The pharmacologic management of delirium in children and adolescents

Recognition and Management of Delirium in the Neonatal Intensive Care Unit: Case Series From a Single-Center Level IV Intensive Care Unit

Delirium often goes unrecognized in neonates and children because of lack of experience in evaluating behavior and cognition, insufficient awareness of the prevalence, and nondistinctive symptoms in this population. Although there are increasing reports of the presence of delirium in neonates, there are little data to guide the pharmacologic treatment in this population. In this retrospective single-center case series, we present our experience using quetiapine to treat delirium in 9 medically complex neonates. Based on an extensive literature review, expert opinion, and institutional experience, we propose an approach for monitoring and treating delirium in neonates and infants.

Non-pharmacological interventions for delirium in the pediatric population: a systematic review with narrative synthesis

BACKGROUND

Delirium is a serious complication experienced by hospitalized children. Therefore, preventive management strategies are recommended for these patients. However, comprehensive analyses of delirium interventions in children remain insufficient. Specifically, this systematic review aimed to summarize non-pharmacological interventions for pediatric delirium, addressing the urgent need for a comprehensive understanding of effective strategies. We also explored frequently measured outcome variables to contribute evidence for future research on delirium outcomes in children.

METHODS

This systematic review searched articles from PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and Excerpta Medica databases. The eligibility criteria were formed under the population, intervention, comparator, outcome, and study design framework. Studies were included if they involved (1) children aged under 18 years receiving hospital care, (2) non-pharmacological delirium interventions, (3) comparators involving no intervention or pharmacological delirium interventions, and (4) outcomes measuring the effectiveness of non-pharmacological delirium interventions. Only peer-reviewed articles published in English were included.

RESULTS

Overall, 16 studies were analyzed; of them, 9 assessed non-pharmacological interventions for emergence delirium and 7 assessed interventions for pediatric delirium. The intervention types were grouped as follows: educational (n = 5), multicomponent (n = 6), and technology-assisted (n = 5). Along with pediatric and emergence delirium, the most frequently measured outcome variables were pain, patient anxiety, parental anxiety, pediatric intensive care unit length of stay, agitation, analgesic consumption, and postoperative maladaptive behavior.

CONCLUSIONS

Non-pharmacological interventions for children are effective treatments without associated complications. However, determining the most effective non-pharmacological delirium intervention for hospitalized children based on current data remains challenging.

Delirium in the NICU

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.

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

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.

Quetiapine for the Treatment of Pediatric Delirium

BACKGROUND

Delirium is a common complication of critical illness, with a prevalence of 25% among pediatric intensive care unit (ICU) patients. Pharmacological treatment options for ICU delirium are limited to off-label use of antipsychotics, but their benefit remains uncertain.

OBJECTIVE

The purpose of this study was to evaluate quetiapine effectiveness for the treatment of delirium in critically ill pediatric patients and to describe the safety profile of quetiapine.

METHODS

A single-center, retrospective review of patients aged ≤ 18 years who screened positive for delirium via the Cornell Assessment of Pediatric Delirium (CAPD ≥ 9) and received ≥ 48 hours of quetiapine therapy was conducted. The relationship between quetiapine and deliriogenic medication doses was evaluated.

RESULTS

This study included 37 patients who received quetiapine for the treatment of delirium. The change in sedation requirements before quetiapine initiation to 48 hours after the highest quetiapine dose demonstrated a downward trend; 68% of patients had a decrease in opioid requirements and 43% of patients had a decrease in benzodiazepine requirements. The median CAPD score at baseline was 17 and the median CAPD score at 48 hours after the highest dose was 16. Three patients experienced QTc prolongation (defined as a QTc ≥ 500), although none developed dysrhythmias.

CONCLUSION AND RELEVANCE

Quetiapine did not have a statistically significant impact on deliriogenic medication doses. There were minimal changes in QTc and dysrhythmias were not identified. Therefore, quetiapine can be safe to use in our pediatric patients but further studies are needed to find an effective dose.

