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Nelligan M, Nellis ME, Mauer EA, Gerber LM, Traube C. Association between Platelet Transfusion and Delirium in Critically Ill Children. CHILDREN (BASEL, SWITZERLAND) 2023; 10:825. [PMID: 37238373 PMCID: PMC10216991 DOI: 10.3390/children10050825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023]
Abstract
Delirium is a frequent, serious, and preventable complication in critically ill children. Inflammation has been implicated as a mechanism for the development of delirium. Platelet transfusions may potentiate the body's pro-inflammatory responses. We hypothesized that receipt of platelets would be associated with delirium development in a pediatric intensive care unit (PICU). We performed a single-center retrospective cohort analysis including children admitted to the PICU between 2014 and 2018 who were transfused platelets within the first 14 days of admission. Data obtained included severity of illness, level of respiratory support, exposure to medications and blood products, as well as daily cognitive status. To account for time-dependent confounding, a marginal structural model (MSM) was constructed to delineate the relationship between platelet transfusion and next-day delirium. MSM demonstrated a 75% increase in the development of next-day delirium after transfusion of platelets (aOR 1.75, 95% CI 1.03-2.97). For every 1 cc/kg of platelet transfused, odds of next-day delirium increased by 9% (odds ratio 1.09, 95% CI 1.03-1.51). We reported an independent association between platelet transfusion and next-day delirium/coma after accounting for time-dependent confounders, with a dose-response effect. Minimizing platelet transfusions as much as clinically feasible may decrease delirium risk in critically ill children.
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Affiliation(s)
- Matthew Nelligan
- Morgan Stanley Children’s Hospital, NewYork-Presbyterian Columbia University, New York, NY 10032, USA
| | - Marianne E. Nellis
- Department of Pediatrics, Weill Cornell Medical College, New York, NY 10065, USA
| | - Elizabeth A. Mauer
- Department of Pediatrics, Weill Cornell Medical College, New York, NY 10065, USA
| | - Linda M. Gerber
- Department of Pediatrics, Weill Cornell Medical College, New York, NY 10065, USA
| | - Chani Traube
- Department of Pediatrics, Weill Cornell Medical College, New York, NY 10065, USA
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Lamoureux AA, Ducharme-Crevier L, Lacelle-Webster F, Jouvet P, Boivin J, Lavoie A, Rossignol E. Pediatric Delirium: An Overlooked Diagnosis? Pediatr Neurol 2023; 145:48-53. [PMID: 37271057 DOI: 10.1016/j.pediatrneurol.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 02/03/2023] [Accepted: 04/02/2023] [Indexed: 06/06/2023]
Abstract
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.
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Affiliation(s)
| | - Laurence Ducharme-Crevier
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Fanny Lacelle-Webster
- Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada; Department of Pediatrics, CHU Sherbrooke, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Philippe Jouvet
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Johanne Boivin
- Department of Psychiatry, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Annie Lavoie
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada; Department of Pharmacy, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Elsa Rossignol
- Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada; Department of Neurosciences, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada.
