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Yaregal Melesse D, Teshale Tesema T, Ayinie Mekonnen Z, Chekol WB, Admass BA, Mengie Workie M. Predictors of postoperative delirium in paediatric patients undergoing surgery under general anaesthesia at Amhara Regional State Tertiary Hospitals: a multicenter prospective study. Front Pediatr 2024; 12:1348789. [PMID: 38523839 PMCID: PMC10957644 DOI: 10.3389/fped.2024.1348789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/23/2024] [Indexed: 03/26/2024] Open
Abstract
Introduction Postoperative delirium in paediatric patients is a recognised issue. Nevertheless, in low- and middle-income nations, researchers have had luck in determining its extent and predictors. Identifying predictors of postoperative delirium in paediatric patients having general anaesthesia at Tertiary Hospitals in Ethiopia was the aim of this study. Methods A multicenter, prospective follow up study was conducted from April 15 to June 15, 2023 at the study settings. During the study period a total of 424 paediatric surgical patients treated under general anaesthesia in all study locations, ranging in age from birth to sixteen were candidates for this study. Charts and direct observation of patient's with assessment tool [Cornell Assessment of Pediatric Delirium (CAPD)] were used from each available patient. Binary logistic regression analysis was performed to determine predictors of postoperative delirium in paediatric patients undergoing surgery under general anaesthesia. Results Postoperative delirium occurred in 160 of the 404 paediatric patients who underwent surgery under general anaesthesia. Ophthalmic surgery, corticosteroid use, anticholinergic use, severe postoperative pain, and preoperative anxiety were found to be predictors of postoperative delirium; whereas, sedative medication premedication and paracetamol used for analgesia were found to be protective against postoperative delirium. Inference and recommendation The postoperative delirium in paediatric patients undergoing surgery under general anaesthesia was higher compared to developed countries. Ophthalmic surgery, corticosteroids, anticholinergic medications, postoperative pain, and preoperative anxiety were found to be predictors. The impact of postoperative delirium might be lessened by concentrating on its screening and factor control.
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Affiliation(s)
- Debas Yaregal Melesse
- Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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2
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Thielen JR, Sawyer JE, Henry BM, Zebracki J, Cooper DS, Koh W. Short-Term Effect of Quetiapine Used to Treat Delirium Symptoms on Opioid and Benzodiazepine Requirements in the Pediatric Cardiac Intensive Care Unit. Pediatr Cardiol 2024; 45:666-672. [PMID: 35933475 DOI: 10.1007/s00246-022-02980-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/21/2022] [Indexed: 10/15/2022]
Abstract
Opioids or benzodiazepines use is known to increase the risk of delirium. The prevalence of delirium is high in pediatric cardiac intensive care units (CICUs) with associated morbidity and mortality. We investigate the short-term effects of quetiapine, an atypical antipsychotic medication, on opioid and benzodiazepine requirements, and any associated adverse events as we utilize quetiapine to treat delirium symptoms in this single-center, retrospective study. Twenty-eight patients who received quetiapine between January 2018 and June 2019 in the CICU met inclusion criteria for the analysis. The quetiapine initiation dose was 0.5 mg/kg/dose every 8 h and we allowed 48 h for quetiapine to reach a steady state. Overall opioid and benzodiazepine requirements were compared 72 h before and 72 h after the quetiapine steady state. There was a statistically significant reduction in the total daily opioid (p = 0.001) and benzodiazepine (p = 0.01) amounts following quetiapine initiation. There was also a statistically significant decrease in the total number of daily PRNs requirement for both opioids (p < 0.001) and benzodiazepines (p = 0.03). Nine out of 13 patients were completely weaned off continuous opioid drips following quetiapine initiation (p = 0.01). The presence of steady-state habituation medications, including methadone or lorazepam, did not have any statistically significant effect on weaning continuous opioid (p = 0.18) or benzodiazepine (p = 0.62) drips. There was no statistically significant effect of quetiapine on the QTc interval after quetiapine initiation (p = 0.58) with no clinically significant arrhythmias observed during the study period. Our study demonstrates a statistically significant reduction in opioid and benzodiazepine requirements following quetiapine initiation to treat delirium symptoms without significant adverse effects in patients with congenital heart disease in the short term.
