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da Silva PSL, Kubo EY, da Motta Ramos Siqueira R, Fonseca MCM. Impact of Prolonged Continuous Ketamine Infusions in Critically Ill Children: A Prospective Cohort Study. Paediatr Drugs 2024:10.1007/s40272-024-00635-9. [PMID: 38762850 DOI: 10.1007/s40272-024-00635-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Ketamine has been considered as an adjunct for children who do not reach their predefined target sedation depth. However, there is limited evidence regarding the use of ketamine as a prolonged infusion (i.e., >24 hours) in the pediatric intensive care unit (PICU). OBJECTIVE We sought to evaluate the safety and effectiveness of continuous ketamine infusion for >24 hours in mechanically ventilated children. METHODS We conducted a prospective cohort study in a tertiary PICU from January 2020 to December 2022. The primary outcome was the incidence of adverse events (AEs) after ketamine initiation. The secondary outcome included assessing the median proportion of time the patient spent on the Richmond Agitation-Sedation Scale (RASS) goal after ketamine infusion. Patients were also divided into two groups based on the sedative regimen, ketamine-based or non-ketamine-based, to assess the incidence of delirium. RESULTS A total of 269 patients were enrolled: 73 in the ketamine group and 196 in the non-ketamine group. The median infusion rate of ketamine was 1.4 mg/kg/h. Delirium occurred in 16 (22%) patients with ketamine and 15 (7.6%) patients without ketamine (p = 0.006). After adjusting for covariates, logistic regression showed that delirium was associated with comorbidities (odds ratio [OR] 4.2), neurodevelopmental delay (OR 0.23), fentanyl use (OR 7.35), and ketamine use (OR 4.17). Thirty-one (42%) of the patients experienced at least one AE following ketamine infusion. Other AEs likely related to ketamine were hypertension (n = 4), hypersecretion (n = 14), tachycardia (n = 6), and nystagmus (n = 2). There were no significant changes in hemodynamic variables 24 h after the initiation of ketamine. Regarding the secondary outcomes, patients were at their goal RASS level for a median of 76% (range 68-80.5%) of the time in the 24 hours before ketamine initiation, compared with 84% (range 74.5-90%) of the time during the 24 h after ketamine initiation (p < 0.001). The infusion rate of ketamine did not significantly affect concomitant analgesic and sedative infusions. The ketamine group experienced a longer duration of mechanical ventilation and a longer length of stay in the PICU and hospital than the non-ketamine group. CONCLUSION The use of ketamine infusion in PICU patients may be associated with an increased rate of adverse events, especially delirium. High-quality studies are needed before ketamine can be broadly recommended or adopted earlier in the sedation protocol.
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Affiliation(s)
- Paulo Sérgio Lucas da Silva
- Department of Pediatrics, Pediatric Intensive Care Unit, Hospital Estadual de Diadema, Rua José Bonifácio 1641, São Paulo, 09980-150, Brazil.
| | - Emerson Yukio Kubo
- Department of Pediatrics, Pediatric Intensive Care Unit, Hospital Estadual de Diadema, Rua José Bonifácio 1641, São Paulo, 09980-150, Brazil
| | - Rafael da Motta Ramos Siqueira
- Department of Pediatrics, Pediatric Intensive Care Unit, Hospital Estadual de Diadema, Rua José Bonifácio 1641, São Paulo, 09980-150, Brazil
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Lei L, Li Y, Xu H, Zhang Q, Wu J, Zhao S, Zhang X, Xu M, Zhang S. Incidence, associated factors, and outcomes of delirium in critically ill children in china: a prospective cohort study. BMC Psychiatry 2023; 23:925. [PMID: 38082396 PMCID: PMC10712132 DOI: 10.1186/s12888-023-05406-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/26/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Delirium occurs frequently in critically ill children and has been reported in many countries, but delirium is not well-characterized in China. The aim of this study was to represent the incidence of delirium in critically ill children in China, its associated factors, and the influence of delirium on in-hospital outcomes. METHODS This observational prospective cohort study was set up in a large academic medical center with a 57-bed PICU in southwestern China. Critically ill children who required PICU stays over 24 h and were admitted between November 2019 and February 2022 were included in this study. The Cornell Assessment of Pediatric Delirium was used twice daily for delirium evaluation by bedside nurses, and twenty-four clinical features were collected from medical and nursing records during hospitalization. RESULTS The incidence of delirium was 26.0% (n = 410/1576). Multivariate analysis revealed that seven independent risk factors including days of mechanical ventilation and physical restraints, admission diagnosis (neurologic disorder), sleep deprivation, use of benzodiazepines and dexmedetomidine, liver failure/liver dysfunction associated with delirium in critically ill children. One potentially protective factor was the watching television /listening to music/playing with toys. Children with delirium had longer lengths of stay in the PICU (median 11 vs. 10 days, p < 0.001) and hospital (median 18 vs. 15 days, p < 0.001) compared to those without delirium. Additionally, the in-hospital mortality rates were 4.63% and 0.77% in patients with and without delirium (p < 0.05). CONCLUSIONS Delirium is common in critically ill children in China and related to poor outcomes. Interventional studies are warranted to determine the best practices to reduce delirium exposure in at-risk children.
