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Lin N, Lv M, Li S, Xiang Y, Li J, Xu H. A nomogram for predicting postoperative delirium in pediatric patients following cardiopulmonary bypass: A prospective observational study. Intensive Crit Care Nurs 2024; 83:103717. [PMID: 38692080 DOI: 10.1016/j.iccn.2024.103717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 04/17/2024] [Accepted: 04/26/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVES To create a nomogram for early delirium detection in pediatric patients following cardiopulmonary bypass. RESEARCH METHODOLOGY/DESIGN This prospective, observational study was conducted in the Cardiac Intensive Care Unit at a Children's Hospital, enrolling 501 pediatric patients from February 2022 to January 2023. Perioperative data were systematically collected through the hospital information system. Postoperative delirium was assessed using the Cornell Assessment of Pediatric Delirium (CAPD). For model development, Least Absolute Shrinkage and Selection Operator (LASSO) regression was employed to identify the most relevant predictors. These selected predictors were then incorporated into a multivariable logistic regression model to construct the predictive nomogram. The performance of the model was evaluated by Harrell's concordance index, receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis. External validity of the model was confirmed through the C-index and calibration plots. RESULTS Five independent predictors were identified: age, SpO2 levels, lymphocyte count, diuretic use, and midazolam administration, integrated into a predictive nomogram. This nomogram demonstrated strong predictive capacity (AUC 0.816, concordance index 0.815) with good model fit (Hosmer-Lemeshow test p = 0.826) and high accuracy. Decision curve analysis showed a significant net benefit, and external validation confirmed the nomogram's reliability. CONCLUSIONS The study successfully developed a precise and effective nomogram for identifying pediatric patients at high risk of post-cardiopulmonary bypass delirium, incorporating age, SpO2 levels, lymphocyte counts, diuretic use, and midazolam medication. IMPLICATIONS FOR CLINICAL PRACTICE This nomogram aids early delirium detection and prevention in critically ill children, improving clinical decisions and treatment optimization. It enables precise monitoring and tailored medication strategies, significantly contributes to reducing the incidence of delirium, thereby enhancing the overall quality of patient care.
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Affiliation(s)
- Nan Lin
- Nursing Department, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Meng Lv
- Nursing Department, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Shujun Li
- Nursing Department, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Yujun Xiang
- Nursing Department, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Jiahuan Li
- Nursing Department, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Hongzhen Xu
- Nursing Department, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China.
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Watson WD, Chen HW, Svingos AM, Ortiz AK, Suskauer SJ, Shah SA, Traube C. Screening for Delirium During Pediatric Brain Injury Rehabilitation. Arch Phys Med Rehabil 2024; 105:1305-1313. [PMID: 38452881 DOI: 10.1016/j.apmr.2024.02.729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVE To assess feasibility of routine delirium screening using the Cornell Assessment of Pediatric Delirium (CAPD) in children admitted for rehabilitation with acquired brain injury (ABI), report on the prevalence of positive delirium screens in this population, and explore longitudinal trends in CAPD scores and their association with rehabilitation outcomes. DESIGN Retrospective study. SETTING Pediatric inpatient rehabilitation unit. PARTICIPANTS 144 children (median 10.8 years) with ABI (N=144). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Percent compliance with twice daily delirium screening; prevalence of positive delirium screens; trajectories in CAPD scores and their relation with FIM for Children (WeeFIM) scores. RESULTS Screening was feasible (mean 75% compliance for each of 144 children). Of 16,136 delirium screens, 29% were positive. 62% of children had ≥1 positive screen. Four primary patterns of CAPD trajectories were identified: Static Encephalopathy (10%), Episodic Delirium (10%), Improving (32%), and No Delirium (48%). Validity of these trajectories was demonstrated through association with WeeFIM and CALS outcomes. Younger age at admission was associated with positive delirium screens, and rehabilitation length of stay was significantly longer for the Improving group. CONCLUSIONS Delirium occurs frequently in children with ABI during inpatient rehabilitation. Routine delirium screening provides clinically relevant information including the potential to facilitate early detection and intervention for medical complications. Longitudinal ratings of delirium symptoms may also have a role in developing a standardized definition for Post Traumatic Confusional State (PTCS) stage of recovery in children.