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Affiliation(s)
- Jessica R Thielen
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 2003, Cincinnati, OH, 45229, USA
| | - Jaclyn E Sawyer
- Division of Pharmacy, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Brandon M Henry
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 2003, Cincinnati, OH, 45229, USA
| | - Jessica Zebracki
- Division of Pharmacy, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David S Cooper
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 2003, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Wonshill Koh
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 2003, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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3
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Tarrell A, Giles L, Smith B, Traube C, Watt K. Delirium in the NICU. J Perinatol 2024; 44:157-163. [PMID: 37684547 DOI: 10.1038/s41372-023-01767-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/18/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023]
Abstract
Delirium in the NICU is an underrecognized phenomenon in infants who are often complex and critically ill. The current understanding of NICU delirium is developing and can be informed by adult and pediatric literature. The NICU population faces many potential risk factors for delirium, including young age, developmental delay, mechanical ventilation, severe illness, and surgery. There are no diagnostic tools specific to infants. The mainstay of delirium treatment is to treat the underlying cause, address modifiable risk factors, and supportive care. This review will summarize current knowledge and areas where more research is needed.
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Affiliation(s)
- Ariel Tarrell
- University of Utah School of Medicine, Department of Pediatrics, Division of Neonatology, Salt Lake City, UT, USA.
| | - Lisa Giles
- University of Utah School of Medicine, Department of Pediatrics, Division of Pediatric Behavioral Health and Psychiatry, Salt Lake City, UT, USA
| | - Brian Smith
- Duke University Medical Center, Division of Neonatology, Durham, NC, USA
| | - Chani Traube
- Weill Cornell Medical College, Division of Pediatric Critical Care Medicine, New York, NY, USA
| | - Kevin Watt
- University of Utah School of Medicine, Department of Pediatrics, Divisions of Pediatric Critical Care Medicine and Clinical Pharmacology, Salt Lake City, UT, USA
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Oschman A, Rao K. Challenges in management of refractory pain and sedation in infants. Front Pharmacol 2024; 14:1259064. [PMID: 38235119 PMCID: PMC10791862 DOI: 10.3389/fphar.2023.1259064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 12/08/2023] [Indexed: 01/19/2024] Open
Abstract
The survival of preterm infants continues to improve, along with an increased in neonatal intensive care unit (NICU) management of chronic infants who are medically complex infants who have prolonged hospital stays, sometimes up until 2 years of age. Despite advances in neonatal and infant care, the management of pain and sedation in chronic NICU patients continues to be a challenge. Challenges such as development of appropriate pain, sedation, and withdrawal scales along with unfamiliarity of the NICU care team with pediatric disease states and pharmacotherapy complicate management of these patients. Opioid induced hyperalgesia (OIH) and delirium may play a large role in these refractory cases, yet are often not considered in the NICU population. Drug therapy interventions such as gabapentin, ketamine, risperidone, and others have limited data for safety and efficacy in this population. This article summarizes the available literature regarding the evidence for diagnosis and management of infants with refractory pain and sedation along with the challenges that clinicians face when managing these patients.
