Changes in Sedation Practices in Association with Delirium Screening in Infants After Cardiopulmonary Bypass

Altered Mental Status and Delirium in Pediatric Patients

Mental status is the collection of an individual's consciousness, perception, emotion, memory, and cognition at a particular point in time, which is inferred by the clinician through careful observation and interaction. The pediatric mental status assessment must be approached with an understanding of cognitive, language, and psychosocial development. Alterations must then be comprehensively and clearly described. Delirium is a phenotypic diagnosis with a specific set of criteria in the DSM and is a serious neurocognitive disorder caused by physiologic changes due to illness, injury, toxins, medications, and/or substances. Recognition of delirium in children is improved by monitoring of predisposing risks and precipitating factors, as well as the regular use of validated pediatric screening tools. Management of delirium is focused on treatment of the underlying etiology, prevention of iatrogenic deliriogenic factors, and patient safety.

Short-Term Effect of Quetiapine Used to Treat Delirium Symptoms on Opioid and Benzodiazepine Requirements in the Pediatric Cardiac Intensive Care Unit

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.

Depth of anesthesia, temperature, and postoperative delirium in children and adolescents undergoing cardiac surgery

BACKGROUND

After pediatric cardiosurgical interventions, postoperative delirium can occur, which can be associated with undesirable consequences during and after the hospital stay. It is therefore important to avoid any factors causing delirium as far as possible. Electroencephalogram (EEG) monitoring can be used during anesthesia to individually adjust dosages of hypnotically acting drugs. It is necessary to gain knowledge about the relationship between intraoperative EEG and postoperative delirium in children.

METHODS

In a dataset comprising 89 children (53 male, 36 female; median age: 0.99 (interquartile range: 0.51, 4.89) years) undergoing cardiac surgery involving use of a heart-lung machine, relationships between depth of anesthesia as measured by EEG (EEG index: Narcotrend Index (NI)), sevoflurane dosage, and body temperature were analyzed. A Cornell Assessment of Pediatric Delirium (CAP-D) score ≥ 9 indicated delirium.

RESULTS

The EEG could be used in patients of all age groups for patient monitoring during anesthesia. In the context of induced hypothermia, EEG monitoring supported individually adjusted sevoflurane dosing. The NI was significantly correlated with the body temperature; decreasing temperature was accompanied by a decreasing NI. A CAP-D score ≥ 9 was documented in 61 patients (68.5%); 28 patients (31.5%) had a CAP-D < 9. Delirious patients with an intubation time ≤ 24 h showed a moderate negative correlation between minimum NI (NImin) and CAP-D (rho = -0.41, 95% CI: -0.70 - -0.01, p = 0.046), i.e., CAP-D decreased with increasing NImin. In the analysis of all patients' data, NImin and CAP-D showed a weak negative correlation (rho = -0.21, 95% CI: -0.40 - 0.01, p = 0.064). On average, the youngest patients had the highest CAP-D scores (p = 0.002). Patients with burst suppression / suppression EEG had a longer median intubation time in the intensive care unit than patients without such EEG (p = 0.023). There was no relationship between minimum temperature and CAP-D score.

CONCLUSIONS

The EEG can be used to individually adjust sevoflurane dosing during hypothermia. Of the patients extubated within 24 h and classified as delirious, patients with deeper levels of anesthesia had more severe delirium symptoms than patients with lighter levels of anesthesia.

The Year in Review: Anesthesia for Congenital Heart Disease 2021

This review focuses on the literature published during the calendar year 2021 that is of interest to anesthesiologists taking care of children and adults with congenital heart disease. Four major themes are discussed, including cardiovascular disease in children with COVID-19, aortic valve repair and replacement, bleeding and coagulation, and enhanced recovery after surgery (ERAS).