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Affiliation(s)
- William D Watson
- Blythedale Children's Hospital, Valhalla, NY; Department of Rehabilitation & Regenerative Medicine, Columbia University, New York, NY.
| | | | - Adrian M Svingos
- Kennedy Krieger Institute, Baltimore, MD; Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ana K Ortiz
- Blythedale Children's Hospital, Valhalla, NY
| | - Stacy J Suskauer
- Kennedy Krieger Institute, Baltimore, MD; Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sudhin A Shah
- Department of Radiology, Weill Cornell Medicine, New York, NY
| | - Chani Traube
- Department of Pediatrics, Weill Cornell Medicine, New York, NY
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Weatherly AJ, Johnson CA, Liu D, Kannankeril PJ, Smith HAB, Betters KA. Association of Hyperoxia During Cardiopulmonary Bypass and Postoperative Delirium in the Pediatric Cardiac ICU. Crit Care Explor 2024; 6:e1119. [PMID: 38968166 PMCID: PMC11230773 DOI: 10.1097/cce.0000000000001119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2024] Open
Abstract
OBJECTIVE ICU delirium commonly complicates critical illness associated with factors such as cardiopulmonary bypass (CPB) time and the requirement of mechanical ventilation (MV). Recent reports associate hyperoxia with poorer outcomes in critically ill children. This study sought to determine whether hyperoxia on CPB in pediatric patients was associated with a higher prevalence of postoperative delirium. DESIGN Secondary analysis of data obtained from a prospective cohort study. SETTING Twenty-two-bed pediatric cardiac ICU in a tertiary children's hospital. PATIENTS All patients (18 yr old or older) admitted post-CPB, with documented delirium assessment scores using the Preschool/Pediatric Confusion Assessment Method for the ICU and who were enrolled in the Precision Medicine in Pediatric Cardiology Cohort from February 2021 to November 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 148 patients, who underwent cardiac surgery, 35 had delirium within the first 72 hours (24%). There was no association between hyperoxia on CPB and postoperative delirium for all definitions of hyperoxia, including hyperoxic area under the curve above 5 predetermined Pao2 levels: 150 mm Hg (odds ratio [95% CI]: 1.176 [0.605-2.286], p = 0.633); 175 mm Hg (OR 1.177 [95% CI, 0.668-2.075], p = 0.572); 200 mm Hg (OR 1.235 [95% CI, 0.752-2.026], p = 0.405); 250 mm Hg (OR 1.204 [95% CI, 0.859-1.688], p = 0.281), 300 mm Hg (OR 1.178 [95% CI, 0.918-1.511], p = 0.199). In an additional exploratory analysis, comparing patients with delirium within 72 hours versus those without, only the z score for weight differed (mean [sd]: 0.09 [1.41] vs. -0.48 [1.82], p < 0.05). When comparing patients who developed delirium at any point during their ICU stay (n = 45, 30%), MV days, severity of illness (Pediatric Index of Mortality 3 Score) score, CPB time, and z score for weight were associated with delirium (p < 0.05). CONCLUSIONS Postoperative delirium (72 hr from CPB) occurred in 24% of pediatric patients. Hyperoxia, defined in multiple ways, was not associated with delirium. On exploratory analysis, nutritional status (z score for weight) may be a significant factor in delirium risk. Further delineation of risk factors for postoperative delirium versus ICU delirium warrants additional study.