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Affiliation(s)
- Lei Lei
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Yi Li
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Huilin Xu
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Qin Zhang
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Jiacai Wu
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Shoujv Zhao
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Xiaochao Zhang
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Min Xu
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Shuai Zhang
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China.
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Ista E, Traube C, de Neef M, Schieveld J, Knoester H, Molag M, Kudchadkar SR, Strik J. Factors Associated With Delirium in Children: A Systematic Review and Meta-Analysis. Pediatr Crit Care Med 2023; 24:372-381. [PMID: 36790201 PMCID: PMC10164044 DOI: 10.1097/pcc.0000000000003196] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
OBJECTIVES Pediatric delirium (PD) is a neuropsychiatric syndrome caused by a complex interplay between predisposing factors (e.g., age, cognitive impairment), acute illness, and environmental triggers. PD is associated with substantial morbidity and mortality. The objective of this study is to systematically review and evaluate factors associated with PD in hospitalized pediatric patients. DATA SOURCES A systematic search of PubMed, Embase, Ovid Medline, Web- of-Science, Cochrane, CIHNAL, and Google Scholar databases was conducted for relevant studies (1990-2022). STUDY SELECTION We included studies that compared pediatric patients with and without delirium. Reviews, editorials, congress abstracts, or studies that did not report factors for PD were excluded. No restrictions were imposed on language. DATA EXTRACTION Title and abstract were independently screened by two reviewers. Individual characteristics, study design, and outcomes were independently extracted. DATA SYNTHESIS Categorical dichotomous data were summarized across groups using Mantel-Haenszel odds ratios (ORs) with 95% 95% CIs. Either fixed-effect or random effects models were used as indicated by the results of a heterogeneity test. Of 1,846 abstracts, 24 studies were included. We identified 54 factors studied in univariate analyses, and 27 of these were associated with PD in multivariable analyses. In pooled analyses, greater odds of PD were associated with developmental delay (OR 3.98; 95% CI 1.54-10.26), need for mechanical ventilation (OR 6.02; 95% CI 4.43-8.19), use of physical restraints (OR 4.67; 95% CI 1.82-11.96), and receipt of either benzodiazepines (OR 4.10; 95% CI 2.48-6.80), opiates (OR 2.88; 95% CI 1.89-4.37), steroids (OR 2.02; 95% CI 1.47-2.77), or vasoactive medication (OR 3.68; 95% CI 1.17-11.60). CONCLUSIONS In this meta-analysis, we identified seven factors associated with greater odds of developing delirium during pediatric critical illness.