Updates and Clinical Implications of Pediatric Delirium

Delirium is a fluctuating level of awareness based on a physiologic disease process. Within pediatrics, delirium affects approximately 30% of patients admitted to critical care units and is associated with increased mortality, morbidity, length of stay, and care costs. Multiple pediatric critical care societies recommend the implementation of screening practices using validated delirium tools. Delirium remains underrecognized because of suboptimal screening and protocol implementation in pediatric critical care units nationally and internationally. The mainstay of delirium prevention and management is nonpharmacologic, focusing on normalizing a patient's environment, sleep/wake cycles, nutritional status, and activity levels.

Pediatric Delirium: An Overlooked Diagnosis?

BACKGROUND

Delirium is well-recognized in adult inpatient care. However, it is often overlooked in children, being mistaken for pain, anxiety, or age-appropriate agitation.

METHODS

To assess the impact of a formal teaching session on the diagnostic rates and management of pediatric delirium (PD) in a tertiary care center, we conducted a retrospective chart review of all hospitalized children diagnosed with PD between August 2003 and August 2018 at the CHU Sainte-Justine (Montreal, Canada). Diagnostic incidence and management were compared before (2003 to 2014) and after (2015 to 2018) a formal teaching session provided to pediatric residents, staff pediatricians, and intensive care physicians in December 2014.

RESULTS

The two cohorts displayed similar demographics, PD symptomatology, PD duration (median: 2 days), and hospital stay duration (median: 11.0 and 10.5 days). However, we saw a major increase in diagnosis frequency after 2014 (from 1.84 to 7.09 cases/year). This increased diagnostic rate was most striking in the pediatric intensive care unit setting. Although symptomatic treatment with antipsychotics and alpha-2 agonists was similar between the two cohorts, patients diagnosed after 2014 were more often weaned from offending medications (benzodiazepines, anesthetics, and anticholinergics). All patients recovered fully.

CONCLUSIONS

Formal teaching on the symptoms and management of PD was associated with an increase in diagnostic rate and an improved management of PD in our institution. Larger studies are required to assess standardized screening tools that may further enhance diagnostic rates and improve care for children with PD.

The Ameliorating Role of A Playful Situational Game Intervention in School-Aged Children Undergoing Ophthalmic Surgeries: A Randomized Controlled Trial

PURPOSE

The objective of the study was to investigate if a playful situational game (PSG) intervention, as a perioperative procedure, could effectively alleviate stress and anxiety and improve postoperative outcomes for children to receive ophthalmic surgeries.

METHODS

This trial enrolled 153 children, among which 116 met inclusion criteria and were randomized to control (n = 58, who did not participate in PSG) or PSG group (n = 58, who participated PSG). In the PSG group, children were arranged in renovated wards and allocated to play situational games specifically designed to improve surgery readiness. Satisfaction of the care from parents, posthospitalization behavioral change incidences, Yale Preoperative Anxiety Scale (YPAS) scores, induction compliance checklist (ICC) scores, and pediatric anesthesia emergence delirium (PAED) scores were documented as postoperative assessments.

RESULTS

The PSG group demonstrated significantly higher satisfaction of the care from the parents (p = 0.004), and posthospitalization behavioral change incidences were markedly rarer in the PSG group (p = 0.015). The YPAS scores of the PSG group showed a slower increase compared to the control group before and after surgery (p < 0.001). ICC and PAED scores were also lower in the PSG group (p < 0.01).

CONCLUSION

Our data could support that PSG is an effective intervention in alleviating the anxiety of children undergoing ophthalmic surgery and PSG can increase the satisfaction rate among patients and decrease behavioral change incidences. The adoption of PSG in children could potentially been promoted in the clinical setting.