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Cleveland M, Baute R, Clindaniel C, Hertz L, Pond R, Centers GI. Inter-Rater Reliability of Delirium Screening of Infants in the Cardiac ICU: A Prospective, Observational Study. Pediatr Crit Care Med 2023; 24:e147-e155. [PMID: 36727939 DOI: 10.1097/pcc.0000000000003182] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To determine the inter-rater reliability (IRR) of the Cornell Assessment for Pediatric Delirium (CAP-D) in infants admitted to a cardiac ICU (CVICU) and to explore the impact of younger age and mechanical ventilation on IRR. DESIGN Prospective cross-sectional study of delirium screening performed by bedside CVICU nurses. We collected data from September 2020 to April 2021. We evaluated IRR with intraclass correlation coefficient (ICC) one-way random effects and Fleiss kappa for multiple raters. SETTING Eighteen-bed academic pediatric CVICU. PARTICIPANTS Subjects: Infants 1 day to 1 year old admitted to the CVICU, stratified in two age groups (≤ 9 wk and 9 wk to < 1 yr). Exclusion criteria were patients' immediate postoperative day, State Behavioral Scale score less than or equal to -2, or at risk for hemodynamic instability with assessment. Raters: CVICU nurses working in the unit during study days. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Groups of four raters performed 91 assessments, a total of 364 CAP-D screens. Forty-five of 91 (49%) were in patients less than or equal to 9 weeks old and 43 of 91 (47%) in mechanically ventilated patients. Sixty-eight of 81 nurses (81%) participated. In infants less than or equal to 9 weeks old, ICC was 0.59 (95% CI 0.44-0.71), poor to moderate reliability, significantly lower than the ICC in infants greater than 9 weeks and 0.72 (95% CI 0.61-0.82), moderate to good reliability. In mechanically ventilated infants, ICC was 0.5 (95% CI 0.34-0.65), poor to moderate reliability, significantly lower than the ICC in nonmechanically ventilated infants and 0.69 (95% CI 0.57-0.8), moderate to good reliability. Fleiss kappa for all infants was 0.47 (95% CI 0.34-0.6), slight to fair agreement. Use of anchor points did not improve reliability. CONCLUSIONS In the youngest, most vulnerable infants admitted to the CVICU, further evaluation of the CAP-D tool is needed.
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Affiliation(s)
- Melissa Cleveland
- Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University Health, Indianapolis, IN
| | - Rebecca Baute
- Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University Health, Indianapolis, IN
| | - Casey Clindaniel
- Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University Health, Indianapolis, IN
| | - Leesa Hertz
- Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University Health, Indianapolis, IN
| | - Rachel Pond
- Division of Pediatric Critical Care, Logan Health Children's Hospital, Kalispell, MT
| | - Gabriela I Centers
- Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University Health, Indianapolis, IN
- Indiana University School of Medicine, Indianapolis, IN
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Simpson CEM, Esterman AJ, Ganu SS, Maki K, Keeley SR, Ward EJ, Tsiros MD. Early mobilisation in critically ill children: Does routine patient screening reduce time to commencing mobilisation? Aust Crit Care 2023; 36:208-214. [PMID: 35135715 DOI: 10.1016/j.aucc.2021.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/19/2021] [Accepted: 12/21/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The objective of this study was to investigate the impact of daily screening for medical readiness to participate in early mobilisation in the paediatric intensive care unit (PICU), on reducing time to mobilisation and to explore the safety-, feasibility-, and patient-level barriers to the practice. METHODS An interventional study with a historical control group was conducted in a PICU in a tertiary teaching hospital in Australia. The Early Mobilisation Screening Checklist was applied at 24-48 h of PICU stay with the aim to reduce time to commencing mobilisation. All patients aged term to 18 years admitted to the PICU for >48 h were included in this study. Data on time to mobilisation and patient characteristics were collected by an unblinded case note audit of children admitted to the PICU over 5 months in 2018 for the baseline group and over a corresponding period in 2019 for the intervention group. MEASUREMENTS AND MAIN RESULTS A total of 71 children were enrolled. Survival analysis was used to compare time to mobilisation between groups, and a cox regression model found that children in the intervention group were 1.26 times more likely to participate in mobility, but this was not statistically significant (P = 0.391, log rank test for equality of survival functions). Early mobilisation was safe, with no adverse events reported in 177 participant mobilisation days. Feasibility was demonstrated by 62% of participants mobilising within 72 h of admission. Mechanical ventilation during stay (P = 0.043) and days receiving sedation infusion (% of days) (P = 0.042) were associated with a decreased likelihood of participating in mobility. CONCLUSIONS Implementation of routine screening alone does not significantly reduce time to commencing mobility in the PICU. Early mobilisation in the PICU is safe and feasible and resulted in no adverse events during mobilisation. Patient characteristics influencing participation in mobility warrant further exploration.