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Affiliation(s)
- Erwin Ista
- Pediatric Intensive Care Unit, Department of Paediatric Surgery, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, The Netherlands
- Nursing Science, department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Chani Traube
- Department of Pediatric Critical Care, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - Marjorie de Neef
- Pediatric Intensive Care, Emma Children’s Hospital, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Jan Schieveld
- Department of Psychiatry and Psychology, Division of Child and Adolescent Psychiatry and Psychology, Maastricht University Medical Center+ (MUMC+), Maastricht, the Netherlands
- European Graduate School For Neuroscience (EURON), South Limburg Mental Health Research & Teaching Network (SEARCH), Maastricht, the Netherlands
- Mutsaers stichting, Pediatric Mental Health Care, Venlo, the Netherlands
| | - Hennie Knoester
- Pediatric Intensive Care, Emma Children’s Hospital, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Marja Molag
- Knowledge Institute of the Dutch Association of Medical Specialists, Utrecht, the Netherlands
| | - Sapna R. Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jacqueline Strik
- Department of Psychiatry and Psychology, Division of Child and Adolescent Psychiatry and Psychology, Maastricht University Medical Center+ (MUMC+), Maastricht, the Netherlands
- European Graduate School For Neuroscience (EURON), South Limburg Mental Health Research & Teaching Network (SEARCH), Maastricht, the Netherlands
- Mutsaers stichting, Pediatric Mental Health Care, Venlo, the Netherlands
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[Risk factors for delirium after sedation in children with convulsion and establishment of a nomogram model for predicting the risk of delirium]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:1238-1245. [PMID: 36398550 PMCID: PMC9678057 DOI: 10.7499/j.issn.1008-8830.2205076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To investigate the risk factors for delirium after sedation in children with convulsion, and to establish a nomogram model for predicting the risk of delirium. METHODS A total of 373 children with convulsion who were hospitalized in the pediatric ward of the Second Affiliated Hospital of Air Force Medical University from August 2020 to January 2022 were prospectively enrolled. There were 245 children in the modeling group and 128 children in the validation group. A multivariate logistic regression analysis was used to identify independent predictive factors for delirium after sedation and establish a nomogram model for predicting the risk of this disorder based on these factors. The calibration curve, the receiver operating characteristic curve, and the decision curve analysis were used to evaluate the accuracy, discriminatory ability, and clinical application value of this model, respectively. RESULTS The incidence of delirium after sedation was 22.3% (83/373) in the children with convulsion. The multivariate logistic regression analysis showed that age>5 years (OR=0.401, P<0.05) was a protective factor against delirium after sedation in these children, while presence of infection (OR=3.020, P<0.05), admission to the pediatric intensive care unit (OR=3.126, P<0.05), use of benzodiazepines (OR=5.219, P<0.05), history of status convulsion (OR=2.623, P<0.05), and history of delirium episodes (OR=3.119, P<0.05) were risk factors for delirium. The H-L deviation test of the nomogram prediction model showed a good degree of fit (χ2=9.494, P=0.302). Internal and external validation showed that the mean absolute errors between the actual and predicted values of the calibration curve were 0.030 and 0.018, respectively, and the areas under the receiver operating characteristic curve were 0.777 and 0.775, respectively. The decision curve analysis showed that the model provided significant net clinical benefit when the predicted risk threshold was >0.01. CONCLUSIONS Age, presence of infection, admission to the pediatric intensive care unit, use of benzodiazepines, history of status convulsion, and history of delirium episodes are closely associated with the development of delirium after sedation in children with convulsion. The nomogram model for predicting this disorder that is established based on these factors has relatively high accuracy, discriminatory ability, and clinical application value.
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Sudhakar G, Aneja J, Gehlawat P, Nebhinani N, Khera D, Singh K. A prospective cohort study of emergence delirium and its clinical correlates in a pediatric intensive care unit in North India. Asian J Psychiatr 2022; 72:103070. [PMID: 35339871 DOI: 10.1016/j.ajp.2022.103070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 02/26/2022] [Accepted: 03/09/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Delirium is a common occurrence in medically compromised adults, but, research is limited in the pediatric population especially from low- and middle-income countries such as India. AIMS This study aimed to evaluate the emergence of delirium in children aged 5-18 years admitted to a pediatric intensive care unit (PICU) of a tertiary care hospital in North India. Other objectives included delineating the clinical characteristics of delirium and its clinical correlates. METHODOLOGY It was a prospective cohort study in which all admitted children during a calendar year were assessed and those fulfilling the inclusion criteria were enrolled for study. The Pediatric Confusion Assessment Method Intensive Care Unit (p-CAM-ICU) scale was used to diagnose delirium. RESULTS ut of 305 total admissions to the PICU, 105 children were included. More than two third were male (68.6%) with a median age of 11 years. The incidence of delirium was 11.4% and median duration of delirium was 2 days. Majority of the children had hypoactive delirium (58.3%), followed by hyperactive (25%) and mixed type (16.7%). Metabolic or respiratory acidosis at baseline was significantly associated with delirium (p = 0.030). Presence of delirium led to significant prolongation of PICU stay (p < 0.001). CONCLUSION The emergence of delirium elicited in this study is on the lower side incomparison to previous studies. Several etiological factors for delirium are preventable and hence protocols and guidelines for management are required.