The Use of Psychotropic Medication in Pediatric Oncology for Acute Psychological and Psychiatric Problems: Balancing Risks and Benefits

Severe acute behavioral and emotional problems represent one of the most serious treatment-related adverse effects for children and adolescents who have cancer. The critical and severe nature of these symptoms often makes necessary the use of psychotropic drugs. A working group composed of experts in multiple disciplines had the task of creating an agreement regarding a management plan for severe acute behavioral and emotional problems (SABEPs) in children and adolescents treated for cancer. To obtain global information on the use of psychotropic drugs in pediatric oncology, the working group first developed and mailed a 15-item questionnaire to many Italian pediatric oncology centers. Overall, an evident lack of knowledge and education regarding the use of psychotropic medications for the treatment of SABEPs was found. Thus, by referring to an adapted version of the Delphi method of consensus and standard methods for the elaboration of clinical questions (PICOs), the working group elaborated evidence-based recommendations for psychotropic drugs in the pediatric oncology setting. Furthermore, based on a thorough multivariate analysis of needs and difficulties, a comprehensive management flow was developed to optimize therapeutic interventions, which allows more accurate and efficient matching of the acute needs of patients while guiding treatment options.

Psychological and Psychiatric Comorbidities in Youth with Serious Physical Illness

An estimated one in six children in the United States suffers from a mental disorder, including mood, anxiety, or behavioral disorders. This rate is even higher in children with chronic medical illness. This manuscript provides a concise review of the symptoms that comprise mental conditions often observed in children with chronic illness or at the end of life. It further provides some guidance to help clinicians distinguish normative from pathological presentations. Evidence-based psychotherapy interventions, potentially applicable to the acute inpatient setting, are briefly summarized. Broad recommendations are made regarding both psychotherapeutic as well as pharmacotherapeutic interventions, with a review of common or serious medication side effects. Finally, delirium recognition and management are summarized.

High-Dose Dexmedetomidine for Severe Hyperactive Delirium Secondary to Intravenous Levetiracetam on Two Separate Occasions in the Same Patient

We describe the case of a 5-year-old male who developed severe hyperactive delirium with aggressive violent behavior following the administration of IV levetiracetam for the treatment of status epilepticus on two occasions. The child's symptoms ranged from attacking his parents and the intensive care staff. Risperidone was given without any improvement in symptoms. A high-dose continuous infusion of IV dexmedetomidine was administered, and his violent behavior and delirium significantly improved. The two episodes of hyperactive delirium following IV levetiracetam administration occurred at ages 3 and 5, resulting in extensive work up including laboratory testing and cranial imaging, along with cerebral spinal fluid analysis and were normal. IV dexmedetomidine provided rapid symptom relief to prevent harm for the child, staff, and family on both occasions.

2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility

RATIONALE

A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available.

OBJECTIVE

To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility.

DESIGN

The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to.

METHODS

Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence.

RESULTS

The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements.

CONCLUSIONS

The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.

[The Pharmacological Management of Emergencies in Child and Adolescent Psychiatry]

The Pharmacological Management of Emergencies in Child and Adolescent Psychiatry Abstract. Emergencies in child and adolescent psychiatry are highly prevalent and often pose significant challenges to physicians, since substantial danger to the patient or others must be avoided through the application of largely moderate interventions. Besides using de-escalating strategies and exploiting psychotherapeutic options, the physician frequently employs psychopharmacological interventions. because of a lack of systematically assessed data, however, in emergencies in child and adolescent psychiatry most administrations of psychotropic drugs occur "off label." This review deduces practice-relevant recommendations for the pharmacological management of occurring child and adolescent emergencies such as acute suicidality, acute psychotic episodes, delirium, disorders of consciousness, acute intoxication, and alcohol withdrawal syndrome. We discuss the issue of quality and safety in pharmacological emergency strategies.

The stability of quetiapine oral suspension compounded from commercially available tablets