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Affiliation(s)
- Allison J Weatherly
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
| | - Cassandra A Johnson
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Prince J Kannankeril
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
| | - Heidi A B Smith
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Kristina A Betters
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
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Patel S, Pfeiffer B, Haddock De Jesus R, Garcia J, Chandar J, Alladin A. Postoperative Delirium Screening Characteristics in Pediatric Intestinal, Liver, and Renal Transplant Recipients: Single-Center Retrospective Cohort Study. Pediatr Crit Care Med 2024:00130478-990000000-00348. [PMID: 38801303 DOI: 10.1097/pcc.0000000000003540] [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] [Indexed: 05/29/2024]
Abstract
OBJECTIVES To describe and compare the results of delirium screening in the immediate post-transplant PICU admission for pediatric intestinal, liver, and renal transplant recipients. We also examined associations with known and suspected risk factors for pediatric delirium (PD). DESIGN Retrospective analysis of a single-center cohort, 2016-2022. SETTING Twenty-four-bed PICU in a high-volume transplant center. PATIENTS All intestinal, liver, and renal transplant recipients under 23 years old admitted between July 2016 and August 2022. MEASUREMENTS AND MAIN RESULTS We identified 211 pediatric transplant recipients: intestinal (n = 36), liver (n = 78), and renal (n = 97). Results of the Cornell Assessment for PD during the immediate post-transplant PICU admission were reviewed and patients were categorized into screen positive, screen negative, and unscreened. Corresponding data on known and suspected risk factors for PD were also collected. Data on delirium subtypes were not collected. Screens were available for 156 of 211 patients (74%) who were included in the final analysis. The prevalence of a positive screen by transplant category was: intestine 80% (24/30), liver 75% (47/63), and renal 14% (9/63). A positive screen was associated with younger age, greater duration of mechanical ventilation, and greater PICU length of stay (LOS) in bivariate analysis. In multivariable analysis, age and PICU LOS remained strongly correlated with a positive screen (p < 0.05). Deep sedation and agitation as categorized by the State Behavioral Scale was associated with a positive screen, as was significant iatrogenic withdrawal symptoms (p < 0.05). Most patients screened positive by post-transplant days 2 and 3 (58/80 [72%] and 64/80 [80%], respectively). CONCLUSIONS In our 2016 to 2022 experience, we found a high prevalence of positive PD screens in pediatric intestinal and liver transplant recipients in the immediate post-transplant PICU admission. A positive screen was associated with younger age and greater PICU LOS.
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Affiliation(s)
- Sagar Patel
- Pediatric Critical Care Fellowship Program, Department of Pediatrics, Holtz Children's Hospital, University of Miami Miller School of Medicine, Miami, FL
| | - Brent Pfeiffer
- Division of Pediatric Critical Care, Department of Pediatrics, Holtz Children's Hospital, University of Miami Miller School of Medicine, Miami, FL
| | - Rosa Haddock De Jesus
- Pediatric Critical Care Fellowship Program, Department of Pediatrics, Holtz Children's Hospital, University of Miami Miller School of Medicine, Miami, FL
| | - Jennifer Garcia
- Department of Pediatrics, Miami Transplant Institute, Holtz Children's Hospital, University of Miami Miller School of Medicine, Miami, FL
| | - Jayanthi Chandar
- Division of Pediatric Nephrology, Department of Pediatrics, Miami Transplant Institute, Holtz Children's Hospital, University of Miami Miller School of Medicine, Miami, FL
| | - Amanda Alladin
- Division of Pediatric Critical Care, Department of Pediatrics, Holtz Children's Hospital, University of Miami Miller School of Medicine, Miami, FL
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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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Liu K, Lin N, Jin T, Xiang Y, Li J, Lai D, Xu H. Association between pediatric postoperative delirium and regional cerebral oxygen saturation: a prospective observational study. BMC Psychiatry 2024; 24:367. [PMID: 38750494 PMCID: PMC11097584 DOI: 10.1186/s12888-024-05832-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 05/09/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Postoperative delirium (POD) represents a prevalent and noteworthy complication in the context of pediatric surgical interventions. In recent times, a hypothesis has emerged positing that cerebral ischemia and regional cerebral oxygen desaturation might serve as potential catalysts in the pathogenesis of POD. The primary aim of this study was to methodically examine the potential relationship between POD and regional cerebral oxygen saturation (rSO2) and to assess the predictive and evaluative utility of rSO2 in the context of POD. METHODS This prospective observational study was conducted at the Children's Hospital, Zhejiang University School of Medicine, Zhejiang, China, spanning the period from November 2020 to March 2021. The research cohort comprised children undergoing surgical procedures within this clinical setting. To measure rSO2 dynamics, cerebral near-infrared spectroscopy (NIRS) was used to monitor rSO2 levels both before and after surgery. In addition, POD was assessed in the paediatric patients according to the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) criteria. The analysis of the association between the rSO2 index and the incidence of POD was carried out through the application of either the independent samples t-test or the nonparametric rank-sum test. To ascertain the threshold value of the adjusted rSO2 index for predictive and evaluative purposes regarding POD in the pediatric population, the Receiver Operating Characteristics (ROC) curve was employed. RESULTS A total of 211 cases were included in this study, of which 61 (28.9%) developed POD. Participants suffering delirium had lower preoperative rSO2mean, lower preoperative rSO2min, and lower postoperative rSO2min, higher ∆rSO2mean, higher amount of ∆rSO2mean, lower ∆rSO2min (P < 0.05). Preoperative rSO2mean (AUC = 0.716, 95%CI 0.642-0.790), ∆rSO2mean (AUC = 0.694, 95%CI 0.614-0.774), amount of ∆rSO2mean (AUC = 0.649, 95%CI 0.564-0.734), preoperative rSO2min (AUC = 0.702, 96%CI 0.628-0.777), postoperative rSO2min (AUC = 0.717, 95%CI 0.647-0.787), and ∆rSO2min (AUC = 0.714, 95%CI 0.638-0.790) performed well in sensitivity and specificity, and the best threshold were 62.05%, 1.27%, 2.41%, 55.68%, 57.36%, 1.29%. CONCLUSIONS There is a close relationship between pediatric POD and rSO2. rSO2 could be used as an effective predictor of pediatric POD. It might be helpful to measure rSO2 with NIRS for early recognizing POD and making it possible for early intervention.