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Affiliation(s)
- Alexandra Oschman
- Department of Pharmacy, Children’s Mercy Hospital, Kansas City, MO, United States
| | - Karishma Rao
- Division of Neonatology, Children’s Mercy Hospital, Kansas City, MO, United States
- University of Missouri Kansas City School of Medicine, Kansas City, MO, United States
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5
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Hardin BG, McCarter A, Hamrick SEG. A Delirium Prevention and Management Initiative: Implementing a Best Practice Recommendation for the NICU. Neonatal Netw 2024; 43:19-34. [PMID: 38267090 DOI: 10.1891/nn-2023-0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Medically complex infants experiencing NICU stays can be difficult to manage, exhibiting refractory agitation, disengagement, or both-all signs of delirium, which can present in a hypoactive, hyperactive, or mixed form. Though documented in other settings, delirium is under-recognized in NICUs. Pediatric studies show that a high percentage of patients with delirium are under the age of 12 months. Delirium is associated with increased ventilation days, hospital days, and costs. It negatively affects neurodevelopment and social interaction. Studies show that pediatric nurses are unprepared to recognize delirium. Our nurse-led multidisciplinary group created a best practice recommendation (BPR) focused on detecting delirium and minimizing risk through thoughtful sedation management, promotion of sleep hygiene and mobility, and facilitation of meaningful caregiver presence. Occasionally, medications, including melatonin and risperidone, are helpful. In 2019, we introduced this BPR to reduce delirium risk in our NICU. Practice changes tied to this initiative correlate with a significant reduction in delirium scores and risk including exposure to deliriogenic medications. A multidisciplinary care bundle correlates with decreased delirium screening scores in NICU patients.
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Zilezinski M, Denninger NE, Tannen A, Kottner J. Non-pharmacological interventions to prevent and manage delirium in critically ill children in neonatal and paediatric intensive care units (NICU/PICU): a scoping review protocol. BMJ Open 2023; 13:e073883. [PMID: 37899161 PMCID: PMC10619068 DOI: 10.1136/bmjopen-2023-073883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 10/10/2023] [Indexed: 10/31/2023] Open
Abstract
INTRODUCTION Delirium is one of the most common forms of acute cerebral dysfunction in critically ill children leading to increased morbidity and mortality. Prevention, identification and management of delirium is an important part of paediatric and neonatological intensive care. This scoping review aims to identify and map evidence on non-pharmacological interventions for paediatric delirium prevention and management in paediatric and neonatal intensive care settings. METHODS AND ANALYSIS This scoping review will be conducted according to the Joanna Briggs Institute methodology for scoping reviews and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Searches will be performed in the databases Medline (via PubMed), CINAHL, Cochrane Library, Ovid (Journals), EMBASE and Web of Science (01/2000-current). Two reviewers will independently review retrieved studies, and relevant information will be extracted using data extraction forms. The results will be presented in tabular format and accompanied by a narrative summary. INCLUSION CRITERIA The review will include references that describe or evaluate non-pharmacological interventions to prevent or manage paediatric delirium. Conference abstracts, editorials, opinion papers and grey literature will be excluded. ETHICS AND DISSEMINATION Due to the nature of research involving humans or unpublished secondary data, approval of an ethics committee are not required. The dissemination of findings is planned via professional networks and publication in an open-access scientific journal.
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Affiliation(s)
- Max Zilezinski
- Institute of Clinical Nursing Science, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Natascha-Elisabeth Denninger
- Department of Primary Care and Health Services Research, Nursing Science and Interprofessional Care, Medical Faculty Heidelberg, Heidelberg University, Heidelberg, Germany
- Institute for Health and Nursing Science, International Graduate Academy, Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Antje Tannen
- Institute of Clinical Nursing Science, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Kottner
- Institute of Clinical Nursing Science, Charité Universitätsmedizin Berlin, Berlin, Germany
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7
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Berhane H, Moss J, Koh E. Effect of a Delirium Screening Tool on Antipsychotic Medication Use in a Pediatric Intensive Care Unit. J Pediatr Pharmacol Ther 2023; 28:156-160. [PMID: 37139246 PMCID: PMC10150905 DOI: 10.5863/1551-6776-28.2.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 03/17/2022] [Indexed: 05/05/2023]
Abstract
Objective Intensive care unit (ICU) delirium has been associated with increased length of hospital stay, morbidity, mechanical ventilation, and health care resource utilization. Antipsychotics are frequently used for ICU delirium management, despite a lack of robust evidence in the literature to support their benefit. Delirium screening may result in pharmacologic or non-pharmacologic treatment. Methods In January 2019 we began screening patients admitted to the pediatric ICU (PICU) for delirium using the Cornell Assessment for Pediatric Delirium (CAPD). We compared prescribing rates of antipsychotic medications before and after implementation. We also assessed length of hospital and ICU stay prior to initiating therapy, delirium score prior to initiation of therapy, time after initiation of therapy until score decreased to a level not suggestive of delirium, and continuation of antipsychotics outside of the PICU. Results We did not observe a difference in the rate of antipsychotics use. There was, however, an increase in variability between pre- and post-intervention rates of prescribing. Patients who received an antipsychotic medication were hospitalized for an average of 18 days and in the ICU for 14 days prior to the first dose of an antipsychotic agent. They had an average CAPD score of 16, and had an average of 4 scores above 8 prior to starting treatment. Conclusion This study highlights the need for additional research to demonstrate the role of antipsychotic medications in managing delirium in the PICU.