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Affiliation(s)
- Catherine E M Simpson
- Allied Health Department, Women's and Children's Health Network, Australia; University of South Australia, Alliance for Research in Exercise, Nutrition and Activity, Allied Health and Human Performance, Australia.
| | - Adrian J Esterman
- University of South Australia, Clinical and Health Sciences, Australia
| | - Subodh S Ganu
- Department of Paediatric Critical Care Medicine, Women's and Children's Health Network, Australia; University of Adelaide, Adelaide, Australia
| | - Kazuhiro Maki
- Department of Paediatric Critical Care Medicine, Women's and Children's Health Network, Australia
| | - Steve R Keeley
- Department of Paediatric Critical Care Medicine, Women's and Children's Health Network, Australia
| | - Emily J Ward
- University of South Australia, Allied Health and Human Performance, Australia
| | - Margarita D Tsiros
- University of South Australia, Alliance for Research in Exercise, Nutrition and Activity, Allied Health and Human Performance, Australia; University of South Australia, UniSA Allied Health and Human Performance, Innovation, Implementation and Clinical Translation in Health (IIMPACT), Australia
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Motwani B, Pandwar U, Agrawal A, Shrivastava J. Risk Factors of Delirium in Children in Pediatric Intensive Care Unit. Indian Pediatr 2022. [PMID: 36036188 DOI: 10.1007/s13312-022-2643-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Oostra Cortés LE, Henao Castaño ÁM, Motta Robayo CL. Rol de enfermería frente al delirium en unidad de cuidado intensivo pediátrico: Scoping Review. REVISTA CUIDARTE 2022. [DOI: 10.15649/cuidarte.2381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introducción: El manejo integral de delirium tiene componentes de diferente índole y el rol de enfermería frente a éste puede ser difuso. Objetivo: Identificar en la literatura disponible los cuidados de enfermería no farmacológicos para niños hospitalizados en Unidad de Cuidado Intensivo Pediátrica que presenten delirium. Materiales y métodos: Se realizó una búsqueda estratégica en Web Of Science, Medline, Science Direct, Scielo, Biblioteca Virtual en Salud, LILACS y Open Grey utilizando los términos “nursing care”, “child OR children”, “delirium”, y “Pediatric Intensive Care Unit”. La extracción y análisis de los datos se dio por medio de una matriz. Resultados: Se identificaron 12 artículos que cumplían con los criterios de inclusión y se clasificaron en 4 categorías según la intervención principal desarrollada en el estudio: Abordaje investigativo, intervenciones de confort, intervenciones integrales, e intervenciones educativas. Discusión: El cuidado de enfermería frente al delirium comprende medidas preventivas o curativas que parten del paciente como centro y se extienden hasta su entorno y su familia. Las intervenciones de enfermería pueden estar interrelacionadas de manera que se sustentan y complementan entre ellas. Algunas actividades de cuidado pueden considerarse un indicador de calidad de la atención en salud. Conclusiones: Para abordar integralmente el delirium pediátrico es necesario incidir sobre los factores individuales, ambientales y estructurales que contribuyen a su aparición. El cuidado de enfermería frente al delirium constituye una forma de proteger y promover el bienestar y el desarrollo inmediato y futuro de los niños.
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Abstract
Purpose of Review To present new findings in order to aid in the provision of high-quality symptom management and psychosocial care for adolescents and young adults with advanced cancer at the end of life. Recent Findings Behavioral health providers support patients by teaching them symptom control skills, building legacies, and making meaning of their lives. Integration of cultural values is essential for comprehensive assessment and decision-making. Effective management of physiological symptoms and psychological distress begins with accurate communication about prognosis and goals of care that focus on patient preferences and priorities. Oncology teams promote quality of life and the successful management of fatigue, pain, decreased mobility, poor appetite, and dyspnea with the early inclusion of palliative care. Summary While provision of end-of-life care in a young person with cancer presents challenges, multidisciplinary teams can effectively accompany patients in this journey by prioritizing patient and family preferences to promote quality of life.