Quetiapine fumarate (QF) is an atypical antipsychotic used off-label for the treatment of delirium in critically-ill infants and children. For the treatment of pediatric populations or patient populations with trouble swallowing tablets, an oral suspension would be an ideal dosage formulation. However, there are no liquid formulations of QF commercially available. Therefore, a compounded oral suspension prepared from the commercial QF tablets is widely used in clinical settings. The extemporaneous preparation of QF compounded oral suspension changes the formulation from a solid form to a liquid form. Thus, the stability of QF compounded oral suspension should be critically evaluated to guide pharmacists for administration and storage of QF compounded oral suspensions. However, the stability of the nonaqueous oral QF suspension was not measured. The objective of this study was to develop QF compounded oral suspensions at 10 mg/mL by using commercial QF tablets in two readily available aqueous vehicles (Ora-Sweet and Ora-Blend) and measure their stability at both room temperature and under refrigeration. Physical stability of the QF compounded suspensions were evaluated by appearance and odor. Chemical stability of the QF compounded suspensions were evaluated based on pH, degradation, drug content and the amount of the drug dissolved in the vehicles. An HPLC method was validated and used to evaluate QF compounded suspensions over 60 days. In addition to the total drug in the suspensions, the dissolved drug in the vehicles was also measured during the stability testing and evaluated as a stability parameter. Overall, QF suspension prepared in Ora-Blend was preferable, demonstrating a superior 60-day stability at both room temperature and refrigerated storage.

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.

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.

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.

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.

Pediatric Consultation-Liaison Psychiatry: An Update and Review

Background

In recent years, there has been an increasing burden of child and adolescent mental illness recognized in the United States, and the need for pediatric mental health care is growing. Pediatric consultation-liaison (C-L) psychiatrists are increasingly playing a role in the management of medical and psychiatric disease for pediatric patients. The field is a fast-moving one, with understanding of new neuropsychiatric disease entities; reformulation of prior disease entities; and new interdisciplinary treatments and models of care.

Methods

In this study, we aim to review recent advances in the field of pediatric C-L psychiatry, including new diagnostic entities, updated management of frequently encountered clinical presentations, and developments in systems of care.

Conclusion

The advances in pediatric C-L psychiatry are broad and serve to promote more streamlined, evidence-based care for the vulnerable population of psychiatrically ill pediatric medical patients. More work remains to determine the most effective interventions for the wide array of presentations seen by pediatric C-L psychiatrists.

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.

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.

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.

Sleep and Delirium in Pediatric Critical Illness: What Is the Relationship?

With growing recognition of pediatric delirium in pediatric critical illness there has also been increased investigation into improving recognition and determining potential risk factors. Disturbed sleep has been assumed to be one of the key risk factors leading to delirium and is commonplace in the pediatric critical care setting as the nature of intensive care requires frequent and invasive monitoring and interventions. However, this relationship between sleep and delirium in pediatric critical illness has not been definitively established and may, instead, reflect significant overlap in risk factors and consequences of underlying neurologic dysfunction. We aim to review the existing tools for evaluation of sleep and delirium in the pediatric critical care setting and review findings from recent investigations with application of these measures in the pediatric intensive care unit.

Impact of Two Educational Modules on Practitioner Knowledge of Pediatric Delirium

OBJECTIVES The purpose of this study was to evaluate the efficacy of education modules in preparing staff before the implementation of a pediatric delirium screening protocol.

METHODS After consenting participants began phase 1 of the study, which covered general information on pediatric delirium. It comprised a 21-question assessment administered as a pretest followed by an education module and then the same 21-question assessment administered as a posttest. After completing phase 1, participants proceeded to phase 2, which focused on use of the Cornell Assessment of Pediatric Delirium (CAPD) tool. It comprised an education module and a 14-question postassessment. Participants completed these phases at their convenience via provided instruction documents. Assessments were delivered through the online service SurveyMonkey. Education modules were available online as invisible YouTube videos.

RESULTS A total of 50 nurses and pharmacists gave consent, and 37 of these participants initiated phase 1. All 37 participants completed the phase 1 preassessment, averaging a score of 46% (range, 29%–71%). A total of 27 participants completed the phase 1 postassessment, with an average score of approximately 76% (range, 48%–95%). A total of 20 participants, with no prior training on the CAPD, completed the phase 2 postassessment, averaging a score of 88% (range, 43%–100%).

CONCLUSIONS Both the pediatric delirium general education module and the CAPD use education module resulted in participant learning, as evidenced by the assessment score averages.