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Affiliation(s)
- Helen Berhane
- Department of Pharmacy (HB), University of California San Diego Medical Center, San Diego, CA
| | - Jeffrey Moss
- Department of Pharmacy (JM), Lucile Packard Children's Hospital Stanford, Palo Alto, CA
| | - Eunice Koh
- Department of Pediatrics (EK), Stanford University School of Medicine, Stanford, CA
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8
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Abstract
Delirium is likely present in the neonatal intensive care unit and has been largely unrecognized. There are several risk factors for delirium including illness severity, neurosedative exposure, and environmental disruptions that put infants at risk for delirium. Regular use of scoring systems should be considered to improve delirium detection. When identified, initial steps in management should include resolving underlying causes and implementation of standard nonpharmacologic measures. Mounting pediatric evidence suggests that the atypical antipsychotics, as well as the α-2 agonists, may be additionally beneficial in treating delirium as well as improving the ability to wean off other neurosedative medications.
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Affiliation(s)
- Samuel J Adams
- Neurology - Child Neurology, Medical College of Wisconsin, Children's Wisconsin, 8915 W. Connell Cţ Milwaukee, WI 53226, USA.
| | - Alicia Sprecher
- Pediatrics - Neonatology, Medical College of Wisconsin, Children's Wisconsin, 8915 W. Connell Ct, Milwaukee, WI 53226, USA
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9
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Siegel EJ, Groves AM, Silver G, Hojsak J, Lim CA, Traube C. Delirium in the NICU: A Point Prevalence Study. Hosp Pediatr 2021; 11:e321-e326. [PMID: 34711646 DOI: 10.1542/hpeds.2020-005736] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Elana J Siegel
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alan M Groves
- Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Gabrielle Silver
- Weill Cornell Medical College, Cornell University, New York, New York
| | - Joanne Hojsak
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - C Anthoney Lim
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Chani Traube
- Weill Cornell Medical College, Cornell University, New York, New York
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10
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Zaccagnini M, Ataman R, Nonoyama ML. The Withdrawal Assessment Tool to identify iatrogenic withdrawal symptoms in critically ill paediatric patients: A COSMIN systematic review of measurement properties. J Eval Clin Pract 2021; 27:976-988. [PMID: 33590613 DOI: 10.1111/jep.13539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES The Withdrawal Assessment Tool (WAT-1) is one of the most widely used clinician-reported outcome measures to evaluate iatrogenic withdrawal symptoms (IWS) in critically ill children. However, the WAT-1's measurement properties have not been aggregated. Aggregating psychometric research on the WAT-1 will enhance appropriate use, and outline gaps for future empirical research. The aim of this systematic review is to critically appraise, compare, and summarize the measurement properties and evidence quality, and describe the interpretability and feasibility of the WAT-1 for identifying IWS symptoms in critically ill children. METHODS A systematic search of Medline, Embase and CINAHL was conducted from inception to 15 April 2020. Study inclusion/exclusion, data extraction, and measurement property evidence and the modified GRADE quality scoring were applied according to the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines. RESULTS Six studies were included in the review. There was sufficient, high-quality evidence for reliability, structural validity, criterion validity, measurement error, construct validity, and feasibility. More information is required to support the WAT-1's content validity, responsiveness, internal consistency, cross-cultural validity, and interpretability according to COSMIN guidelines. CONCLUSION The results of this review indicate that the WAT-1 is a precise, easy to use measure of IWS in critically ill children despite some measurement property inconsistencies and gaps in the publication record. More information is required to support its content validity, responsiveness, internal consistency, cross-cultural validity, and interpretability.