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Egbuta C, Mason KP. Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit. J Clin Med 2021; 10:1847. [PMID: 33922824 PMCID: PMC8122992 DOI: 10.3390/jcm10091847] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
| | - Keira P. Mason
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA;
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Accuracy of delirium assessments in critically ill children: A prospective, observational study during routine care. Aust Crit Care 2020; 34:226-234. [PMID: 33909556 DOI: 10.1016/j.aucc.2020.07.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 07/29/2020] [Accepted: 07/31/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES The objectives of this study was to explore the accuracy of the Cornell Assessment for Pediatric Delirium (CAP-D), Pediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU), and Preschool Confusion Assessment Method for the Intensive Care Unit (psCAM-ICU) when implemented in routine care as delirium screening tools, and to assess patient characteristics and clinical variables that may affect their validity. DESIGN This is a prospective observational study. SETTING The study was conducted in a 36-bed, mixed paediatric intensive care unit (PICU) at an Australian tertiary hospital. PATIENTS The study included critically ill children developmentally aged 6 months to 17 years, with a PICU length of stay >18 h. INTERVENTIONS No interventions were provided in the study. MEASUREMENTS AND MAIN RESULTS Patients were screened for delirium by their bedside nurse (CAP-D and pCAM-ICU/psCAM-ICU) once daily, for up to 5 d. Delirium status identified using screening instruments was compared with delirium diagnosis using the diagnostic criteria for delirium (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition). In this sample, the CAP-D retained its high sensitivity (91.3%) and good specificity (75.2%), whereas the psCAM-ICU and pCAM-ICU had moderate sensitivity (58.8% and 75.0%, respectively) and excellent specificity (89.8% and 84.9%, respectively). There was moderate agreement between the CAP-D and the psCAM-ICU (κ = 0.52, p < .001) and good agreement between the CAP-D and the pCAM-ICU (κ = 0.80, p < .01). CONCLUSIONS Although the CAP-D, psCAM-ICU, and pCAM-ICU all appear promising in their validation studies, when implemented in routine care, their performance can be variable. The CAP-D performed well in routine clinical practice, but follow-up diagnosis is required to confirm delirium. The psCAM-ICU and pCAM-ICU both provide valuable, objective assessments of delirium in critically ill children; however, further evaluation of their implementation in routine clinical practice is needed.
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Opioid use is Associated with ICU Delirium in Mechanically Ventilated Children. J Crit Care Med (Targu Mures) 2020; 6:167-174. [PMID: 32864462 PMCID: PMC7430359 DOI: 10.2478/jccm-2020-0026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 06/27/2020] [Indexed: 11/25/2022] Open
Abstract
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.
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Henao Castaño ÁM, Pinzon Casas EY. Assessment of delirium in children admitted into the Intensive Care Unit: psCAM-ICU Tool. AVANCES EN ENFERMERÍA 2020. [DOI: 10.15446/av.enferm.v38n2.78690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Delirium has been identified as a risk factor for the mortality of critically ill patients, generating great social and economic impacts, since patients require more days of mechanical ventilation and a prolonged hospital stay in the intensive care unit (ICU), thus increasing medical costs. Objective: To describe the prevalence and characteristics of delirium episodes in a sample of 6-month to 5-year-old children who are critically ill. Methods: Cohort study at a Pediatric Intensive Care Unit (PICU) in Bogotá (Colombia). Participants were assessed by the Preschool Confusion Assessment Method for the ICU (psCAM-ICU) within the first twenty-four hours of hospitalization. Results: One quarter of the participants (25.8%) presented some type of delirium. Among them, two sub-types of delirium were observed: 62.5% of the cases were hypoactive and 37.5% hyperactive. Moreover, from them, six were male (75%) and 2 female (25%). Primary diagnosis was respiratory tract infection in 62.55% of the patients, while respiratory failure was diagnosed in the remaining 37.5%. Conclusions: The implementation of delirium monitoring tools in critically ill children provides a better understanding of the clinical manifestation of this phenomenon and associated risk factors in order to contribute to the design of efficient intervention strategies.
