pediatric post-intensive care syndrome. Recently, the Society of Critical Care Medicine has proposed the implementation of daily interventions to minimize the incidence of these morbidities and optimize children functional outcomes and quality of life. Unfortunately, these interventions require important clinical and economical efforts which prevent their use in many pediatric intensive care units (PICU). Aim: First, to evaluate the feasibility and safety of a PICU bundle implementation prioritizing delirium screening and treatment, early mobilization (<72 h from PICU admission) and benzodiazepine-limited sedation in a human resource-limited PICU. Second, to evaluate the incidence of delirium and describe the early mobilization practices and sedative drugs used during the pre- and post-implementation periods. Third, to describe the barriers and adverse events encountered during early mobilization. Methods: This observational study was structured in a pre- (15th November 2019-30th June 2020) and post-implementation period (1st July 2020-31st December 2020). All patients admitted in PICU for more than 72 h during the pre and post-implementation period were included in the study. Patients were excluded if early mobilization was contraindicated. During the pre-implementation period, a rehabilitation program including delirium screening and treatment, early mobilization and benzodiazepine-sparing sedation guidelines was developed and all PICU staff trained. During the post-implementation period, delirium screening with the Connell Assessment of Pediatric Delirium scale was implemented at bedside. Early mobilization was performed using a structured tiered protocol and a new sedation protocol, limiting the use of benzodiazepine, was adopted. Results: Two hundred and twenty-five children were enrolled in the study, 137 in the pre-implementation period and 88 in the post-implementation period. Adherence to delirium screening, benzodiazepine-limited sedation and early mobilization was 90.9, 81.1, and 70.4%, respectively. Incidence of delirium was 23% in the post-implementation period. The median cumulative dose of benzodiazepines corrected for the total number of sedation days (mg/kg/sedation days) was significantly lower in the post-implementation period compared with the pre-implementation period: [0.83 (IQR: 0.53-1.31) vs. 0.74 (IQR: 0.55-1.16), p = 0.0001]. The median cumulative doses of fentanyl, remifentanil, and morphine corrected for the total number of sedation days were lower in the post-implementation period, but these differences were not significant. The median number of mobilizations per patient and the duration of each mobilization significantly increased in the post-implementation period [3.00 (IQR: 2.0-4.0) vs. 7.00 (IQR: 3.0-12.0); p = 0.004 and 4 min (IQR: 3.50-4.50) vs. 5.50 min (IQR: 5.25-6.5); p < 0.0001, respectively]. Barriers to early mobilization were: disease severity and bed rest orders (55%), lack of physicians' order (20%), lack of human resources (20%), and lack of adequate devices for patient mobilization (5%). No adverse events related to early mobilization were reported in both periods. Duration of mechanical ventilation and PICU length of stay was significantly lower in the post-implementation period as well as the occurrence of iatrogenic withdrawal syndrome. Conclusion: This study showed that the implementation of a PICU liberation bundle prioritizing delirium screening and treatment, benzodiazepine-limited sedation and early mobilization was feasible and safe even in a human resource-limited PICU. Further pediatric studies are needed to evaluate the clinical impact of delirium, benzodiazepine-limited sedation and early mobilization protocols on patients' long-term functional outcomes and on hospital finances.

A systematic review of the impact of intensive care admissions on post discharge cognition in children

Understanding how hospitalization affects cognitive development is crucial to safeguard children's cognition; however, there is little research evaluating the associations between NICU or PICU hospitalization and survivors' cognition. The objective of this study is to identify and characterize the associations between a neonatal or pediatric ICU hospitalization and the short- and long-term cognition of survivors. The databases Cochrane Library, Medline, EBSCO, Embase, and Google Scholar and the journals JAMA Pediatrics, Journal of Pediatrics, Pediatrics, Archives of Disease in Childhood, Academic Pediatrics, Pediatric Critical Care Medicine and Child Development were searched until April 2021. Retrieved article references were analyzed. Included articles investigated cognition as an outcome of ICU hospitalization in non-preterm neonatal or pediatric patients. Case studies and studies analyzing diagnosis or treatment interventions were excluded. Four prospective cohort or case-control studies and two retrospective cohort studies were included, totaling 2172 neonatal and 42368 pediatric patients. Quality assessment using the BMJ Criteria and Cochrane Collaboration's Risk-of-Bias tool displayed good results. Significant negative associations were found between neonatal cognition and length-of-ICU-stay at 9- (p<0.001) and 24 months (p<0.01), and between pediatric cognition and length-of-ICU-stay at discharge (p<0.001). Additional weeks on the neonatal ICU increased odds of impairment at 9- (OR 1.08, 95%CI 1.034-1.112) and 24 months (OR 1.11, 95%CI 1.065-1.165).Conclusion: There is a significant negative correlation between NICU and PICU hospitalization and the short- and long-term cognitive status. Future research must identify patient- and hospital-related risk factors and develop management strategies. What is Known: • Cognitive development relies on the presence of stimulating factors and absence of risk factors, and is hypothesized to be directly and indirectly affected by hospitalization in the short and long term. • No research examines the relation between survivor cognition post-discharge of a general pediatric hospitalization, and scarcely more of a neonatal or pediatric intensive care hospitalization. What is New: • NICU and PICU hospitalization is independent risk factors for survivor impaired cognition in the short and in the long term with a dose-response effect. High risk patients for cognitive impairment should be identified and appropriately followed-up. • Patients with an ICU hospitalization of over 2.5 days and two or more of the following factors should be considered high risk: increased mortality risk, invasive interventions, neurological or oncological diagnosis, postnatal complications or decreased maternal mental health status.

