Haloperidol and Quetiapine for the Treatment of ICU-Associated Delirium in a Tertiary Pediatric ICU: A Propensity Score-Matched Cohort Study

Impact of Benzodiazepines on Outcomes of Mechanically Ventilated Pediatric Intensive Care Patients: A Retrospective Cohort Study

IMPORTANCE

Benzodiazepines are the most frequently used sedatives in PICUs, but they are increasingly associated with negative outcomes. Understanding their impact on patient outcomes is critical to provide better sedative management for patients.

OBJECTIVE

Our objective was to determine the impact of midazolam and lorazepam on clinical outcomes among subjects requiring mechanical ventilation in the PICU. We hypothesized that subjects receiving benzodiazepines for tolerance of mechanical ventilation will demonstrate worse clinical outcomes when compared with those not receiving benzodiazepines.

DESIGN

Single-center, retrospective cohort study.

SETTING AND PARTICIPANTS

PICU of a tertiary-care medical center. One thousand fifty-four pediatric participants requiring invasive mechanical ventilation between June 2018 and December 2022. Participants were categorized into those who received benzodiazepine-inclusive sedation regimens (n = 747) and those who received nonbenzodiazepine regimens (n = 307).

INTERVENTIONS

None.

MAIN OUTCOMES AND MEASURES

Subjects were sorted into groups of benzodiazepine-sedative regimens (midazolam and lorazepam, only lorazepam) or nonbenzodiazepine-sedation regimens. The primary outcome was ventilator-free days (VFDs). Statistical analysis was performed using multivariable linear regression and propensity-score matching.

RESULTS

Subjects receiving continuous and/or intermittent benzodiazepines had fewer VFDs compared with the nonbenzodiazepine group (median 21.0 vs. 26.7; p < 0.001). The benzodiazepine group had fewer ICU-free and hospital-free days, higher delirium scores, and a greater need for withdrawal-tapering medications. This was redemonstrated in subjects only receiving intermittent benzodiazepines as well. Younger subjects were more likely to receive benzodiazepines.

CONCLUSIONS AND RELEVANCE

Our study demonstrates an association between children receiving both continuous and intermittent benzodiazepine sedation and worse clinical outcomes. These patients have fewer VFDs and longer length of stay, higher doses of nonbenzodiazepine sedatives, and increased need for withdrawal tapering medications and antipsychotics. It is unclear in this retrospective study if the outcomes were worse because the subjects received benzodiazepines or because subjects receiving benzodiazepines were sicker and thus required benzodiazepines in their analgosedative regimen. Further investigation is warranted into the impact of benzodiazepines on patient outcomes, nonpharmacologic management of sedation, improvement in bedside assessment of analgosedation, and optimal balance between over- and under-sedation.

Antipsychotic Drug Prescription in Pediatric Intensive Care Units: A 10-Year U.S. Retrospective Database Study

Delirium recognition during pediatric critical illness may result in the prescription of antipsychotic medication. These medications have unclear efficacy and safety. We sought to describe antipsychotic medication use in pediatric intensive care units (PICUs) contributing to a U.S. national database. This study is an analysis of the Pediatric Health Information System Database between 2008 and 2018, including children admitted to a PICU aged 0 to 18 years, without prior psychiatric diagnoses. Antipsychotics were given in 16,465 (2.3%) of 706,635 PICU admissions at 30 hospitals. Risperidone (39.6%), quetiapine (22.1%), and haloperidol (20.8%) were the most commonly used medications. Median duration of prescription was 4 days (interquartile range: 2-11 days) for atypical antipsychotics, and haloperidol was used a median of 1 day (1-3 days). Trend analysis showed quetiapine use increased over the study period, whereas use of haloperidol and chlorpromazine (typical antipsychotics) decreased ( p  < 0.001). Compared with no antipsychotic administration, use of antipsychotics was associated with comorbidities (81 vs. 65%), mechanical ventilation (57 vs. 36%), longer PICU stay (6 vs. 3 days), and higher mortality (5.7 vs. 2.8%) in univariate analyses. In the multivariable model including demographic and clinical factors, antipsychotic prescription was associated with mortality (odds ratio [OR] = 1.09, 95% confidence interval [CI]: 1.02-1.18). Use of atypical antipsychotics increased over the 10-year period, possibly reflecting increased comfort with their use in pediatric patients. Antipsychotics were more common in patients with comorbidities, mechanical ventilation, and longer PICU stay, and associated with higher mortality in an adjusted model which warrants further study.