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Rosenberg L, Traube C. Sedation strategies in children with pediatric acute respiratory distress syndrome (PARDS). ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:509. [PMID: 31728362 DOI: 10.21037/atm.2019.09.16] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
In this review, we discuss the changing landscape of sedation in mechanically ventilated children with pediatric acute respiratory distress syndrome (PARDS). While previous approaches advocated for early and deep sedation with benzodiazepines, emerging literature has highlighted the benefits of light sedation and use of non-benzodiazepine sedating agents, such as dexmedetomidine. Recent studies have emphasized the importance of monitoring multiple factors including, but not limited to, sedation depth, analgesia efficacy, opiate withdrawal, and development of delirium. Through this approach, we hope to improve PARDS outcomes. Overall, more research is needed to further our understanding of the best sedation strategies in children with PARDS.
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Affiliation(s)
- Lynne Rosenberg
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Chani Traube
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
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Bryant KJ. Pediatric Delirium in the Cardiac Intensive Care Unit: Identification and Intervention. Crit Care Nurse 2018; 38:e1-e7. [PMID: 30068726 DOI: 10.4037/ccn2018947] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Kristen J Bryant
- Kristen J. Bryant is a pediatric acute care advanced practice nurse at The Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson University Hospital, New Brunswick, New Jersey.
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Bettencourt A, Mullen JE. Delirium in Children: Identification, Prevention, and Management. Crit Care Nurse 2018; 37:e9-e18. [PMID: 28572112 DOI: 10.4037/ccn2017692] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Amanda Bettencourt
- Amanda Bettencourt is a pediatric clinical nurse specialist at UF Health Shands Children's Hospital, Gainesville, Florida.,Jodi E. Mullen is a clinical leader, pediatric intensive care unit, UF Health Shands Children's Hospital
| | - Jodi E Mullen
- Amanda Bettencourt is a pediatric clinical nurse specialist at UF Health Shands Children's Hospital, Gainesville, Florida. .,Jodi E. Mullen is a clinical leader, pediatric intensive care unit, UF Health Shands Children's Hospital.
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Cano Londoño EM, Mejía Gil IC, Uribe Hernández K, Alexandra Ricardo Ramírez C, Álvarez Gómez ML, Consuegra Peña RA, Agudelo Vélez CA, Zuluaga Penagos S, Elorza Parra M, Franco Vásquez JG. Delirium during the first evaluation of children aged five to 14 years admitted to a paediatric critical care unit. Intensive Crit Care Nurs 2018; 45:37-43. [PMID: 29428252 DOI: 10.1016/j.iccn.2017.12.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 12/24/2017] [Accepted: 12/28/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe the prevalence and characteristics of delirium during the initial evaluation of critically ill patients aged 5-14 years. METHOD/DESIGN This is a cross-sectional descriptive study in a critical care unit. For six months, all patients were evaluated within the first 24-72 hours or when sedation permitted the use of the paediatric confusion assessment method for the intensive care unit (PCAM-ICU) and the Delirium Rating Scale-Revised-98 items #7 and #8 to determine motor type. We report the characteristics of PCAM-ICU delirium (at least three of the required items scored positive) and of subthreshold score cases (two positive items). RESULTS Of 77 admissions, 15 (19.5%) had delirium, and 11 (14.2%) were subthreshold. A total of 53.3% of delirium and 45.5% of subthreshold cases were hypoactive. The prevalence of delirium and subthreshold PCAM-ICU was 83.3% and 16.7% in mechanically ventilated children. The most frequent combination of PCAM-ICU alterations in subthreshold cases was acute onset-fluctuation with altered alertness. The main nursing diagnoses were related to reduced cellular respiration. CONCLUSIONS Delirium is common in critically ill children. It is necessary to assess whether certain nursing diagnoses imply an increase in delirium. Longitudinal studies of subthreshold PCAM-ICU cases are needed to understand their importance better.