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Affiliation(s)
- Kexian Liu
- Nursing Department, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, 310052, China
- Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Nan Lin
- Nursing Department, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, 310052, China
- Department of Neonatal Surgery, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, 310052, China
| | - Ting Jin
- Nursing Department, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, 310052, China
| | - Yujun Xiang
- Nursing Department, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, 310052, China
| | - Jiahuan Li
- Nursing Department, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, 310052, China
| | - Dengming Lai
- Department of Neonatal Surgery, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, 310052, China.
| | - Hongzhen Xu
- Nursing Department, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, 310052, China.
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Stenkjaer RL, Egerod I, Moszkowicz M, Ista E, Greisen G, Weis J, Pagsberg AK, Herling SF. Prospective validation of Sophia observation withdrawal symptoms: A paediatric delirium scale in critically ill children in Denmark. Aust Crit Care 2024; 37:400-406. [PMID: 37164889 DOI: 10.1016/j.aucc.2023.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 03/27/2023] [Accepted: 04/01/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Paediatric delirium (PD) is increasingly recognised as a common disorder in critically ill children with a reported prevalence ranging from 9% to 66%. We validated the PD component of the Sophia Observation withdrawal Symptoms-Paediatric Delirium (SOS-PD) scale in a Danish setting to provide increased awareness and reliable identification of this critical condition, thereby paving the way for improved pathways to targeted delirium care. OBJECTIVE The objectives of this study were to criterion validate the PD component of the SOS-PD screening tool by comparing blinded psychiatric and nurse assessments and to estimate the prevalence of delirium in critically ill children in a Danish context. METHODS A prospective observational study was performed on critically ill children aged between 3 m and 18 y, admitted to an intensive care unit, with a hospital stay of 48 h or more. Assessments took place on a fixed weekday over an 18-month period. To test accuracy and criterion validity, bedside nurses' SOS-PD assessments were compared to the reference standard, a diagnostic assessment performed by a child psychiatrist according to the Diagnostic and Statistical Manual-V criteria by use of the Vanderbilt Assessment of Delirium in Infants and Children. RESULTS We included 141 children in the study, 30 (21%) of whom were diagnosed with delirium by the child psychiatrist. The accuracy of the delirium diagnosis was 93.6% (95% confidence interval [CI]: 88.3-97.1) among the nurses' SOS-PD assessments compared to the reference standard. The SOS-PD demonstrated a high sensitivity of 83.3% (95% CI: 65.3-94.4) and a high specificity of 96.4% (95% CI: 91.0-99.0) with five false-negative and four false-positive cases. CONCLUSION The PD component of the SOS-PD tool has good accuracy and validity for assessments performed by nurses compared to a child psychiatrist's diagnosis in critically ill children in a Danish setting. We recommend the use of the SOS-PD instrument in clinical practice.