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Affiliation(s)
- Marco Zaccagnini
- School of Physical and Occupational Therapy, McGill University, Montréal, Québec, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Québec, Canada.,Department of Respiratory Therapy, McGill University Health Centre, Montréal, Québec, Canada
| | - Rebecca Ataman
- School of Physical and Occupational Therapy, McGill University, Montréal, Québec, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Québec, Canada
| | - Mika Laura Nonoyama
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada.,Respiratory Therapy & Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Physical Therapy & Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
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11
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Liviskie C, McPherson C, Luecke C. Assessment and Management of Delirium in the Pediatric Intensive Care Unit: A Review. J Pediatr Intensive Care 2021; 12:94-105. [PMID: 37082469 PMCID: PMC10113017 DOI: 10.1055/s-0041-1730918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/31/2021] [Indexed: 10/21/2022] Open
Abstract
AbstractMany 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.
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Affiliation(s)
- Caren Liviskie
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, Missouri, United States
| | - Christopher McPherson
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, Missouri, United States
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Caitlyn Luecke
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, Missouri, United States
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12
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Hughes KM, Thorndyke A, Tillman EM. Incidence of Corrected QT Prolongation With Concomitant Methadone and Atypical Antipsychotics in Critically Ill Children. J Pediatr Pharmacol Ther 2021; 26:271-276. [PMID: 33833629 DOI: 10.5863/1551-6776-26.3.271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 09/17/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the safety of the combination of methadone and an atypical antipsychotic in PICU patients. METHODS This was a retrospective observational cohort pilot study in a single-center PICU in an academic children's hospital. Children 1 month to 18 years of age were included if they received methadone, were then initiated on an atypical antipsychotic (i.e., quetiapine or risperidone), and had EKG monitoring before and after medication initiation. RESULTS Prolongation of the corrected QT (QTc) interval occurred in 5 of the 34 included patients when an atypical antipsychotic was added to methadone. Of the 5 patients who had a prolonged QTc interval, 4 (80%) were older than 12 years and had a median weight of 91.3 kg. There were statistical differences between age and weight when comparing patients who experienced QTc prolongation, but no differences in sex, ethnicity, electrolyte deficiencies, number of additional QTc-prolonging medications, and number of additional drug-drug interactions were identified. When comparing atypical antipsychotics, 9.5% of patients receiving risperidone had a prolonged QTc interval, versus 23% of patients receiving quetiapine (p = 0.04). The net change in QTc interval after initiation of methadone was 0.19 milliseconds (IQR: -3, 15), which increased after atypical antipsychotic initiation to 4 milliseconds (IQR: -16, 15). CONCLUSIONS Our pilot trial suggests there is no clinically significant difference in incidence of QTc prolongation with addition of atypical antipsychotics to methadone.
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13
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Abstract
Delirium is a frequent complication of critical illness in adult and pediatric populations and is associated with significant morbidity and mortality. Little is known about the incidence, risk, symptoms, or treatment of delirium in the NICU. Only 4 cases of NICU delirium have been reported, but many pediatric studies include infants. The Cornell Assessment of Pediatric Delirium tool has been validated in neonatal and infant populations for identification of delirium. Initial treatment should focus on identification and reversal of the cause, with pharmacologic management reserved for patients with symptoms that do not resolve or that significantly impact medical care. Routine use of intravenous haloperidol should be avoided because of the high incidence of serious adverse effects, but it may be considered in patients with significant symptoms who are unable to take oral medications. Atypical antipsychotics (olanzapine, quetiapine, and risperidone) appear to be efficacious with a low incidence of adverse effects. Risperidone has weight-based dosing and a liquid dosage form available, making it a good option for use in the NICU. Additional data from large cohorts of NICU patients routinely screened for delirium, and treated as indicated, are needed.