Evaluation of Pediatric Delirium Awareness and Management in Pediatric Intensive Care Units in Turkey

Delirium has been associated with prolonged pediatric intensive care unit (PICU) stay and mechanical ventilation times as well as high hospital costs and mortality rates. This work aimed to examine pediatric delirium awareness and delirium management in Turkey. A total of 19 physicians responsible for their respective PICUs completed the survey. Most of the units (57.9%) did not use any assessment tool. Varying measures were applied in different units to reduce the prevalence of delirium. The number of units that continuously measured noise was very low (15.8%). Eye mask and earpiece usage rates were also very low. In pharmacological treatment, haloperidol, dexmedetomidine, benzodiazepines, and atypical antipsychotics were the most preferred options. Some units have reached a sufficient level of pediatric delirium awareness and management. However, insufficiencies in delirium awareness and management remain in general.

Pediatric delirium: epidemiology and outcomes

PURPOSE OF REVIEW

Delirium is a frequent complication of serious medical illness in children. The purpose of this review is to highlight recent data on the epidemiology and outcomes related to pediatric delirium, and discuss prevention strategies.

RECENT FINDINGS

Delirium rates in the pediatric ICU are greater than 25%. Delirium in children is associated with prolonged mechanical ventilation and hospital length of stay, increased costs, and excess mortality. Pediatric delirium may affect postdischarge cognition and quality of life. Recent initiatives targeting universal screening, early mobilization, and minimization of benzodiazepine-based sedation have shown reduction in delirium prevalence.

SUMMARY

Widespread screening is needed in critically ill children to detect and mitigate delirium. The identification of modifiable risk factors has provided an opportunity for delirium prevention. Large-scale longitudinal studies are needed to investigate the long-term sequelae of delirium in children.

Delirium

Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.

Delirio en niños críticamente enfermos

El delirio en pacientes críticos es una condición médica que afecta tanto a adultos como a niños; en ambas poblaciones implica graves complicaciones como estancia hospitalaria prolongada, alto riesgo de muerte y deterioro cognitivo a largo plazo, así como mayores costos económicos en cuanto a la prestación de servicios de salud. La principal dificultad de esta condición en la población pediátrica es su adecuado reconocimiento, ya que puede presentarse en edades muy tempranas, incluso en niños lactantes, cuando sus signos y síntomas pueden confundirse o superponerse con otras patologías, tales como el síndrome de abstinencia. En consecuencia, en estos casos el uso de herramientas diagnósticas puede ser una labor compleja que implica múltiples dificultades.Antes de 2011 no había muchos estudios que abordaran la evaluación del delirio en niños. Sin embargo, ese mismo año se estableció la primera escala desarrollada específicamente para el monitoreo de pacientes en unidades de cuidado intensivo pediátrico, lo que llevó a un aumento significativos del número de casos de delirio en niños menores de 5 años críticamente enfermos; esta situación hizo que los pediatras se interesaran más en estudiar esta importante patología.La presente reflexión, basada en una revisión de la literatura, busca actualizar el amplio espectro fisiopatológico del delirio en niños críticamente enfermos y, de esta forma, mejorar su tamizaje, diagnóstico e intervenciones terapéuticas tempranas en todas las edades pediátricas, incluso en menores de 5 años.

Practice Variability in Screening and Treating Pediatric Critical Illness Delirium: Survey

The best practice in pediatric delirium (PD) screening and treatment is still unknown. Current recommendations come from small studies and adult data. In this article, we surveyed the Pediatric Critical Care Medicine fellowship directors on PD screening and treatment practices in their centers. We reported high variability in the screening and treatment practices for PD in large academic medical centers in the United States. The Cornell Assessment of Pediatric Delirium tool is the most commonly used tool for screening, and quetiapine is the most commonly used pharmacologic agent. A national guideline on PD screening, prevention, and treatment is needed to standardize practice and provide guidance.

Opioid use is Associated with ICU Delirium in Mechanically Ventilated Children

Introduction

Pediatric delirium is a significant problem when encounterd in an intensive care unit (ICU). The pathophysiology of pediatric delirium is complex and the etiology is typically multifactorial. Even though various risk factors associated with pediatric delirium in a pediatric ICU have been identified, there is still a paucity of literature associated with the condition, especially in extremely critically ill children, sedated and mechanically ventilated.

Aim of the study

To identify factors associated with delirium in mechanically ventilated children in an ICU.