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Affiliation(s)
- Rikke Louise Stenkjaer
- Department of Neonatology, Copenhagen University Hospital, Rigshospitalet Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Ingrid Egerod
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet Blegdamsvej 9, 2100 Copenhagen, Denmark; University of Copenhagen, Department of Clinical Medicine Copenhagen, Denmark.
| | - Mala Moszkowicz
- Child and Adolescent Mental Health Center, Copenhagen University Hospital, Mental Health Services CPH, Gentofte Hospitalsvej 3A, 1. sal, Copenhagen 2900 Hellerup, Denmark.
| | - Erwin Ista
- Department of paediatric Surgery, paediatric Intensive Care, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Gorm Greisen
- Department of Neonatology, Copenhagen University Hospital, Rigshospitalet Blegdamsvej 9, 2100 Copenhagen, Denmark; University of Copenhagen, Department of Clinical Medicine Copenhagen, Denmark.
| | - Janne Weis
- Department of Neonatology, Copenhagen University Hospital, Rigshospitalet Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Anne Katrine Pagsberg
- Child and Adolescent Mental Health Center, Copenhagen University Hospital, Mental Health Services CPH, Gentofte Hospitalsvej 3A, 1. sal, Copenhagen 2900 Hellerup, Denmark.
| | - Suzanne Forsyth Herling
- The Neuroscience Centre, Copenhagen University Hospital Rigshospitalet Blegdamsvej 9, 2100 Copenhagen, Denmark; University of Copenhagen, Department of Clinical Medicine Copenhagen, Denmark.
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Gray MC, Traube C, Sewell TB, Geneslaw AS. Delirium Associated with COVID-19 in Critically ill Children: An Observational Cohort Study. J Intensive Care Med 2024:8850666241249169. [PMID: 38689485 DOI: 10.1177/08850666241249169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
OBJECTIVE Delirium is an under-recognized problem in critically ill children. Although delirium is common in adults hospitalized with COVID-19, the relationship between pediatric COVID-19 and delirium has not been described. To address this gap, we characterized delirium in critically ill children with different manifestations of COVID-19 and investigated associations among demographic, disease, and treatment factors. We hypothesized that multisystem inflammatory syndrome in children (MIS-C) would be associated with a higher incidence of delirium given its underlying pathophysiology of hyperinflammation. DESIGN Retrospective, single-center cohort study. SETTING Quaternary-care pediatric intensive care unit (PICU). PATIENTS Children less than 18 years of age hospitalized in the PICU between March 2020 and March 2023 with either active SARS-CoV-2 infection or serological evidence of prior infection. MEASUREMENTS AND MAIN RESULTS The cohort included 149 PICU hospitalizations among children with evidence of COVID-19. Patients were categorized by reason for PICU admission: 75 (50%) for COVID-19 respiratory disease, 36 (24%) MIS-C, and 38 (26%) any other primary reason with positive COVID-19 testing. Delirium was diagnosed in 43 (29%) patients. Delirium incidence was highest in patients requiring invasive mechanical ventilation (IMV) (56% vs 7.5% in patients who did not require IMV, p < .001). Patients who were exposed to opioids, dexmedetomidine, paralytics or benzodiazepines more frequently experienced delirium compared to those unexposed (p < .001, p < .001, p < .001 and p = .001, respectively). After multivariable adjustment, delirium was associated with IMV (HR 3 [95% CI 1.5-5.7]), female sex (HR 2.4 [1.2-4.7]), and developmental disability (HR 3.4 [95% CI 1-11.1]). There was no association between delirium and reason for PICU hospitalization. CONCLUSIONS Delirium was common among children hospitalized with COVID-19. The overall incidence was much less than has been reported in adults with COVID-19. Delirium reduction efforts should focus on children with developmental disability and minimizing ongoing risks during IMV.
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Affiliation(s)
- Meghan C Gray
- Division of Pediatric Critical Care & Hospital Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Chani Traube
- Division of Pediatric Critical Care Medicine, New York-Presbyterian Weill Cornell Medical College, New York, NY, USA
| | - Taylor B Sewell
- Division of Pediatric Critical Care & Hospital Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Andrew S Geneslaw
- Division of Pediatric Critical Care & Hospital Medicine, Columbia University Irving Medical Center, New York, NY, USA
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Fu CH, Li Y, Zhang YC, Yang XY, Liu J, Ju MJ, Xu TT. Nursing Care of a Child With Delirium Receiving Venoarterial Extracorporeal Membrane Oxygenation: A Case Report. Crit Care Nurse 2024; 44:13-20. [PMID: 38555967 DOI: 10.4037/ccn2024150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
INTRODUCTION Children receiving extracorporeal membrane oxygenation are prone to delirium. This case report describes the nursing care of a child with delirium who received venoarterial extracorporeal membrane oxygenation. Relevant interventions and precautions are also discussed. CLINICAL FINDINGS A 6-year-old girl was admitted to the pediatric intensive care unit with a 2-day history of vomiting and fever. The child underwent cannulation for venoarterial extracorporeal membrane oxygenation. DIAGNOSIS The child was diagnosed with acute fulminant myocarditis, cardiac shock, and ventricular arrhythmia. INTERVENTIONS On the third day of extracorporeal membrane oxygenation, bedside nurses began using the Cornell Assessment of Pediatric Delirium to assess the child for delirium symptoms. The team of physicians and nurses incorporated a nonpharmacologic delirium management bundle into pediatric daily care. Delirium screening, analgesia and sedation management, sleep promotion, and family participation were implemented. OUTCOMES During the 18 days of pediatric intensive care unit hospitalization, the child had 6 days of delirium: 1.5 days of hypoactive delirium, 1.5 days of hyperactive delirium, and 3 days of mixed delirium. The child was successfully discharged home on hospital day 22. CONCLUSION Caring for a child with delirium receiving venoarterial extracorporeal membrane oxygenation required multidimensional nursing capabilities to prevent and reduce delirium while ensuring safe extracorporeal membrane oxygenation. This report may assist critical care nurses caring for children under similar circumstances.