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Affiliation(s)
- Eliana María Cano Londoño
- Escuela de Ciencias de la Salud, Facultad Enfermería, Universidad Pontificia Bolivariana, Grupo de Investigación en Cuidado de la Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Isabel Cristina Mejía Gil
- Escuela de Ciencias de la Salud, Facultad Enfermería, Universidad Pontificia Bolivariana, Grupo de Investigación en Cuidado de la Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Katerine Uribe Hernández
- Escuela de Ciencias de la Salud, Facultad Enfermería, Universidad Pontificia Bolivariana, Grupo de Investigación en Cuidado de la Universidad Pontificia Bolivariana, Medellín, Colombia; Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Carmenza Alexandra Ricardo Ramírez
- Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Grupo de Investigación en Psiquiatría de Enlace de la Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - Matilde Ligia Álvarez Gómez
- Escuela de Ciencias de la Salud, Facultad Enfermería, Universidad Pontificia Bolivariana, Grupo de Investigación en Cuidado de la Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Ricardo Antonio Consuegra Peña
- Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Grupo de Investigación en Psiquiatría de Enlace de la Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Camilo Andrés Agudelo Vélez
- Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Grupo de Investigación en Psiquiatría de Enlace de la Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Susana Zuluaga Penagos
- Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Grupo de Investigación en Psiquiatría de Enlace de la Universidad Pontificia Bolivariana, Medellín, Colombia
| | | | - José G Franco Vásquez
- Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Grupo de Investigación en Psiquiatría de Enlace de la Universidad Pontificia Bolivariana, Medellín, Colombia
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Paterson RS, Kenardy JA, De Young AC, Dow BL, Long DA. Delirium in the Critically Ill Child: Assessment and Sequelae. Dev Neuropsychol 2017; 42:387-403. [PMID: 28949771 DOI: 10.1080/87565641.2017.1374961] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Delirium is a common and serious neuropsychiatric complication in critically ill patients of all ages. In the context of critical illness, delirium may emerge as a result of a cascade of underlying pathophysiologic mechanisms and signals organ failure of the brain. Awareness of the clinical importance of delirium in adults is growing as emerging research demonstrates that delirium represents a serious medical problem with significant sequelae. However, our understanding of delirium in children lags significantly behind the adult literature. In particular, our knowledge of how to assess delirium is complicated by challenges in recognizing symptoms of delirium in pediatric patients especially in critical and intensive care settings, and our understanding of its impact on acute and long-term functioning remains in its infancy. This paper focuses on (a) the challenges associated with assessing delirium in critically ill children, (b) the current literature on the outcomes of delirium including morbidity following discharge from PICU, and care-giver well-being, and (c) the importance of assessment in determining impact of delirium on outcome. Current evidence suggests that delirium is a diagnostic challenge for clinicians and may play a detrimental role in a child's recovery after discharge from the pediatric intensive care unit (PICU). Recommendations are proposed for how our knowledge and assessment of delirium in children could be improved.