Material and Methods

This is a single-center study conducted at a tertiary care pediatric ICU. Patients admitted to the pediatric ICU requiring sedation and mechanical ventilation for >48 hours were included. Cornell Assessment of Pediatric Delirium scale was used to screen patients with delirium. Baseline demographic and clinical factors as well as daily and cumulative doses of medications were compared between patients with and without delirium. Firth’s penalized maximum likelihood logistic regression was used on a priori set of variables to examine the association of potential factors with delirium. Two regression models were created to assess the effect of daily medication doses (Model 1) as well as cumulative medication doses (Model 2) of opioids and benzodiazepines.

Results

95 patient visits met the inclusion criteria. 19 patients (20%) were diagnosed with delirium. Older patients (>12 years) had higher odds of developing delirium. Every 1mg/kg/day increase in daily doses of opioids was associated with an increased risk of delirium (OR=1.977, p=0.017). Likewise, 1 mg/kg increase in the cumulative opioid dose was associated with a higher odds of developing delirium (OR=1.035, p=0.022). Duration of mechanical ventilation was associated with the development of delirium in Model 1 (p=0.007).

Conclusions

Age, daily and cumulative opioid dosage and the duration of mechanical ventilation are associated with the development of delirium in mechanically ventilated children.

Incidence and risk factors for acute delirium in older patients with a hip fracture: A retrospective cohort study

This retrospective cohort study aimed to determine the incidence, and preoperative, intraoperative, and postoperative risk factors for postoperative delirium in older patients undergoing surgical fixation of a hip fracture. Electronic medical records were examined of 260 patients who underwent a surgical fixation of a hip fracture between June 2017 and October 2018 at a university-affiliated tertiary care hospital in Victoria, Australia. Demographic, clinical, and perioperative data were examined for potential risk factors for postoperative delirium. Of the 260 patients, 63 patients (24.2%) developed delirium postoperatively. Univariate logistic regression analysis indicated that advanced age, comorbidity, cognitive impairment, dementia, American Society of Anesthesiologists score, and antipsychotic usage were significant risk factors for delirium, while doses of paracetamol, fentanyl, and diazepam showed complex associations. Multivariate logistic regression analysis determined comorbidity and cognitive impairment as independent risk factors for the development of delirium. This study demonstrates the importance of evaluation of medications prescribed in the perioperative period as modifiable risk factors, in order to identify patients at high risk of delirium and enable targeted monitoring and treatment during patients' hospitalization.

State of the science in pediatric ICU delirium: An integrative review

Delirium is a complication of critical illness associated with poor outcomes. Although widely studied in adults, comparatively little is understood about delirium in pediatric intensive care units (ICUs). The purpose of this integrative review is to determine the extent and nature of current evidence, identify gaps in the literature, and outline future areas for investigation of pediatric ICU delirium. Eligible articles included research reports of delirium in pediatric ICU samples published in English since 2009. After an extensive literature search and consideration for inclusion/exclusion criteria, 22 articles were chosen for review. Delirium was highly prevalent in the ICU. Delirium episodes developed early in hospitalization, lasted several days, and consisted of hypoactive or mixed motor subtypes. Frequently identified independent risk factors included young age, developmental delay, mechanical ventilation, and benzodiazepine exposure. Pediatric delirium was independently associated with increased length of stay, costs, and mortality. The long-term cognitive, psychological, and functional morbidities associated with pediatric delirium remain largely unknown. Few researchers have implemented interventions to prevent or manage delirium. There was little evidence for the efficacy or safety of pharmacological management. Multicomponent delirium bundles may significantly decrease delirium incidence. Key quality issues among studies included variation in delirium screening, low levels of evidence (i.e., observational studies), and limited ability to determine intervention efficacy in quasi-experimental designs. Although the quantity and quality of pediatric delirium research has rapidly increased, further studies are needed to understand the long-term effects of pediatric delirium and determine the efficacy and safety of interventions for prevention and management.

The Validity and Reliability of the Japanese Version of the Cornell Assessment of Pediatric Delirium

OBJECTIVES

To examine validity and reliability of the Japanese version of the Cornell Assessment of Pediatric Delirium.

DESIGN

Prospective double-blinded observational cohort study.

SETTING

Eight-bed mixed PICU (post-surgical and internal medicine) from May 2017 to June 2018.

PATIENTS

All children between the ages of 0-13 years who were admitted to the PICU for at least 24 hours were eligible for inclusion, as long as the child was arousable to verbal stimulation.

INTERVENTIONS

Two nurses simultaneously and independently assessed each patient for pediatric delirium with the Japanese version of the Cornell Assessment of Pediatric Delirium; this was compared to the gold standard of psychiatric diagnosis based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition standards.

MEASUREMENTS AND MAIN RESULTS

Forty-one children were enrolled and 92 assessments (ranging from one to four per subject) were completed. Congenital heart disease patients accounted for 73 enrollees (79%). Forty-three percent of observations were performed in children on invasive mechanical ventilation. Pediatric delirium prevalence (as determined by psychiatric diagnosis) was 53%. The Japanese version of the Cornell Assessment of Pediatric Delirium demonstrated an optimal scoring cutpoint of 9. Overall, area under the curve was 92%, sensitivity 90% (95% CI, 79-97%), specificity 88% (95% CI, 75-96%), positive predictive value of 90% (95% CI, 79-97%), negative predictive value of 91% (95% CI, 80-97%), and a Cohen's κ of 0.89 (95% CI, 0.8-0.98). In children on invasive mechanical ventilation, the Japanese version of the Cornell Assessment of Pediatric Delirium maintained an area under the curve 87%, sensitivity 97%, and specificity 64%.

