Psychopharmacology in pediatric critical care

Analgesia, sedation, and delirium in pediatric surgical critical care

The alleviation of discomfort and distress is an essential component of the management of critically ill surgical patients. Pain and anxiety have multifocal etiologies that may be related to an underlying disease or surgical procedure, ongoing medical therapy, invasive monitors, an unfamiliar, complex and chaotic environment, as well as fear. Pharmacologic and non-pharmacologic therapies have complex risk benefit profiles. A fundamental understanding of analgesia, sedation, and delirium is essential for optimizing important outcomes in critically ill pediatric surgical patients. There has been a recent emphasis on goal directed, evidence based, and patient-centered management of the physical and psychological needs of these children. The purpose of this article is to review and summarize recent advances and describe current practice of these important subjects in the pediatric surgical intensive care environment.

Post-traumatic Stress Disorder After Sexual Abuse in Adolescent Girls

The sexual assault of girls and women in this country is estimated at approximately 20%. The development of post-traumatic stress disorder (PTSD) after sexual abuse and assault is one of the potential lingering aftereffects. In this article we describe PTSD after sexual abuse and its effect on presenting complaints, such as sexually transmitted infections, contraception, and chronic pain, for the pediatric and adolescent gynecology (PAG) clinician. Treatment approaches, including the use of antidepressants and anxiolytics, as well as evidenced-based psychotherapies, are highlighted. In addition, this article will assist the PAG clinician in identifying trauma-related concerns during clinic visits and will cover specific screening tools to aid in identification of PTSD. A better understanding of PTSD after sexual abuse will allow PAG providers to deliver better care to their patients.

The pharmacologic management of delirium in children and adolescents

Delirium is a serious and common problem in severely medically ill patients of all ages. It has been less addressed in children and adolescents. Treatment of delirium is predicated on addressing its underlying cause. The management of its symptoms depends on the off-label use of antipsychotics, while avoiding agents that precipitate or worsen delirium. Olanzapine, quetiapine, and risperidone are presently considered first-line drugs, usually replacing haloperidol. Other agents have shown promise, including melatonin to address the sleep disturbance characteristic of delirium, and dexmedetomidine, an α2-agonist, that may facilitate lower doses of benzodiazepines and opioids that may worsen delirium.

The diagnosis and management of delirium in infancy

OBJECTIVE

Atypical antipsychotics have been documented to be effective in the management of delirium in adults and older children, but despite considerable need, their use has been less studied in the very young. A retrospective chart review was undertaken to describe the use of atypical antipsychotics in controlling symptoms of delirium in infants and toddlers.

METHODS

All psychiatric inpatient consultations performed during a 3 year period were reviewed to identify children <36 months old diagnosed with delirium. Delirium Rating Scale (DRS) scores were retrospectively calculated when the antipsychotic was initiated and discontinued, to confirm the diagnosis of delirium and evaluate symptom severity, and then to assess symptom response to pharmacologic intervention.

RESULTS

There were 10 boys and 9 girls in the study population (ages 7-30 months, mean 20.5 months). Olanzapine (n=16) and risperidone (n=3) were used, and length of treatment and response were comparable for both medications. Mean DRS scores decreased significantly (p<0.001) with antipsychotic administration, without significant adverse side effects.

CONCLUSIONS

Although randomized placebo controlled studies are needed to better characterize the indications, risks, and benefits, these atypical antipsychotic medications appeared to be effective and safe for managing delirium symptoms in very young pediatric patients.

Atypical antipsychotic medications to control symptoms of delirium in children and adolescents

BACKGROUND

Atypical antipsychotics have been documented to be effective in the management of delirium in adults, but despite considerable need, their use has been less studied in pediatric patients.

OBJECTIVE

A retrospective chart review was done to describe the use of atypical antipsychotics in controlling symptoms of delirium in children and adolescents.

METHODS

Pharmacy records at Children's Hospital Los Angeles were reviewed to identify patients to whom antipsychotic agents were dispensed over a 24-month period. Psychiatric inpatient consultations during the same 24-month period were reviewed. Patients 1-18 years old diagnosed with delirium given antipsychotics constituted the study population. Delirium Rating Scale-Revised-98 (DRS-R98) scores were retrospectively calculated, when possible, at time antipsychotic was started to confirm the initial diagnosis of delirium and evaluate symptom severity, and again when antipsychotic was stopped, to assess symptom response.

RESULTS

Olanzapine (n=78), risperidone (n=13), and quetiapine (n=19) were used during the 2 years of the study. Mean patient age, length of treatment, and response were comparable for the three medications. For patients with two DRS-R98 scores available (n=75/110), mean DRS-R98 scores decreased significantly (p<0.001) with antipsychotic without significant adverse side effects.

CONCLUSION

Although randomized placebo-controlled studies are needed, atypical antipsychotic medications appeared to be effective and safe for managing delirium symptoms in pediatric patients while underlying etiology was addressed.

A randomized controlled trial of sertraline to prevent posttraumatic stress disorder in burned children

BACKGROUND

This study evaluated the potential benefits of a centrally acting selective serotonin reuptake inhibitor, sertraline, versus placebo for prevention of symptoms of posttraumatic stress disorder (PTSD) and depression in burned children. This is the first controlled investigation based on our review of the early use of a medication to prevent PTSD in children.

METHODS

Twenty-six children aged 6-20 were assessed in a 24-week double-blind placebo-controlled design. Each child received either flexibly dosed sertraline between 25-150 mg/day or placebo. At each reassessment, information was collected in compliance with the study medication, parental assessment of the child's symptomatology and functioning, and the child's self-report of symptomatology. The protocol was approved by the Human Studies Committees of Massachusetts General Hospital and Shriners Hospitals for Children.