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Affiliation(s)
- Rebecca S Paterson
- a School of Psychology , The University of Queensland , Brisbane , Australia.,c Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland , Brisbane , QLD , Australia
| | - Justin A Kenardy
- a School of Psychology , The University of Queensland , Brisbane , Australia.,b RECOVER Injury Research Centre , The University of Queensland , Brisbane , Australia
| | - Alexandra C De Young
- d Centre for Children's Burn and Trauma Research, The University of Queensland , Brisbane , Australia
| | - Belinda L Dow
- b RECOVER Injury Research Centre , The University of Queensland , Brisbane , Australia
| | - Debbie A Long
- c Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland , Brisbane , QLD , Australia.,e Paediatric Intensive Care Unit, Lady Cilento Children's Hospital , Brisbane , Australia
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Differentiating Delirium From Sedative/Hypnotic-Related Iatrogenic Withdrawal Syndrome: Lack of Specificity in Pediatric Critical Care Assessment Tools. Pediatr Crit Care Med 2017; 18:580-588. [PMID: 28430755 DOI: 10.1097/pcc.0000000000001153] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To identify available assessment tools for sedative/hypnotic iatrogenic withdrawal syndrome and delirium in PICU patients, the evidence supporting their use, and describe areas of overlap between the components of these tools and the symptoms of anticholinergic burden in children. DATA SOURCES Studies were identified using PubMed and EMBASE from the earliest available date until July 3, 2016, using a combination of MeSH terms "delirium," "substance withdrawal syndrome," and key words "opioids," "benzodiazepines," "critical illness," "ICU," and "intensive care." Review article references were also searched. STUDY SELECTION Human studies reporting assessment of delirium or iatrogenic withdrawal syndrome in children 0-18 years undergoing critical care. Non-English language, exclusively adult, and neonatal intensive care studies were excluded. DATA EXTRACTION References cataloged by study type, population, and screening process. DATA SYNTHESIS Iatrogenic withdrawal syndrome and delirium are both prevalent in the PICU population. Commonly used scales for delirium and iatrogenic withdrawal syndrome assess signs and symptoms in the motor, behavior, and state domains, and exhibit considerable overlap. In addition, signs and symptoms of an anticholinergic toxidrome (a risk associated with some common PICU medications) overlap with components of these scales, specifically in motor, cardiovascular, and psychiatric domains. CONCLUSIONS Although important studies have demonstrated apparent high prevalence of iatrogenic withdrawal syndrome and delirium in the PICU population, the overlap in these scoring systems presents potential difficulty in distinguishing syndromes, both clinically and for research purposes.
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Striving for Optimum Noise-Decreasing Strategies in Critical Care: Initial Measurements and Observations. J Perinat Neonatal Nurs 2017; 31:58-66. [PMID: 28121760 DOI: 10.1097/jpn.0000000000000229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
To identify baseline sound levels, patterns of sound levels, and potential barriers and facilitators to sound level reduction. The study setting was neonatal and pediatric intensive care units in a tertiary care hospital. Participants were staff in both units and parents of currently hospitalized children or infants. One 24-hour sound measurements and one 4-hour sound measurement linked to observed sound events were conducted in each area of the center's neonatal intensive care unit. Two of each measurement type were conducted in the pediatric intensive care unit. Focus groups were conducted with parents and staff. Transcripts were analyzed with descriptive content analysis and themes were compared against results from quantitative measurements. Sound levels exceeded recommended standards at nearly every time point. The most common code was related to talking. Themes from focus groups included the critical care context and sound levels, effects of sound levels, and reducing sound levels-the way forward. Results are consistent with work conducted in other critical care environments. Staff and families realize that high sound levels can be a problem, but feel that the culture and context are not supportive of a quiet care space. High levels of ambient sound suggest that the largest changes in sound levels are likely to come from design and equipment purchase decisions. L10 and Lmax appear to be the best outcomes for measurement of behavioral interventions.