CONCLUSIONS

The Japanese version of the Cornell Assessment of Pediatric Delirium is a valid and reliable tool for use in Japanese PICUs. This will allow for detection of delirium in real-time and may lead to better identification of the population and risk factors for appropriate management and therapeutic and preventative interventions.

Delirium and Developmental Disability: Improving Specificity of a Pediatric Delirium Screen

OBJECTIVES

Children with developmental disabilities are at high risk for developing delirium when critically ill. However, existing pediatric delirium screening tools were designed for children with typical development. The objective of this study was to improve the specificity of the Cornell Assessment for Pediatric Delirium, to allow for accurate detection of delirium in developmentally delayed children admitted to the PICU. We hypothesized that the Cornell Assessment for Pediatric Delirium, when combined with fluctuation in level of awareness as measured by the Richmond Agitation-Sedation Scale, would be valid and reliable for the diagnosis of delirium in developmentally delayed children.

DESIGN

Prospective observational double-blind cohort study.

SETTING

Tertiary care academic PICU.

PATIENTS

Children with moderate to severe developmental delay.

INTERVENTIONS

Each child was evaluated by the bedside nurse with the Cornell Assessment for Pediatric Delirium once every 12 hours and the Richmond Agitation-Sedation Scale every 4 hours. Cornell Assessment for Pediatric Delirium (score ≥ 9) + Richmond Agitation-Sedation Scale fluctuation (change in Richmond Agitation-Sedation Scale score of at least 2 points during a 24-hr period) was compared with the criterion standard psychiatric evaluation for diagnosis of delirium.

MEASUREMENTS AND MAIN RESULTS

Forty children participated; 94 independent paired assessments were completed. The psychiatrists' diagnostic evaluations were compared with the detection of delirium by the Cornell Assessment for Pediatric Delirium and Richmond Agitation-Sedation Scale. Specificity of the Cornell Assessment for Pediatric Delirium + Richmond Agitation-Sedation Scale fluctuation was 97% (CI, 90-100%), positive predictive value of Cornell Assessment for Pediatric Delirium + Richmond Agitation-Sedation Scale fluctuation was 89% (CI, 65-99%); and negative predictive value remained acceptable at 87% (95% CI, 77-94%). In addition, to confirm interrater reliability of the criterion standard, 11 assessments were performed by two or more psychiatrists in a blinded fashion. There was perfect agreement (κ = 1), indicating reliability in psychiatric diagnosis of delirium in developmentally delayed children.

CONCLUSION

When used in conjunction with Richmond Agitation-Sedation Scale score fluctuation, the Cornell Assessment for Pediatric Delirium is a sensitive and specific tool for the detection of delirium in children with developmental delay. This allows for reliable delirium screening in this hard-to-assess population.

Intensive Care Unit Admission Following Surgery for Pediatric Spinal Deformity: An Analysis of the ACS-NSQIP Pediatric Spinal Fusion Procedure Targeted Dataset

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To understand which patient and surgical factors are predictive of an increased odds of undergoing an admission and a prolonged stay >2 days in an intensive care unit (ICU) following corrective surgery for pediatric deformity.

METHODS

The 2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric Spinal Fusion Procedure Targeted database records, merged with original 2016 ACS-NSQIP Pediatric file variables, were used for this study. Univariate and multivariate analyses were used to identify independent risk factors associated with admission, as well as a prolonged length of stay in the ICU following surgery.

RESULTS

A total of 1398 (39.5%) patients required an ICU admission following the procedure-out of whom 416 (29.8%) stayed for more than 2 days. Following adjusted analysis, patient and surgical factors independently associated with an ICU admission were black/African American versus white race, anterior fusion, combined fusion, nonidiopathic scoliosis, preoperative ventilator dependence, asthma, having structural pulmonary abnormality, developmental delay, having a neuromuscular disorder, requiring nutritional support and a total operative time >270 minutes. The only significant factors associated with a prolonged length of ICU stay >2 days were preoperative ventilator dependence, nutritional support requirement, and undergoing anterior or combined fusion.

CONCLUSIONS

This study is the first of its kind to identify significant patient- and procedure-level factors associated with an ICU admission, and also explores predictors for a prolonged stay in the ICU. Surgeons can use this data to preoperatively counsel families and ensure postoperative course of care is appropriately planned ahead of time.

Delirium in hospitalised children

Delirium is a syndrome characterised by an acute and fluctuating alteration in cognition and awareness. It occurs frequently in children with serious medical illness, and is associated with adverse outcomes such as increased length of hospital stay, duration of mechanical ventilation, hospital costs, and mortality. Delirium-especially the hypoactive subtype-is often overlooked by paediatric practitioners, but can be reduced by mitigating risks and effectively managed if detected early. Non-modifiable risk factors of delirium include young age (age <2 years), cognitive or neurological disabilities, need for invasive mechanical ventilation, severe underlying illness and pre-existing chronic conditions, and poor nutritional status. Routine bedside screening using validated tools can enable early detection of delirium. To reduce delirium in hospitalised children, health-care providers should optimise the hospital environment (eg, by reducing sleep disruption and keeping the child stimulated during the day), improve pain management, and decrease sedation (particularly use of benzodiazepines).