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Affiliation(s)
- Gautam Sudhakar
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan 342005, India.
| | - Jitender Aneja
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Bathinda, Punjab 151001, India.
| | - Pratibha Gehlawat
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan 342005, India.
| | - Naresh Nebhinani
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan 342005, India.
| | - Daisy Khera
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan 342005, India.
| | - Kuldeep Singh
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan 342005, India.
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Recommendations for analgesia and sedation in critically ill children admitted to intensive care unit. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2022. [PMCID: PMC8853329 DOI: 10.1186/s44158-022-00036-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We aim to develop evidence-based recommendations for intensivists caring for children admitted to intensive care units and requiring analgesia and sedation. A panel of national paediatric intensivists expert in the field of analgesia and sedation and other specialists (a paediatrician, a neuropsychiatrist, a psychologist, a neurologist, a pharmacologist, an anaesthesiologist, two critical care nurses, a methodologist) started in 2018, a 2-year process. Three meetings and one electronic-based discussion were dedicated to the development of the recommendations (presentation of the project, selection of research questions, overview of text related to the research questions, discussion of recommendations). A telematic anonymous consultation was adopted to reach the final agreement on recommendations. A formal conflict-of-interest declaration was obtained from all the authors. Eight areas of direct interest and one additional topic were considered to identify the best available evidence and to develop the recommendations using the Evidence-to-Decision framework according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. For each recommendation, the level of evidence, the strength of the recommendation, the benefits, the harms and the risks, the benefit/harm balance, the intentional vagueness, the values judgement, the exclusions, the difference of the opinions, the knowledge gaps, and the research opportunities were reported. The panel produced 17 recommendations. Nine were evaluated as strong, 3 as moderate, and 5 as weak. Conclusion: a panel of national experts achieved consensus regarding recommendations for the best care in terms of analgesia and sedation in critically ill children.
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Ishii K, Kuroda K, Tokura C, Michida M, Sugimoto K, Sato T, Ishikawa T, Hagioka S, Manabe N, Kurasako T, Goto T, Kimura M, Sunami K, Inoue K, Tsukiji T, Yasukawa T, Nogami S, Tsukioki M, Okabe D, Tanino M, Morimatsu H. Current status of delirium assessment tools in the intensive care unit: a prospective multicenter observational survey. Sci Rep 2022; 12:2185. [PMID: 35140285 PMCID: PMC8828828 DOI: 10.1038/s41598-022-06106-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 01/24/2022] [Indexed: 01/01/2023] Open
Abstract
Delirium is a critical challenge in the intensive care unit (ICU) or high care unit (HCU) setting and is associated with poor outcomes. There is not much literature on how many patients in this setting are assessed for delirium and what tools are used. This study investigated the status of delirium assessment tools of patients in the ICU/HCU. We conducted a multicenter prospective observational study among 20 institutions. Data for patients who were admitted to and discharged from the ICU/HCU during a 1-month study period were collected from each institution using a survey sheet. The primary outcome was the usage rate of delirium assessment tools on an institution- and patient-basis. Secondary outcomes were the delirium prevalence assessed by each institution’s assessment tool, comparison of delirium prevalence between delirium assessment tools, delirium prevalence at the end of ICH/HCU stay, and the relationship between potential factors related to delirium and the development of delirium. Result showed that 95% of institutions used the Intensive Care Delirium Screening Checklist (ICDSC) or the Confusion Assessment Method for the ICU (CAM-ICU) to assess delirium in their ICU/HCU, and the remaining one used another assessment scale. The usage rate (at least once during the ICU/HCU stay) of the ICDSC and the CAM-ICU among individual patients were 64.5% and 25.1%, and only 8.2% of enrolled patients were not assessed by any delirium assessment tool. The prevalence of delirium during ICU/HCU stay was 17.9%, and the prevalence of delirium at the end of the ICU/HCU stay was 5.9%. In conclusion, all institutions used delirium assessment tools in the ICU/HCU, and most patients received delirium assessment. The prevalence of delirium was 17.9%, and two-thirds of patients had recovered at discharge from ICU/HCU. Trial registration number: UMIN000037834.