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14
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Jesus AO, Jones L, Linares R, Buck ML, Frank DU. Management of Hyperactive Delirium in the Pediatric Intensive Care Unit: Case Series of Three Young Children. J Pediatr Intensive Care 2019; 9:119-123. [PMID: 32351766 DOI: 10.1055/s-0039-3400458] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/12/2019] [Indexed: 10/25/2022] Open
Abstract
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.
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Affiliation(s)
- Anna O Jesus
- Division of Neurodevelopmental and Behavioral Pediatrics, University of Virginia, Charlottesville, Virginia, United States
| | - Lotte Jones
- Division of Pediatric Critical Care, Children's Hospital of the King's Daughters, Norfolk, Virginia, United States
| | - Rebecca Linares
- Division of Pediatric Critical Care, University of Virginia, Charlottesville, Virginia, United States
| | - Marcia L Buck
- American College of Clinical Pharmacy, Washington, DC, United States
| | - Deborah U Frank
- Division of Pediatric Critical Care, University of Virginia, Charlottesville, Virginia, United States
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15
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Castro REVD, Sousa CDC, de Magalhães-Barbosa MC, Prata-Barbosa A, Cheniaux E. Ranitidine-Induced Delirium in a 7-Year-Old Girl: A Case Report. Pediatrics 2019; 143:peds.2018-2428. [PMID: 30635349 DOI: 10.1542/peds.2018-2428] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2018] [Indexed: 11/24/2022] Open
Abstract
Ranitidine is a histamine-2 blocker commonly prescribed in PICUs for the prophylaxis of gastrointestinal bleeding and stress ulcers. However, it can be associated to central nervous system side effects, such as delirium, in adults. We present the first case of a child presenting delirium possibly caused by anticholinergic toxidrome secondary to the use of ranitidine, resolving after drug discontinuation. With this case report, we reinforce that a wide variety of clinical conditions can trigger delirium and that the best therapeutic approach is to minimize risk factors.
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Affiliation(s)
- Roberta Esteves Vieira de Castro
- Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil; .,Hospital Vitória, Americas Medical City, Rio de Janeiro, Brazil
| | | | | | | | - Elie Cheniaux
- Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.,Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Alvarez RV, Palmer C, Czaja AS, Peyton C, Silver G, Traube C, Mourani PM, Kaufman J. Delirium is a Common and Early Finding in Patients in the Pediatric Cardiac Intensive Care Unit. J Pediatr 2018; 195:206-212. [PMID: 29395177 DOI: 10.1016/j.jpeds.2017.11.064] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 11/08/2017] [Accepted: 11/29/2017] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To determine incidence, associated risk factors, and characteristics of delirium in a pediatric cardiac intensive care unit (CICU). Delirium is a frequent and serious complication in adults after cardiac surgery, but there is limited understanding of its impact in children with critical cardiac disease. STUDY DESIGN Single-center prospective observational study of CICU patients ≤21 years old. All were screened for delirium using the Cornell Assessment for Pediatric Delirium each 12-hour shift. RESULTS Ninety-nine patients were included. Incidence of delirium was 57%. Median time to development of delirium was 1 day (95% CI 0, 1 days). Children with delirium were younger (geometric mean age 4 vs 46 months; P < .001), had longer periods of mechanical ventilation (mean 35.9 vs 8.8 hours; P = .002) and had longer cardiopulmonary bypass times (geometric mean 126 vs 81 minutes; P = .001). Delirious patients had longer length of CICU stay than those without delirium (median 3 (IQR 2, 12.5) vs 1 (IQR1, 2) days; P < .0001). A multivariable generalized linear mixed model showed a significant association between delirium and younger age (OR 0.35 for each additional month, 95% CI 0.19, 0.64), need for mechanical ventilation (OR 4.1, 95% CI 1.7, 9.89), and receipt of benzodiazepines (OR 3.78, 95% CI 1.46, 9.79). CONCLUSIONS Delirium is common in patients in the pediatric CICU and is associated with longer length of stay. There may be opportunities for prevention of delirium by targeting modifiable risk factors, such as use of benzodiazepines.