Delirium in a Tertiary PICU: Risk Factors and Outcomes

OBJECTIVES

To determine risk factors and outcomes associated with delirium in PICU patients.

DESIGN

Retrospective cohort study.

SETTING

Thirty-two-bed PICU within a tertiary care academic children's hospital.

PATIENTS

All children admitted to the PICU March 1, 2014, to October 1, 2016, with at least one Cornell Assessment of Pediatric Delirium score (n = 2,446).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Cornell Assessment of Pediatric Delirium score was performed twice daily as standard of care. We characterized delirium as: 1) presence of greater than or equal to 1 positive score (Cornell Assessment of Pediatric Delirium ≥ 9) and 2) number of days with a positive score. We built multivariable logistic and linear regression models using electronic medical records data. Many patients (n = 1,538; 63%) had a short length of stay (< 48 hr). Compared with patients with length of stay greater than or equal to 48 hours, fewer experienced delirium (30% vs 69%; p < 0.0001). Among 908 patients with length of stay greater than or equal to 48 hours, presence of delirium was independently associated with age less than 2 years old, baseline cognitive dysfunction, primary diagnosis, and duration of mechanical ventilation. Benzodiazepines demonstrated a dose-response effect (odds ratio for presence of delirium, 1.8 [p = 0.03], 3.4 [p < 0.001], and 9.7 [p = 0.005] for < 25th percentile, 25-75th percentile, and > 75th percentile of total dose, vs no exposure). In terms of outcomes, presence of delirium was independently associated with increased ICU length of stay (p < 0.001), whereas days of delirium were independently associated with decline in cognitive function from ICU admission to discharge (odds ratio, 1.06; p < 0.001), increased ICU (p < 0.001), and hospital length of stay (p < 0.001). Neither delirium presence nor total days were independently associated with mortality.

CONCLUSIONS

Delirium is common in the PICU, particularly among patients with length of stay greater than or equal to 48 hours. It is independently associated with patient characteristics and PICU exposures, including benzodiazepines. The role of delirium as an independent causal factor in patient outcome requires further investigation.

Management of Hyperactive Delirium in the Pediatric Intensive Care Unit: Case Series of Three Young Children

Children in the intensive care unit (ICU) are at high risk of developing delirium, given their underlying disease processes, the adverse effects of treatments and medications, and the stressful, abnormal environment. If prevention and nonpharmacologic measures to treat delirium are unsuccessful, atypical antipsychotics are considered, although they are not approved by Food and Drug Administration for the treatment of pediatric delirium and could have significant adverse side effects. This case report presents three pediatric patients with hyperactive ICU delirium that risked life-threating complications who were successfully treated with short courses of atypical antipsychotic medications.

A Clinical Pathway to Standardize Care of Children With Delirium in Pediatric Inpatient Settings

Pediatric delirium is an important comorbidity of medical illness in inpatient pediatric care that has lacked a consistent approach for detection and management. A clinical pathway (CP) was developed to address this need. Pediatric delirium contributes significantly to morbidity, mortality, and costs of inpatient care of medically ill children and adolescents. Screening for delirium in hospital settings with validated tools is feasible and effective in reducing delirium and improving outcomes; however, multidisciplinary coordination is required for implementation. The workgroup, composed of international experts in child and adolescent consultation psychiatry, reviewed the literature and developed a flowchart for feasible screening and management of pediatric delirium. When evidence was lacking, expert consensus was reached; stakeholder feedback was included to create the final pathway. A CP expert collaborated with the workgroup. Two sequential CPs were created: (1) "Prevention and Identification of Pediatric Delirium" emphasizes the need for systematic preventive measures and screening, and (2) "Diagnosis and Management of Pediatric Delirium" recommends an urgent and ongoing search for the underlying causes to reverse the syndrome while providing symptomatic management focused on comfort and safety. Detailed accompanying documents explain the supporting literature and the rationale for recommendations and provide resources such as screening tools and implementation guides. Additionally, the role of the child and adolescent consultation-liaison psychiatrist as a resource for collaborative care of patients with delirium is discussed.

Not just to survive but to thrive: delirium in the pediatric cardiac ICU

PURPOSE OF REVIEW

Pediatric delirium has recently been recognized to occur frequently in the pediatric general and cardiac ICU. The purpose of this review is to highlight recent data on the prevalence, prevention, and management of this condition.

RECENT FINDINGS

Pediatric delirium occurs in the pediatric cardiac ICU (PCICU) in as many as 67% of patients. Validated screening tools are now available to assist clinicians in the diagnosis of this condition. Research has shown a growing relationship between benzodiazepines, mainstays in the realm of sedation, and delirium. The full spectrum of risk factors has yet to be clearly elucidated. After normalization of the ICU environment, antipsychotics are infrequently required for treatment. While pediatric delirium has been associated with increased length of stay and cost, long-term morbidities are unknown at this time.