Differences in Delirium Evaluation and Pharmacologic Management in Children With Developmental Delay: A Retrospective Case-Control Study

Delirium is associated with increased mortality and cost, decreased neurocognition, and decreased quality of life in the pediatric intensive care unit (PICU) population. The Cornell Assessment for Pediatric Delirium (CAPD) is used in PICUs for delirium screening but lacks specificity in children with developmental delay (DD). Within a cohort of children receiving pharmacologic treatment for intensive care unit (ICU) delirium, we compared delirium scoring and medication management between children with and without DD. We hypothesized that CAPD scores and treatment decisions would differ between DD and neurotypical (NT) patients. In this retrospective case-control study, we queried the medical record of patients admitted to our PICU with respiratory failure from June 2018 to March 2022 who received antipsychotics typically used for ICU delirium. Antipsychotics prescribed for home use were excluded. Nonparametric statistics compared demographics, CAPD scores, medication choice, dosing (mg/kg), and medication continuation after discharge between those with and without DD based on the ICD-10 codes. Twenty-one DD admissions and 59 NT admissions were included. Groups did not significantly differ by demographics, LOS, drug, or initial dosage. DD patients had higher median CAPD scores at admission (17 vs 13; P = .02) and treatment initiation (18 vs 16.5; P = .05). Providers more frequently escalated doses in DD patients (13/21 vs 21/59; P = .04) and discharged them home on new antipsychotics (7/21 vs 5/59; P = .01). DD patients experience delirium screening and management differently than NT counterparts. Providers should be aware of baseline elevated scores in DD patients and carefully attend to indications for dosage escalation. Further work is needed to understand if prolonged duration, even after hospital discharge, benefits patients, or represents potential disparity in care.

Delirium Assessment Treatment Strategies in Critically Ill Pediatric Patients: A Pediatric Pharmacy Association Practice-Based Research Network Survey Study

OBJECTIVES

The purpose of this study was to describe overall screening, prevention, and treatments for pediatric delirium at various neonatal intensive care units (NICUs), cardiac intensive care units (CICUs), and pediatric intensive care units (PICUs) from the Pediatric Pharmacy Association (PPA) membership. The primary objective was to identify the number of respondents that had a defined delirium-based protocol. The secondary objectives included identification of delirium assessment tools used, first- and second-line delirium treatment options, and monitoring practices for antipsychotics for delirium management.

METHODS

A cross-sectional questionnaire was distributed to PPA members from February 8, 2022, to March, 25, 2022. Comparisons between the NICUs, PICUs, and CICUs were conducted by using chi-square tests, with a priori p value of <0.05.

RESULTS

The questionnaire was completed by 84 respondents at 62 institutions; respondents practiced in the PICU or mixed PICU (n = 48; 57.1%), CICU (n = 13; 15.5%), and NICU (n = 23; 27.4%). Sixty-one respondents (72.6%) noted their units routinely screen for delirium, and there was a significant difference between the respondents of different units that use a delirium scoring tool (p < 0.01). Only 33 respondents (39.3%) had a defined delirium protocol, and there was no difference between units (p = 0.31). The most common agents used for delirium treatment were quetiapine and risperidone. There was variability in the monitoring used between respondents, but the majority (n = 74; 88%) monitor electrocardiograms to assess the corrected QT interval, but practice variability existed.

CONCLUSIONS

Most respondents did not have a defined delirium protocol. Variations were noted in the treatment options and monitoring for critically ill pediatric patients with delirium.

Analgesia, Sedation, Paralytics, Delirium, and Iatrogenic Withdrawal

The care of the critically ill child often includes medications used for the relief of pain and anxiety. Children have key differences in pharmacokinetics and pharmacodynamics compared with adults that should always be considered to achieve safe medication use in this population. Pain must be addressed, and sedative use should be minimized when possible. Our understanding of sedation safety is evolving, and studies have shown that minimizing exposure to multiple medications can reduce the burden of delirium and iatrogenic withdrawal.

Actigraphy in mechanically ventilated pediatric ICU patients: comparison to PSG and evaluation of behavioral circadian rhythmicity

Sleep disruption is common in pediatric intensive care unit (PICU) patients, but measuring sleep in this population is challenging. We aimed to evaluate the utility of actigraphy for estimating circadian rhythmicity in mechanically ventilated PICU patients and its accuracy for measuring sleep by comparing it to polysomnogram (PSG). We conducted a single-center prospective observational study of children 6 months - 17 years of age receiving mechanical ventilation and standard, protocolized sedation for acute respiratory failure, excluding children with acute or historical neurologic injury. We enrolled 16 children and monitored them with up to 14 days of actigraphy and 24 hours of simultaneous limited (10 channel) PSG. Daily actigraphy-based activity profiles demonstrated that patients had a high level of nighttime activity (30-41% of total activity), suggesting disrupted circadian activity cycles. Among n = 12 patients with sufficient actigraphy and PSG data overlap, actigraphy-based sleep estimation showed poor agreement with PSG-identified sleep states, with good sensitivity (94%) but poor specificity (28%), low accuracy (70%,) and low agreement (Cohen's kappa = 0.2, 95% CI = 0.08-0.31). Using univariate linear regression, we identified that Cornell Assessment of Pediatric Delirium scores were associated with accuracy of actigraphy but that other clinical factors including sedative medication doses, activity levels, and restraint use were not. In this population, actigraphy did not reliably discern between sleep and wake states. However, in select patients, actigraphy was able to distinguish diurnal variation in activity patterns, and therefore may be useful for evaluating patients' response to circadian-oriented interventions.