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Affiliation(s)
- Kenzo Ishii
- Department of Anesthesiology, Intensive Care Unit, Fukuyama City Hospital, 5-23-1 Zao-cho, Fukuyama, Hiroshima, 721-8511, Japan. .,Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
| | - Kosuke Kuroda
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Chika Tokura
- Department of Anesthesia, Kagawa Rosai Hospital, Marugame, Kagawa, Japan
| | - Masaaki Michida
- Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | | | - Tetsufumi Sato
- Department of Anesthesia and Intensive Care, National Cancer Center Hospital, Tokyo, Japan
| | - Tomoki Ishikawa
- Department of Anesthesia, Okayama Red Cross General Hospital, Okayama, Japan
| | - Shingo Hagioka
- Department of Anesthesia, Tsuyama Chuo Hospital, Tsuyama, Okayama, Japan
| | - Nobuki Manabe
- Department of Anesthesia, Saiseikai Imabari Hospital, Imabari, Ehime, Japan
| | - Toshiaki Kurasako
- Department of Anesthesiology, Japanese Red Cross Society Himeji Hospital, Himeji, Hyogo, Japan
| | - Takashi Goto
- Department of Anesthesia, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Masakazu Kimura
- Department of Anesthesia, Okayama City Hospital, Okayama, Japan
| | - Kazuharu Sunami
- Department of Internal Medicine, Okayama Kyoritsu Hospital, Okayama, Japan
| | - Kazuyoshi Inoue
- Department of Anesthesia, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
| | - Takashi Tsukiji
- Department of Anesthesia, Takasago Municipal Hospital, Takasago, Hyogo, Japan
| | - Takeshi Yasukawa
- Department of Anesthesia, Okayama Kyokuto Hospital, Okayama, Japan
| | - Satoshi Nogami
- Department of Anesthesia, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Mitsunori Tsukioki
- Department of Anesthesia, Onomichi Municipal Hospital, Onomichi, Hiroshima, Japan
| | - Daisuke Okabe
- Department of Anesthesia, Himeji St. Mary's Hospital, Himeji, Hyogo, Japan
| | - Masaaki Tanino
- Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School Hospital, Kurashiki, Okayama, Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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A Systematic Review and Pooled Prevalence of Delirium in Critically Ill Children. Crit Care Med 2021; 50:317-328. [PMID: 34387241 DOI: 10.1097/ccm.0000000000005260] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Pediatric delirium is a neuropsychiatric disorder with disrupted cerebral functioning due to underlying disease and/or critical care treatment. Pediatric delirium can be classified as hypoactive, hyperactive, and mixed. This systematic review was conducted to estimate the pooled prevalence of pediatric delirium using validated assessment tools in children (Cornell Assessment of Pediatric Delirium, Pediatric Confusion Assessment Method for the ICU, PreSchool Confusion Assessment Method for the ICU, Pediatric Confusion Assessment Method for the ICU Severity Scale, and Sophia Observation Withdrawal Symptoms Pediatric Delirium scale), identify modifiable and nonmodifiable risk factors, and explore the association of pediatric delirium with clinical outcomes. DATA SOURCES A systematic search of PubMed, EMBASE, and CINAHL databases was undertaken for full articles pertaining to pediatric delirium prevalence. STUDY SELECTION No language or date barriers were set. Studies were included where the following eligibility criteria were met: study design aimed to estimate pediatric delirium prevalence arising from treatment in the intensive care setting, using a validated tool. Only randomized controlled trials, cross-sectional studies, or cohort studies allowing an estimate of the prevalence of pediatric delirium were included. DATA EXTRACTION Data were extracted by the primary researcher (D.S.) and accuracy checked by coauthors. DATA SYNTHESIS A narrative synthesis and pooled prevalence meta-analysis were undertaken. CONCLUSIONS Pediatric delirium, as determined by the Cornell Assessment of Pediatric Delirium score, is estimated to occur in 34% of critical care admissions. Eight of 11 studies reporting on subtype identified hypoactive delirium as most prevalent (46-81%) with each of the three remaining reporting either hyperactive (44%), mixed (57%), or equal percentages of hypoactive and mixed delirium (43%) as most prevalent. The development of pediatric delirium is associated with cumulative doses of benzodiazepines, opioids, the number of sedative classes used, deep sedation, and cardiothoracic surgery. Increased time mechanically ventilated, length of stay, mortality, healthcare costs, and associations with decreased quality of life after discharge were also found. Multi-institutional and longitudinal studies are required to better determine the natural history, true prevalence, long-term outcomes, management strategies, and financial implications of pediatric delirium.