Crisis in the Emergency Department: The Evaluation and Management of Acute Agitation in Children and Adolescents

Acute agitation in children and adolescents in the emergency department carries significant risks to patients and staff and requires skillful management, using both nonpharmacologic and pharmacologic strategies. Effective management of agitation requires understanding and addressing the multifactorial cause of the agitation. Careful observation and multidisciplinary collaboration is important. Medical work-up of agitated patients is also critical. Nonpharmacologic deescalation strategies should be first line for preventing and managing agitation and should continue during and after medication administration. Choice of medication should focus on addressing the cause of the agitation and any underlying psychiatric syndromes.

Delirium in Children: Identification, Prevention, and Management

Delirium in children is an often underrecognized but serious complication of hospitalization. Delirium in this age group has been described as behaviors such as refractory agitation and restlessness, visual or auditory hallucinations, children being "not themselves," and a lethargic state. Often, children with delirium are at risk for harming themselves by dislodging tubes, falling, or refusing care. Pediatric nurses must recognize and intervene to prevent and treat delirium in hospitalized children because the delirium may be an indicator of worsening clinical status and is associated with high mortality and morbidity in children of all ages and with posttraumatic stress disorder. Pediatric nurses are uniquely positioned to design care interventions to both reduce risk for delirium and treat active delirium. Many treatment recommendations are nonpharmacological and are part of excellent nursing care.

Pediatric Delirium: Recognition, Management, and Outcome

PURPOSE OF REVIEW

This review seeks to provide an update on the diagnosis, management, and outcome of pediatric delirium.

RECENT FINDINGS

Care of patients with delirium depends on correct diagnosis and treatment of its underlying cause. A variety of instruments are available to aid diagnosis. Management of delirium currently depends on atypical antipsychotics, while avoiding agents that may precipitate or exacerbate it. While most critically ill children survive delirium, many children die or have worsening function after their illness. The longer the duration of delirium, the more severe its subsequent problems including postintensive care syndrome and posttraumatic stress disorder. Possible serious long-term consequences emphasize the importance of efforts to improve diagnosis and outcome in critically ill children suffering from delirium.

Delirium in the Critically Ill Child

PURPOSE/OBJECTIVE

The purposes of this article are to describe the scientific literature on assessment, prevention, and management of delirium in critically ill children and to articulate the implications for clinical nurse specialists, in translating the evidence into practice.

DESCRIPTION

A literature search was conducted in 4 databases-OvidMEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsychINFO, and Web of Science-using the terms "delirium," "child," and "critically ill" for the period of 2006 to 2016.

OUTCOME

The scientific literature included articles on diagnosis, prevalence, risk factors, adverse outcomes, screening tools, prevention, and management. The prevalence of delirium in critically ill children is up to 30%. Risk factors include age, developmental delay, severity of illness, and mechanical ventilation. Adverse outcomes include increased mortality, hospital length of stay, and cost for the critically ill child with delirium. Valid and reliable delirium screening tools are available for critically ill children. Prevention and management strategies include interventions to address environmental triggers, sleep disruption, integrated family care, and mobilization.

CONCLUSION

Delirium is a common occurrence for the critically ill child. The clinical nurse specialist is accountable for leading the implementation of practice changes that are based on evidence to improve patient outcomes. Screening and early intervention for delirium are key to mitigating adverse outcomes for critically ill children.

Retrospective study of intranasal dexmedetomidine as a prophylactic against emergence delirium in pediatric patients undergoing ear tube surgery

OBJECTIVES

This study evaluated the effect of intranasal dexmedetomidine on emergence delirium (ED) in pediatric patients who underwent ear tube surgeries. Due to the brief nature of the surgery and low levels of pain experienced, an IV is rarely needed, limiting the medications available to anesthesiologists to manage postoperative delirium that may arise during recovery from inhalational anesthesia. Intravenous dexmedetomidine is an alpha-2 agonist anesthetic that is used in pediatric patients for the management of ED in various surgical procedures. However, intranasal medication has not been evaluated specifically in ear tube surgeries for ED prevention.

METHODS

We conducted a retrospective chart review of pediatric patients at Nemours Children's Hospital who had undergone ear tube insertion or removal surgery between 2013 and 2015, controlling for confounding variables such as age, surgery duration, and anesthesiologist. We used the post anesthesia emergence delirium (PAED) tool, an instrument created to assess ED in the clinical setting. We analyzed the data for significant differences in PAED score and time in the post anesthesia care unit (PACU) between patients treated with intranasal dexmedetomidine and the control group that did not receive the medication.