RESULTS

The final sample was 17 subjects who received sertraline versus 9 placebo control subjects matched for age, severity of injury, and type of hospitalization. There was no significant difference in change from baseline with child-reported symptoms; however, the sertraline group demonstrated a greater decrease in parent-reported symptoms over 8 weeks (-4.1 vs. -0.5, p=0.005), over 12 weeks (-4.4 vs. -1.2, p=.008), and over 24 weeks (-4.0 vs. -0.2, p=0.017).

CONCLUSIONS

Sertraline was a safe drug, and it was somewhat more effective in preventing PTSD symptoms than placebo according to parent report but not child report. Based on this study, sertraline may prevent the emergence of PTSD symptoms in children.

Partnerships between pediatric palliative care and psychiatry

Children with life-threatening illnesses and their families may face physical, emotional, psychosocial, and spiritual challenges throughout the children's course of illness. Pediatric palliative care is designed to meet such challenges. Given the psychosocial and emotional needs of children and their families it is clear that psychiatrists can, and do, play a role in delivering pediatric palliative care. In this article the partnership between pediatric palliative care and psychiatry is explored. The authors present an overview of pediatric palliative care followed by a summary of some of the roles for psychiatry. Two innovative pediatric palliative care programs that psychiatrists may or may not be aware of are described. Finally, some challenges that are faced in further developing this partnership and suggestions for future research are discussed.

Posttraumatic stress disorder in children and adolescents: a review of psychopharmacological treatment

PTSD in children and adolescents differs from the adult disease. Therapeutic approaches involve both psychotherapy and psychopharmacotherapy.

OBJECTIVES

The current paper aims at reviewing studies on psychopharmacological treatment of childhood and adolescent PTSD. Additionally, developmental frameworks for PTSD diagnosis and research along with an experimental model of quenching and kindling in the context of stress exposure are presented. We conducted an extensive literature search of reviews on psychopharmacotherapy as well as studies on psychopharmacological treatment for PTSD among children and adolescents. We used the database PubMed and focused on the time period of the last 10 years up to January 2009. Pertinent earlier papers were also included.There are a limited number of studies specifically assessing the psychopharmacological treatment of PTSD in children and adolescents. The vast majority of them lack verification in RCTs. Only the use of imipramine, divalproex sodium and sertraline were already evaluated in RCTs. Future studies should take into account developmental approaches to the diagnosis and treatment of PTSD in children and adolescents. In this context, different underlying neurobiological patterns, which are reflected in distinct clinical symptomatology, require a precise investigation and a symptom-orientated psychopharmacological approach.

Delirium in children and adolescents: A systematic review of the literature

OBJECTIVES

The purpose of this study was to collate all works relating to delirium and probable delirium in children and adolescents published since 1980.

METHODS

A systematic review of the literature in all languages published between 1980 and March 2009 was conducted.

RESULTS

The literature is limited to small case series and case reports including a total of 217 children or adolescents with definite delirium and a further 136 children and adolescents with "probable delirium." These articles, in addition to unsystematic reviews, overviews, editorials, journal commentaries, and pertinent book chapters, are discussed in relation to prevalence, predisposing and precipitating factors, phenomenology, residual psychopathology, mortality, management, and prevention of delirium in childhood and adolescence.

CONCLUSIONS

Delirium is an important but neglected disorder of childhood associated with significant morbidity and high mortality. Current clinical practice for management is based on slim empirical evidence.

Partnerships between pediatric palliative care and psychiatry

Children with life-threatening illnesses and their families may face physical, emotional, psychosocial, and spiritual challenges throughout the children's course of illness. Pediatric palliative care is designed to meet such challenges. Given the psychosocial and emotional needs of children and their families it is clear that psychiatrists can, and do, play a role in delivering pediatric palliative care. In this article the partnership between pediatric palliative care and psychiatry is explored. The authors present an overview of pediatric palliative care followed by a summary of some of the roles for psychiatry. Two innovative pediatric palliative care programs that psychiatrists may or may not be aware of are described. Finally, some challenges that are faced in further developing this partnership and suggestions for future research are discussed.

Psychobiology of posttraumatic stress disorder in pediatric injury patients: A review of the literature

Research suggests that about a quarter to a third of children with traffic-related injuries develop posttraumatic stress disorder (PTSD). Early symptoms of PTSD have been found to predict poor mental and physical outcome in studies of medically injured children. However, these symptoms are rarely recognized by physicians who provide emergency care for these children. In addition, there is insufficient knowledge about predictors of posttraumatic stress symptoms in this specific pediatric population. Early identification of those children at particular risk is needed to target preventive interventions appropriately. After some introducing remarks on the classification and the nature of posttraumatic stress reactions, current research findings on psychological and biological correlates of PTSD in pediatric injury patients are presented. The particular focus in this paper is on the neurobiological mechanisms that influence psychological responses to extreme stress and the development of PTSD. Continued study of the psychobiology of trauma and PTSD in pediatric injury patients, both in terms of neurobiology and treatment is needed.

Psychosocial and spiritual needs of children living with a life-limiting illness

Quality end-of-life care includes the management of distressing symptoms; provisions of care, including the assessment and management of psychosocial and spiritual needs; and respite from diagnosis through death and bereavement. Meeting the palliative care goal of improved quality of life depends on medical and nursing practitioners understatnding and effectively assessing psychosocial symptoms.