SUMMARY

Application of bundles to normalize the PCICU environment may lead to decreased incidence of pediatric delirium. Multiinstitutional studies are indicated to further delineate optimal bundles, stratify treatment strategies, and investigate long-term morbidity in pediatric delirium.

Sedation strategies in children with pediatric acute respiratory distress syndrome (PARDS)

In this review, we discuss the changing landscape of sedation in mechanically ventilated children with pediatric acute respiratory distress syndrome (PARDS). While previous approaches advocated for early and deep sedation with benzodiazepines, emerging literature has highlighted the benefits of light sedation and use of non-benzodiazepine sedating agents, such as dexmedetomidine. Recent studies have emphasized the importance of monitoring multiple factors including, but not limited to, sedation depth, analgesia efficacy, opiate withdrawal, and development of delirium. Through this approach, we hope to improve PARDS outcomes. Overall, more research is needed to further our understanding of the best sedation strategies in children with PARDS.

Benzodiazepines and Development of Delirium in Critically Ill Children: Estimating the Causal Effect

OBJECTIVES

Benzodiazepine use may be associated with delirium in critically ill children. However, benzodiazepines remain the first-line sedative choice in PICUs. Objectives were to determine the temporal relationship between administration of benzodiazepines and delirium development, control for time-varying covariates such as mechanical ventilation and opiates, and evaluate the association between dosage of benzodiazepines and subsequent delirium.

DESIGN

Retrospective observational study.

SETTING

Academic tertiary care PICU.

PATIENTS

All consecutive admissions from January 2015 to June 2015.

INTERVENTIONS

Retrospective assessment of benzodiazepine exposure in a population that had been prospectively screened for delirium.

MEASUREMENTS AND MAIN RESULTS

All subjects were prospectively screened for delirium throughout their stay, using the Cornell Assessment for Pediatric Delirium, with daily cognitive status assigned as follows: delirium, coma, or normal. Multivariable mixed effects modeling determined predictors of delirium overall, followed by subgroup analysis to assess effect of benzodiazepines on subsequent development of delirium. Marginal structural modeling was used to create a pseudorandomized sample and control for time-dependent variables, obtaining an unbiased estimate of the relationship between benzodiazepines and next day delirium. The cumulative daily dosage of benzodiazepines was calculated to test for a dose-response relationship. Benzodiazepines were strongly associated with transition from normal cognitive status to delirium, more than quadrupling delirium rates (odds ratio, 4.4; CI, 1.7-11.1; p < 0.002). Marginal structural modeling demonstrated odds ratio 3.3 (CI, 1.4-7.8), after controlling for time-dependent confounding of cognitive status, mechanical ventilation, and opiates. With every one log increase in benzodiazepine dosage administered, there was a 43% increase in risk for delirium development.

CONCLUSIONS

Benzodiazepines are an independent and modifiable risk factor for development of delirium in critically ill children, even after carefully controlling for time-dependent covariates, with a dose-response effect. This temporal relationship suggests causality between benzodiazepine exposure and pediatric delirium and supports limiting the use of benzodiazepines in critically ill children.

The Cornell Assessment of Pediatric Delirium: Translation and inter-rater reliability in a Danish pediatric intensive care unit

BACKGROUND

Delirium is a serious medical problem and recognized as a common syndrome in critically ill children. Without routine screening, delirium diagnosis is often missed by the medical providers. Internationally, there are tools to assess pediatric delirium (PD), but none currently available in Danish. The aim of this project was to translate the Cornell Assessment of Pediatric Delirium (CAPD) into Danish and determine its feasibility and reliability in a Danish clinical setting.

METHODS

Translation was done in accordance with WHO guidelines. Linguistic and cultural differences were reconciled with the original developers of the instrument. The Danish CAPD was then tested in a prospective cohort of children admitted to a single pediatric intensive care unit at a university hospital in Denmark. Inter-rater reliability was determined using weighted Kappa statistics.

RESULTS

Thirty children were enrolled, and 92 delirium assessments were completed. Inter-rater reliability (n = 84) revealed that inter-observer agreement among the nurses was high (κ 0.85). The Danish version of the CAPD was successfully administered in all children.

CONCLUSIONS

Standardized assessment tools are a pre-requisite to identify PD. A Danish version of the CAPD now exists, and preliminary testing has demonstrated it as feasible and reliable for use in a Danish clinical setting. A multi-institutional study is needed to determine the prevalence of PD in Denmark.

Pediatric Delirium: Early Identification of Barriers to Optimize Success of Screening and Prevention

INTRODUCTION

Pediatric delirium has a 25% prevalence rate in the pediatric intensive care unit. The purpose of this project was to evaluate the impact/effect of implementing nonpharmacologic nursing bundles on the incidence of pediatric delirium. It is not yet known whether or not bundles consistently reduce the incidence of delirium.

METHOD

A nonpharmacologic nursing bundle was implemented for pediatric intensive care unit patients, 2 to 18years of age, admitted to an Arizona metropolitan children's hospital. Data were collected using the Cornell Assessment of Pediatric Delirium (CAP-D) screening tool.