RESULTS

We found no significant difference between the PAED scores of those patients treated with intranasal dexmedetomidine prior to ear tube surgeries and those who did not receive the medication, and no difference in the duration of PACU stay.

CONCLUSION

These results conflict with other research on intranasal dexmedetomidine and its potential to prevent ED in pediatric patients. This information should prompt further prospective investigation into the most efficacious use of dexmedetomidine for ED prevention, both in terms of timing and dosage required.

Pediatric Delirium: Evaluation, Management, and Special Considerations

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.

A case of infant delirium in the neonatal intensive care unit

Infant delirium is an under-recognized clinical entity in neonatal intensive care, and earlier identification and treatment could minimize morbidities associated with this condition. We describe a case of a 6-month-old former 32 weeks gestation infant undergoing a prolonged mechanical ventilation course diagnosed with delirium related to the combination of his underlying illness and the use of multiple sedative and analgesic medications. Initiation of the atypical antipsychotic risperidone allowed for weaning from continuous infusions of benzodiazepines and opiods, and lower dosages of bolus-dosed sedation and analgesics. The patient experienced no adverse side effects from use of this neuroleptic.

Diagnosis and Management of Delirium in Critically Ill Infants: Case Report and Review

Delirium in children is common but not widely understood by pediatric practitioners, often leading to underdiagnosis and lack of treatment. This presents a significant challenge in the young patients in the PICU who are most at risk for delirium and in whom the core features of delirium are difficult to assess and treat. However, because of the potential increased morbidity and mortality associated with untreated delirium in adults and children, it remains important to address it promptly. The literature for delirium in this age group is limited. Here we present the case of an infant with multiple underlying medical risk factors who exhibited waxing and waning motor restlessness with disrupted sleep-wake cycles contributing significantly to destabilization of vital parameters. Making a diagnosis of delirium was key to guiding further treatment. After appropriate environmental interventions are implemented and underlying medical causes are addressed, antipsychotic medications, although not Food and Drug Administration-approved in infants, are the mainstay of pharmacotherapy for delirium in older age groups. They may lengthen corrected QT interval (QTc) intervals, presenting a challenge in infants who frequently have other coexisting risks for QTc prolongation, as in our case. The risk from QTc prolongation needs to be balanced against that from untreated delirium. Low doses of risperidone were successfully used in this patient and without side effects or worsening of QTc interval. This case illustrates the importance of increased recognition of delirium in children, including infants, and the role for cautious consideration of atypical antipsychotics in the very young.

Evaluation of the Safety of Quetiapine in Treating Delirium in Critically Ill Children: A Retrospective Review

OBJECTIVE

Quetiapine is an atypical antipsychotic that has been used off-label for the treatment of intensive care unit (ICU) delirium in the adult population, with studies demonstrating both efficacy and a favorable safety profile. Although there is a potential role for quetiapine in the treatment of pediatric ICU delirium, there has been no systematic reporting to date of safety in this patient population.

METHODS

Pharmacy records were used to identify 55 consecutive pediatric ICU patients who were diagnosed with delirium and received quetiapine. A comprehensive retrospective medical chart review was performed to collect data on demographics, dosing, and side effects.

RESULTS

Fifty patients treated between January 2013 and November 2014 were included, and five patients were excluded from the study. Subjects ranged in age from 2 months to 20 years. Median daily dose was 1.3 mg/kg/day, and median duration of treatment was 12 days. There were three episodes of QTc prolongation that were clinically nonsignificant with no associated dysrhythmia: Two resolved over time without intervention, and one resolved with decrease in quetiapine dosage. There were no episodes of extrapyramidal symptoms or neuroleptic malignant syndrome.

CONCLUSIONS

In this population of critically ill youth, short-term use of quetiapine as treatment for delirium appears to be safe, without serious adverse events. Further research is required to assess efficacy and evaluate for long-term effects. A prospective, randomized, placebo-controlled study of quetiapine in managing pediatric delirium is necessary.