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Huang X, Lei L, Zhang S, Yang J, Yang L, Xu M. Implementation of the "awakening and breathing trials, choice of drugs, delirium management, and early exercise/mobility" bundle in the pediatric intensive care unit of tertiary hospitals in southwestern China: a cross-sectional survey. J Int Med Res 2021; 49:300060520987770. [PMID: 33513055 PMCID: PMC7871094 DOI: 10.1177/0300060520987770] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To investigate management and implementation of the “awakening and breathing trials, choice of drugs, delirium management, and early exercise/mobility” (ABCDE) bundle in the pediatric intensive care unit (PICU) in southwestern China Methods A self-designed questionnaire for determining implementation of the ABCDE bundle was distributed to healthcare professionals in the PICU. Multiple linear regression was used to analyze results. Results A total of 270 questionnaires were collected. There was no significant difference in the awareness of the ABCDE bundle rate among Sichuan, Guizhou, and Yunnan workers. Only dynamic adjustment of drug dose accounted for more than half (55.5%) of “frequent implementation” and “general implementation”, followed by implementation of sedation assessment, pain assessment, and spontaneous breathing trials (46.4%, 39.3%, and 35.6%, respectively). A total of 80.4% of healthcare professionals never performed screening of delirium. Multivariate analysis showed that the healthcare professionals’ scores of ABCDE bundle behavior significantly differed regarding awareness of the ABCDE bundle, years of work at the hospital, the region of hospitals, and occupational category. Conclusion Implementation of the ABCDE bundle in the PICU in southwestern China is not sufficient. Existing problems need to be identified and a standardized sedation and analgesia management model needs to be established.
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Affiliation(s)
- Xiaoming Huang
- Department of Pediatric Intensive Care Unit, Nursing Department, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Lei Lei
- Department of Pediatric Intensive Care Unit, Nursing Department, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Shuai Zhang
- Department of Pediatric Intensive Care Unit, Nursing Department, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Jinrong Yang
- Department of Pediatric Intensive Care Unit, Nursing Department, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Lin Yang
- Department of Pediatric Intensive Care Unit, Nursing Department, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Min Xu
- Department of Pediatric Intensive Care Unit, Nursing Department, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
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Abstract
PURPOSE OF REVIEW Delirium is a frequent complication of serious medical illness in children. The purpose of this review is to highlight recent data on the epidemiology and outcomes related to pediatric delirium, and discuss prevention strategies. RECENT FINDINGS Delirium rates in the pediatric ICU are greater than 25%. Delirium in children is associated with prolonged mechanical ventilation and hospital length of stay, increased costs, and excess mortality. Pediatric delirium may affect postdischarge cognition and quality of life. Recent initiatives targeting universal screening, early mobilization, and minimization of benzodiazepine-based sedation have shown reduction in delirium prevalence. SUMMARY Widespread screening is needed in critically ill children to detect and mitigate delirium. The identification of modifiable risk factors has provided an opportunity for delirium prevention. Large-scale longitudinal studies are needed to investigate the long-term sequelae of delirium in children.