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Affiliation(s)
- Cong-Hui Fu
- Cong-hui Fu is a clinical nurse in the Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Li
- Yan Li is a clinical nurse in the Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine
| | - Yu-Cai Zhang
- Yu-cai Zhang is the Unit Director of the Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine
| | - Xiao-Ya Yang
- Xiao-ya Yang is a clinical nurse in the Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine
| | - Ji Liu
- Ji Liu is a clinical nurse in the Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine
| | - Min-Jie Ju
- Min-jie Ju is a clinical nurse in the Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine
| | - Ting-Ting Xu
- Ting-ting Xu is a superintendent nurse in the Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine
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Shon S, Kang M. Nursing experiences and knowledge of paediatric delirium: Analysing knowledge-practice gaps. Nurs Crit Care 2024. [PMID: 38516768 DOI: 10.1111/nicc.13068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/27/2024] [Accepted: 03/11/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Delirium commonly occurs in paediatric patients with acute critical illness and negatively affects clinical outcomes. Variations in delirium knowledge levels and its management have been noted among nurses. AIMS This study investigated nurses' experiences and knowledge levels regarding paediatric delirium. Additionally, we aimed to assess the gap between knowledge levels and practical experiences with paediatric delirium. STUDY DESIGN This cross-sectional descriptive study conveniently sampled paediatric nurses from a university hospital in South Korea between September 2022 and March 2023. Nursing experiences with paediatric delirium and delirium knowledge levels were measured using structured survey questionnaires. Delirium knowledge was scored 0 to 47, and higher scores indicated higher levels of delirium-related knowledge. Data were analysed using descriptive statistics and presented as mean, standard deviation, frequency and percentage. RESULTS A total of 127 paediatric nurses participated in this study; 40.2% had experience with 1-5 delirium cases in the previous year, and 86.6% (n = 110) had never used assessment tools for paediatric delirium assessment. The mean total delirium knowledge score was 34.45 ± 5.4; the mean scores of knowledge regarding aetiology, signs and symptoms and nursing management of delirium were 8.93 ± 1.31, 13.24 ± 2.81 and 12.3 ± 2.7, respectively. Interventions associated with a lower level of delirium-related knowledge and a lower performance rate included avoiding restraint use and maintaining hydration and electrolyte levels. Interventions associated with a higher level of delirium-related knowledge but a lower rate of performance comprised providing orientation, offering emotional support, allowing participants to stay with family members and administering medications to manage delirium. CONCLUSIONS Although nurses working in paediatric units exhibited high rate of delirium nursing care, there was the gap between their delirium-related knowledge and practice. Nurses need to be aware of the insufficient part of delirium care, and paediatric delirium education should be reinforced. RELEVANCE TO CLINICAL PRACTICE Preventing, assessing and systematically managing paediatric delirium is crucial, and considering the study results, delirium education among nurses is needed.
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Affiliation(s)
- Soonyoung Shon
- College of Nursing, Keimyung University, Daegu, Republic of Korea
| | - Minkyung Kang
- College of Nursing, Ajou University, Suwon, Republic of Korea
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Kim K, Jeong JH, Choi EK. Non-pharmacological interventions for delirium in the pediatric population: a systematic review with narrative synthesis. BMC Pediatr 2024; 24:108. [PMID: 38347509 PMCID: PMC10863154 DOI: 10.1186/s12887-024-04595-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 01/25/2024] [Indexed: 02/15/2024] Open
Abstract
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.