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Daoud A, Duff JP, Joffe AR. Diagnostic accuracy of delirium diagnosis in pediatric intensive care: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:489. [PMID: 25672219 PMCID: PMC4207322 DOI: 10.1186/s13054-014-0489-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 08/05/2014] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Delirium is common in adult intensive care, with validated tools for measurement, known risk factors and adverse neurocognitive outcomes. We aimed to determine what is known about pediatric delirium in the pediatric intensive care unit (PICU). METHODS We conducted a systematic search for and review of studies of the accuracy of delirium diagnosis in children in the PICU. Secondary aims were to determine the prevalence, risk factors and outcomes associated with pediatric delirium. We created screening and data collection tools based on published recommendations. RESULTS After screening 145 titles and abstracts, followed by 35 full-text publications and reference lists of included publications, 9 reports of 5 studies were included. Each of the five included studies was on a single index test: (1) the Pediatric Anesthesia Emergence Delirium Scale (PAED; for ages 1 to 17 years), (2) the Pediatric Confusion Assessment Method for the Intensive Care Unit (p-CAM-ICU; for ages ≥ 5 years), (3) the Cornell Assessment of Pediatric Delirium (CAP-D; a modification of the PAED designed to detect hypoactive delirium), (4) the revised Cornell Assessment of Pediatric Delirium (CAP-D(R)) and (5) clinical suspicion. We found that all five studies had a high risk of bias on at least one domain in the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). Sample size, sensitivity, specificity, and effectiveness (correct classification divided by total tests done) were: PAED 144, 91%, 98%, <91% (>16% of scores required imputation for missing data); p-CAM 68, 78%, 98%, 96%; CAP-D 50, 91%, 100%, 89%; CAP-D (R) 111, and of assessments 94%, 79%, <82% (it is not clear if any assessments were not included); and clinical suspicion 877, N/A (only positive predictive value calculable, 66%). Prevalence of delirium was 17%, 13%, 28%, 21%, and 5% respectively. Only the clinical suspicion study researchers statistically determined any risk factors for delirium (pediatric risk of mortality, pediatric index of mortality, ventilation, age) or outcomes of delirium (length of stay and mortality). CONCLUSION High-quality research to determine the accuracy of delirium screening tools in the PICU are required before prevalence, risk factors and outcomes can be determined and before a routine screening tool can be recommended. Direct comparisons of the p-CAM-ICU and CAP-D(R) should be performed.
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Kudchadkar SR, Aljohani OA, Punjabi NM. Sleep of critically ill children in the pediatric intensive care unit: a systematic review. Sleep Med Rev 2014; 18:103-10. [PMID: 23702219 PMCID: PMC3883975 DOI: 10.1016/j.smrv.2013.02.002] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 02/11/2013] [Accepted: 02/12/2013] [Indexed: 12/16/2022]
Abstract
Critically ill children in the pediatric intensive care unit (PICU) are exposed to multiple physical, environmental and pharmacologic factors which increase the propensity for sleep disruption and loss and may, in turn, play a role in short-term recovery from critical illness and long-term neurocognitive outcomes. Mechanically ventilated children receive sedative and analgesic medications, often at high doses and for long durations, to improve comfort and synchrony with mechanical ventilation. Sedatives and analgesics can decrease slow wave sleep and rapid eye movement sleep. Paradoxically, sedative medication doses are often increased in critically ill children to improve the subjective assessment of sedation and sleep, leading to further agitation and deterioration of sleep quality. The heterogeneity in age and critical illness encountered in the PICU pose several challenges to research on sleep in this setting. The present article reviews the available evidence on sleep in critically ill children admitted to the PICU, with an emphasis on subjective and objective methods of sleep assessment used and special populations studied, including mechanically ventilated children and children with severe burns.
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Affiliation(s)
- Sapna R Kudchadkar
- Johns Hopkins University School of Medicine, Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Baltimore, USA.
| | - Othman A Aljohani
- Johns Hopkins University School of Medicine, Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Baltimore, USA
| | - Naresh M Punjabi
- Johns Hopkins University School of Medicine, Departments of Medicine and Epidemiology, Division of Pulmonary and Critical Care Medicine, Baltimore, USA
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Abstract
Medically ill adolescents are at increased risk for psychological distress and/or functional impairment. However, there are few research studies examining the optimal psychiatric treatments for this population. Psychiatric medication recommendations are largely based on studies of youth with a primary psychiatric disorder, adult studies, hypothesized mechanisms of action, and/or clinical experience. This paper provides evidence-informed recommendations for the psychopharmacological treatment of acutely medically ill adolescents suffering from significant psychological distress and/or functional impairment. Representing the most common problems among medically ill adolescents that are treated with psychiatric medications, recommendations are provided for anxiety and depression; iatrogenic medical trauma, inadequate sleep and insomnia; and, delirium.
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