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Affiliation(s)
- Rita V Alvarez
- Section of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Wauwatosa, WI.
| | - Claire Palmer
- Research Institute Biostatistics Core, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Angela S Czaja
- Section of Critical Care, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Chris Peyton
- Department of Pediatrics, The Heart Institute, Children's Hospital Colorado, University of Colorado, Aurora, CO
| | - Gabrielle Silver
- Department of Child Psychiatry, Weill Cornell Medical College, New York, NY
| | - Chani Traube
- Pediatric Critical Care Medicine, Weill Cornell Medical College, New York, NY
| | - Peter M Mourani
- Section of Critical Care, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Jon Kaufman
- Department of Pediatrics, The Heart Institute, Children's Hospital Colorado, University of Colorado, Aurora, CO
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Malas N, Brahmbhatt K, McDermott C, Smith A, Ortiz-Aguayo R, Turkel S. Pediatric Delirium: Evaluation, Management, and Special Considerations. Curr Psychiatry Rep 2017; 19:65. [PMID: 28801871 DOI: 10.1007/s11920-017-0817-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Delirium describes a syndrome of acute brain dysfunction with severe consequences on patient outcomes, medical cost, morbidity, and mortality. It represents a final common pathway of numerous pathophysiologic disturbances disrupting cerebral homeostasis. The diagnosis is predicated on recognition of the clinical features of the syndrome through ongoing clinical assessment. Early identification can be aided by routine screening, particularly in high-risk populations. Evaluation and management are continuous and simultaneous processes involving a multidisciplinary care team including child psychiatry consultation. Prevention, early identification and management are critical in alleviating symptoms, improving outcomes, and reducing distress for patients, families, and care teams. This review highlights our current understanding regarding pediatric delirium, its mechanisms, clinical manifestations, detection and management.
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Affiliation(s)
- Nasuh Malas
- Department of Psychiatry and Pediatrics, University of Michigan Medical School, 1500 East Medical Center Drive, L5023, SPC 5277, Ann Arbor, MI, 48109, USA.
| | - Khyati Brahmbhatt
- Department of Psychiatry, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Cristin McDermott
- Department of Psychiatry and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Allanceson Smith
- Department of Psychiatry, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Roberto Ortiz-Aguayo
- Department of Psychiatry and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Susan Turkel
- Department of Psychiatry and Pediatrics, Keck School of Medicine, University of Southern California, Children's Hospital of Los Angeles, CA, Los Angeles, USA
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Motta E, Luglio M, Delgado AF, Carvalho WBD. Importance of the use of protocols for the management of analgesia and sedation in pediatric intensive care unit. Rev Assoc Med Bras (1992) 2016; 62:602-609. [DOI: 10.1590/1806-9282.62.06.602] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/26/2016] [Indexed: 02/03/2023] Open
Abstract
Summary Introduction: Analgesia and sedation are essential elements in patient care in the intensive care unit (ICU), in order to promote the control of pain, anxiety and agitation, prevent the loss of devices, accidental extubation, and improve the synchrony of the patient with mechanical ventilation. However, excess of these medications leads to rise in morbidity and mortality. The ideal management will depend on the adoption of clinical and pharmacological measures, guided by scales and protocols. Objective: Literature review on the main aspects of analgesia and sedation, abstinence syndrome, and delirium in the pediatric intensive care unit, in order to show the importance of the use of protocols on the management of critically ill patients. Method: Articles published in the past 16 years on PubMed, Lilacs, and the Cochrane Library, with the terms analgesia, sedation, abstinence syndrome, mild sedation, daily interruption, and intensive care unit. Results: Seventy-six articles considered relevant were selected to describe the importance of using a protocol of sedation and analgesia. They recommended mild sedation and the use of assessment scales, daily interruptions, and spontaneous breathing test. These measures shorten the time of mechanical ventilation, as well as length of hospital stay, and help to control abstinence and delirium, without increasing the risk of morbidity and morbidity. Conclusion: Despite the lack of controlled and randomized clinical trials in the pediatric setting, the use of protocols, optimizing mild sedation, leads to decreased morbidity.
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