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Affiliation(s)
- Kyua Kim
- Department of Nursing, Yonsei University Graduate School & Pediatric Intensive Care Unit, Severance Hospital, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, South Korea
| | - Ju Hee Jeong
- Department of Nursing, Yonsei University Graduate School & Emergency Nursing, Severance Hospital, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, South Korea
| | - Eun Kyoung Choi
- College of Nursing &, Mo-Im Kim Nursing Research Institute, Yonsei University, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, South Korea.
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12
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Fu M, Yuan Q, Yang Q, Song W, Yu Y, Luo Y, Xiong X, Yu G. Risk factors and incidence of postoperative delirium after cardiac surgery in children: a systematic review and meta-analysis. Ital J Pediatr 2024; 50:24. [PMID: 38331831 PMCID: PMC10854157 DOI: 10.1186/s13052-024-01603-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/28/2024] [Indexed: 02/10/2024] Open
Abstract
Delirium, a form of acute cerebral dysfunction, is a common complication of postoperative cardiac surgery in children. It is strongly associated with adverse outcomes, including prolonged hospitalization, increased mortality, and cognitive dysfunction. This study aimed to identify risk factors and incidence of delirium after cardiac surgery in children to facilitate early identification of delirium risk and provide a reference for the implementation of effective prevention and management. A systematic literature search was conducted in PubMed, Web of Science, Embase, Cochrane Library, Scopus, CNKI, Sinomed, and Wanfang for studies published in English or Chinese from the inception of each database to November 2023. The PRISMA guidelines were followed in all phases of this systematic review. The Risk of Bias Assessment for Nonrandomized Studies tool was used to assess methodological quality. A total of twelve studies were included in the analysis, with four studies classified as overall low risk of bias, seven studies as moderate risk of bias, and one study as high risk of bias. The studies reported 39 possible predictors of delirium, categorized into four broad groups: intrinsic and parent-related factors, disease-related factors, surgery and treatment-related factors, and clinical scores and laboratory parameters. By conducting qualitative synthesis and quantitative meta-analysis, we identified two definite factors, four possible factors, and 32 unclear factors related to delirium. Definite risk factors included age and mechanical ventilation duration. Possible factors included developmental delay, cyanotic heart disease, cardiopulmonary bypass time, and pain score. With only a few high-quality studies currently available, well-designed and more extensive prospective studies are still needed to investigate the risk factors affecting delirium and explore delirium prevention strategies in high-risk children.
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Affiliation(s)
- Maoling Fu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Qiaokou District, Wuhan, Hubei, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Quan Yuan
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Qiaokou District, Wuhan, Hubei, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Qiaoyue Yang
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Qiaokou District, Wuhan, Hubei, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wenshuai Song
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Qiaokou District, Wuhan, Hubei, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yaqi Yu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Qiaokou District, Wuhan, Hubei, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ying Luo
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Qiaokou District, Wuhan, Hubei, China
| | - Xiaoju Xiong
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Qiaokou District, Wuhan, Hubei, China
| | - Genzhen Yu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Qiaokou District, Wuhan, Hubei, China.
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13
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Kolmar AR, Paton AM, Kramer MA, Guilliams KP. Differences in Delirium Evaluation and Pharmacologic Management in Children With Developmental Delay: A Retrospective Case-Control Study. J Intensive Care Med 2024; 39:170-175. [PMID: 37563949 PMCID: PMC10938448 DOI: 10.1177/08850666231194534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Delirium is associated with increased mortality and cost, decreased neurocognition, and decreased quality of life in the pediatric intensive care unit (PICU) population. The Cornell Assessment for Pediatric Delirium (CAPD) is used in PICUs for delirium screening but lacks specificity in children with developmental delay (DD). Within a cohort of children receiving pharmacologic treatment for intensive care unit (ICU) delirium, we compared delirium scoring and medication management between children with and without DD. We hypothesized that CAPD scores and treatment decisions would differ between DD and neurotypical (NT) patients. In this retrospective case-control study, we queried the medical record of patients admitted to our PICU with respiratory failure from June 2018 to March 2022 who received antipsychotics typically used for ICU delirium. Antipsychotics prescribed for home use were excluded. Nonparametric statistics compared demographics, CAPD scores, medication choice, dosing (mg/kg), and medication continuation after discharge between those with and without DD based on the ICD-10 codes. Twenty-one DD admissions and 59 NT admissions were included. Groups did not significantly differ by demographics, LOS, drug, or initial dosage. DD patients had higher median CAPD scores at admission (17 vs 13; P = .02) and treatment initiation (18 vs 16.5; P = .05). Providers more frequently escalated doses in DD patients (13/21 vs 21/59; P = .04) and discharged them home on new antipsychotics (7/21 vs 5/59; P = .01). DD patients experience delirium screening and management differently than NT counterparts. Providers should be aware of baseline elevated scores in DD patients and carefully attend to indications for dosage escalation. Further work is needed to understand if prolonged duration, even after hospital discharge, benefits patients, or represents potential disparity in care.