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11
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Kalvas LB, Harrison TM. State of the science in pediatric ICU delirium: An integrative review. Res Nurs Health 2020; 43:341-355. [PMID: 32632985 PMCID: PMC8006059 DOI: 10.1002/nur.22054] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/23/2020] [Indexed: 11/08/2022]
Abstract
Delirium is a complication of critical illness associated with poor outcomes. Although widely studied in adults, comparatively little is understood about delirium in pediatric intensive care units (ICUs). The purpose of this integrative review is to determine the extent and nature of current evidence, identify gaps in the literature, and outline future areas for investigation of pediatric ICU delirium. Eligible articles included research reports of delirium in pediatric ICU samples published in English since 2009. After an extensive literature search and consideration for inclusion/exclusion criteria, 22 articles were chosen for review. Delirium was highly prevalent in the ICU. Delirium episodes developed early in hospitalization, lasted several days, and consisted of hypoactive or mixed motor subtypes. Frequently identified independent risk factors included young age, developmental delay, mechanical ventilation, and benzodiazepine exposure. Pediatric delirium was independently associated with increased length of stay, costs, and mortality. The long-term cognitive, psychological, and functional morbidities associated with pediatric delirium remain largely unknown. Few researchers have implemented interventions to prevent or manage delirium. There was little evidence for the efficacy or safety of pharmacological management. Multicomponent delirium bundles may significantly decrease delirium incidence. Key quality issues among studies included variation in delirium screening, low levels of evidence (i.e., observational studies), and limited ability to determine intervention efficacy in quasi-experimental designs. Although the quantity and quality of pediatric delirium research has rapidly increased, further studies are needed to understand the long-term effects of pediatric delirium and determine the efficacy and safety of interventions for prevention and management.
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Affiliation(s)
- Laura Beth Kalvas
- Graduate Fellow at The Ohio State University College of Nursing, Columbus, OH
| | - Tondi M. Harrison
- Associate Professor at The Ohio State University College of Nursing, Columbus, OH
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12
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Abstract
OBJECTIVES To describe the relationships between anticholinergic drug exposure, cholinesterase enzyme activity, inflammation, and the development of postoperative delirium in children. DESIGN Single-center prospective cohort study. SETTING Twenty-two bed PICU in a tertiary-care academic medical center in Germany. PATIENTS A consecutive cohort of children admitted after major elective surgery. INTERVENTIONS Children were screened for delirium bid over 5 consecutive postoperative days. Acetylcholinesterase and butyrylcholinesterase plasma activity levels were measured prior to surgery and once daily during the 5 day study period. Number of anticholinergic drugs and Anticholinergic Drug Scale score were calculated for each patient. MEASUREMENTS AND MAIN RESULTS Ninety-three children (age range, 0-17 yr) were included. The number of anticholinergic drugs as well as the Anticholinergic Drug Scale score were significantly correlated with development of postoperative delirium, independently of disease severity. Baseline cholinesterase enzyme levels did not differ between patients who did and did not develop postoperative delirium. Butyrylcholinesterase levels, but not acetylcholinesterase levels, dropped by 33% postoperatively, independent of the presence of postoperative delirium. Postoperative butyrylcholinesterase levels were inversely related to number of anticholinergic drugs, Anticholinergic Drug Scale score, and C-reactive protein levels. CONCLUSIONS Anticholinergic drug exposure was related to development of postoperative delirium in this cohort, with demonstration of a dose-response relationship. As there are alternative options available for many of these medications, it may be reasonable to avoid anticholinergic exposure in the PICU whenever possible.
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13
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Rodríguez-Rubio M, Álvarez-Rojas E, de la Oliva P. The diagnosis of delirium in pediatric intensive care: A burdensome yet essential task. Med Intensiva 2019; 44:128. [PMID: 31097217 DOI: 10.1016/j.medin.2019.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 04/07/2019] [Indexed: 10/26/2022]
Affiliation(s)
- M Rodríguez-Rubio
- Servicio de Cuidados Intensivos Pediátricos, Hospital Universitario La Paz, Madrid, España; Departamento de Pediatría, Universidad Autónoma de Madrid, Madrid, España.
| | - E Álvarez-Rojas
- Servicio de Cuidados Intensivos Pediátricos, Hospital Universitario La Paz, Madrid, España
| | - P de la Oliva
- Servicio de Cuidados Intensivos Pediátricos, Hospital Universitario La Paz, Madrid, España; Departamento de Pediatría, Universidad Autónoma de Madrid, Madrid, España
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