RESULTS

Control group scores and post-bundle CAP-D scores (mean = 5.57, standard deviation = 5.78 and mean = 7.10, standard deviation = 5.61, respectively) did not differ among the participants. Control participants required an intervention 26.7% of the time for delirium compared with 31.6% in the post-bundle population. No statistical significance was seen between the control group and the post-bundle CAP-D scores t(59) = 7.46; t(205) = 18.17 (p = .08, Fisher exact test).

DISCUSSION

The use of nonpharmacologic bundles for delirium prevention have shown some promising results in helping with delirium reduction. Whether they consistently reduce the incidence has yet to be fully proven. This project shows that significant barriers exist when implementing them in a complex pediatric intensive care environment.

Delirium Knowledge, Self-Confidence, and Attitude in Pediatric Intensive Care Nurses

PURPOSE

A diagnosis of delirium places a critically ill child at risk of increased morbidity/mortality. Although delirium is common in critically ill children, only 2% of pediatric intensive care units (PICU) screen for delirium. The impediments to screening include knowledge deficits regarding delirium and delirium screening tools. The purpose of this improvement science project was two-fold. The first was to implement delirium screening in a PICU. The second was to evaluate the impact of multifaceted education on PICU nurses' delirium knowledge, self-confidence and attitude towards delirium.

DESIGN & METHOD

A series of three plan-do-study-act cycles (PDSA) were used to implement this practice change. Multifaceted education was provided during the PDSA cycles. Two questionnaires were used to assess for changes in delirium knowledge, self-confidence and attitude towards delirium among PICU nurses. Analysis of variance (ANOVA) was used for data analysis.

RESULTS

Forty-two PICU nurses completed a questionnaire measuring delirium knowledge, self-confidence, and attitude during each PDSA cycle. A significant increase in delirium knowledge, self-confidence, and attitude towards delirium was found after education (p = .003; p < .001; p = .036) and 3 months post implementation of delirium screening (p = .023; p < .001; p = .027) as compared to pre-education.

CONCLUSION & PRACTICE IMPLICATIONS

Multifaceted education is a successful tool in improving nurses' knowledge, self-confidence and attitude regarding delirium. The use of PDSA cycles is a practical systematic method to improve quality of care. Improving knowledge, self-confidence and attitude have the potential to mitigate adverse effects of delirium in the critically ill child.

Antipsychotic Treatment of Delirium in Critically Ill Children: A Retrospective Matched Cohort Study

OBJECTIVE

To describe the use of pharmacologic treatment in critically ill children treated according to a delirium protocol and compare those treated with antipsychotics to those treated non-pharmacologically.

METHODS>

The study included a retrospective matched cohort describing patients who were pharmacologically treated for delirium compared to those with delirium but not treated in a PICU from December 2013 to September 2015, using a delirium management protocol. Patients were matched by age, sex, diagnosis, mechanical ventilation (MV), and presence of delirium.

RESULTS

Of 1875 patients screened, 188 (10.03%) were positive for delirium. Of those, 15 patients (8%) were treated with an antipsychotic for delirium. Patients with delirium treated with antipsychotics were younger, had more delirium days (6 vs. 3, p=0.022), longer MV days (14 vs. 7, p=0.017), and longer PICU length of stay (34 vs. 16 days, p=0.029) than in the untreated group. Haloperidol, risperidone, and quetiapine were used in 9, 6, and 2 patients, respectively. Two patients were treated with multiple antipsychotics. Antipsychotic treatment was initiated on day 2 of delirium for 8 of 15 patients (53.3%). Ten patients in the treatment group had improved delirium scores by day 2 of treatment. No significant differences in sedation exposure between groups. No significant adverse effects were reported.

CONCLUSIONS

No significant adverse events seen in this small cohort of critically ill pediatric patients with delirium treated with antipsychotic therapy. Patients with early-onset delirium refractory to non-pharmacologic treatment may have a more effective response to antipsychotic therapy than patients with late-onset refractory delirium.

Determining Interrater Reliability of the Cornell Assessment of Pediatric Delirium Screening Tool Among PICU Nurses

OBJECTIVES

To determine the interrater reliability of the Cornell Assessment of Pediatric Delirium Screening Tool amount PICU nurses.

DESIGN

The design was setup as a cross-sectional study and conducted over the course of a year.

SETTING

This study setting was a PICU and a pediatric cardiac ICU at Seattle Children's Hospital, a tertiary freestanding university-affiliated hospital in Seattle, Washington.

PATIENTS

A total sample of 108 patients were included in this study. Patients were selected using a convenience sample. Inclusion in this study involved all patients eligible for a Cornell Assessment of Pediatric Delirium assessment, reflecting practice standards. Exclusion criteria included patients who had a Richmond Agitation and Sedation Score of (-4) or (-5), based on the Cornell Assessment of Pediatric Delirium procedure. There were 113 patients screened, but five were excluded from the final sample size due to missing information.

INTERVENTIONS

The research nurse would screen the patient using the Cornell Assessment of Pediatric Delirium during the 12:00 noon hour, which coincided with the clinical nurse Cornell Assessment of Pediatric Delirium assessment. The clinical and research nurse were kept blind to each other's assessment. Scores were then analyzed to determine the kappa coefficient.

MEASUREMENTS AND MAIN RESULTS

The kappa coefficient between nurses was found to be 0.60 (95% CI, 0.44-0.76), indicating moderate agreement. Age was found to have a higher association with agreement. In children 2 years old or greater, the kappa coefficient was 0.85 (95% CI, 0.68-1.00). Children whose raters did not agree on scoring were more likely to be younger than those who had raters that agreed (p < 0.01).

CONCLUSIONS

Evaluating the interrater reliability of clinical tool, such as the Cornell Assessment of Pediatric Delirium, may be important to more accurately identify patients at high risk of delirium in a PICU or pediatric cardiac ICU. The evaluation of the tool's performance in practice may also be helpful to ensure ongoing consistency among the clinical nurses that complete these assessments on a daily basis.

The Life Course Health Development Model: A theoretical research framework for paediatric delirium

AIMS AND OBJECTIVES

To create a framework for future research through application and critique of the Life Course Health Development Model to the phenomenon of paediatric delirium.

BACKGROUND

Delirium in the paediatric intensive care unit is associated with increased duration of mechanical ventilation, length of stay and mortality. Nurses are uniquely positioned at the bedside to identify, prevent and treat delirium. An understanding of the potential long-term consequences of paediatric delirium is necessary to provide impetus for nursing research and practice change. The Life Course Health Development Model is a valuable tool when considering the multiple mechanisms and processes through which the experience of delirium could affect a child's life trajectory.

DESIGN

Critical review of the literature through application and critique of the Life Course Health Development Model in the context of paediatric delirium. Gaps in the current understanding of paediatric delirium, as well as future directions for research and practice, are discussed.

METHODS

The seven core principles of the model are considered in the context of paediatric delirium. Each of the principles has the potential to further understanding of paediatric delirium and identify areas for future inquiry. This discussion leads to a critique of the ability of the model to lead future research and practice change.

CONCLUSIONS

The Life Course Health Development Model depicts a process in which the acute and severe stress of critical illness leads to maladaptive neurologic changes that contribute to the development of delirium and impair a child's life trajectory.

RELEVANCE TO CLINICAL PRACTICE

By emphasising the potential lifelong consequences for critically ill children who experience delirium, this application of the Life Course Health Development Model will stimulate discussion, research and practice change among paediatric clinicians and researchers.

Pediatric Delirium in the Cardiac Intensive Care Unit: Identification and Intervention

Delirium is characterized by transient behavioral manifestations of acute brain disturbances. Delirium in the intensive care unit has been well researched and documented in the adult population. Pediatric delirium research has lagged, but recent developments in screening tools have shed light on the prevalence of delirium among children. The overall prevalence of delirium in the pediatric intensive care unit is 25%. A recent study showed a prevalence of 49% in the pediatric cardiac intensive care unit; this higher prevalence may be due to factors related to critical illness and the postoperative environment. This article is intended to increase awareness of delirium in the pediatric cardiac intensive care unit and give nurses the tools to identify it and intervene when necessary. A definition of delirium is provided, and its prevalence, risk factors, and current knowledge are reviewed. Available screening tools and environmental and pharmacological interventions are explored.

Overcoming Barriers to Delirium Screening in the Pediatric Intensive Care Unit

BACKGROUND

Delirium is associated with poor outcomes in adults but is less extensively studied in children.

OBJECTIVES

To describe a quality improvement initiative to implement delirium assessment in a pediatric intensive care unit and to identify barriers to delirium screening completion.

METHODS

A survey identified perceived barriers to delirium assessment. Failure modes and effects analysis characterized factors likely to impede assessment. A randomized case-control study evaluated factors affecting assessment by comparing patients always assessed with patients never assessed.

RESULTS

Delirium assessment was completed in 57% of opportunities over 1 year, with 2% positive screen results. Education improved screening completion by 20%. Barriers to assessment identified by survey (n = 25) included remembering to complete assessments, documentation outside workflow, and "busy patient." Factors with high risk prediction numbers were lack of time and paper charting. Patients always assessed had more severe illness (median Pediatric Index of Mortality 2 score, 0.90 vs 0.36; P < .001), more developmental disabilities (moderate to severe pediatric cerebral performance category score, 54% vs 32%; P = .007), and admission during lower pediatric intensive care unit census (median [interquartile range], 10 [9-12] vs 12 [10-13]; P < .001) than did those never assessed (each group, n = 80). Patients receiving mechanical ventilation were less likely to be assessed (41.0% vs 51.2%, P < .001).

CONCLUSIONS

Successful implementation of pediatric delirium screening may be associated with early use of quality improvement tools to identify assessment barriers, comprehensive education, monitoring system with feedback, multidisciplinary team involvement, and incorporation into nursing workflow models.

Paediatric emergence delirium: a comprehensive review and interpretation of the literature

There remain unanswered questions and implications related to emergence delirium in children. Although we know that there are some predisposing factors to emergence delirium, we still are unable to predict accurately those who are at greatest risk. Emergence delirium should be considered as a ‘vital sign’, which should be followed and documented in every child in the postanaesthesia recovery period. Standardized screening tools should be adopted for paediatric emergence delirium.