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Affiliation(s)
- Amanda R Kolmar
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Anneliese M Paton
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Michael A Kramer
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Kristin P Guilliams
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Department of Neurology, Division of Pediatric and Developmental Neurology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Mallinckrodt Institution of Radiology, Division of Neuroradiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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Tarrell A, Giles L, Smith B, Traube C, Watt K. Delirium in the NICU. J Perinatol 2024; 44:157-163. [PMID: 37684547 DOI: 10.1038/s41372-023-01767-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/18/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023]
Abstract
Delirium in the NICU is an underrecognized phenomenon in infants who are often complex and critically ill. The current understanding of NICU delirium is developing and can be informed by adult and pediatric literature. The NICU population faces many potential risk factors for delirium, including young age, developmental delay, mechanical ventilation, severe illness, and surgery. There are no diagnostic tools specific to infants. The mainstay of delirium treatment is to treat the underlying cause, address modifiable risk factors, and supportive care. This review will summarize current knowledge and areas where more research is needed.
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Affiliation(s)
- Ariel Tarrell
- University of Utah School of Medicine, Department of Pediatrics, Division of Neonatology, Salt Lake City, UT, USA.
| | - Lisa Giles
- University of Utah School of Medicine, Department of Pediatrics, Division of Pediatric Behavioral Health and Psychiatry, Salt Lake City, UT, USA
| | - Brian Smith
- Duke University Medical Center, Division of Neonatology, Durham, NC, USA
| | - Chani Traube
- Weill Cornell Medical College, Division of Pediatric Critical Care Medicine, New York, NY, USA
| | - Kevin Watt
- University of Utah School of Medicine, Department of Pediatrics, Divisions of Pediatric Critical Care Medicine and Clinical Pharmacology, Salt Lake City, UT, USA
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15
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Goldstein M, Jergel A, Karpen S, He Z, Austin TM, Hall M, Deep A, Gilbertson L, Kamat P. Trends in sedation-analgesia practices in pediatric liver transplant patients admitted postoperatively to the pediatric intensive care unit: An analysis of data from the pediatric health information system (PHIS) database. Pediatr Transplant 2024; 28:e14660. [PMID: 38017659 DOI: 10.1111/petr.14660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/26/2023] [Accepted: 11/16/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Children admitted to the pediatric intensive care unit (PICU), after liver transplantation, frequently require analgesia and sedation in the immediate postoperative period. Our objective was to assess trends and variations in sedation and analgesia used in this cohort. METHODS Multicenter retrospective cohort study using the Pediatric Health Information System from 2012 to 2022. RESULTS During the study period, 3963 patients with liver transplantation were admitted to the PICU from 32 US children's hospitals with a median age of 2 years [IQR: 0.00, 10.00]. 54 percent of patients received mechanical ventilation (MV). Compared with patients without MV, those with MV were more likely to receive morphine (57% vs 49%, p < .001), fentanyl (57% vs 44%), midazolam (45% vs 31%), lorazepam (39% vs. 24%), dexmedetomidine (38% vs 30%), and ketamine (25% vs 12%), all p < .001. Vasopressor usage was also higher in MV patients (22% vs. 35%, p < .001). During the study period, there was an increasing trend in the utilization of dexmedetomidine and ketamine, but the use of benzodiazepine decreased (p < .001). CONCLUSION About 50% of patients who undergo liver transplant are placed on MV in the PICU postoperatively and receive a greater amount of benzodiazepines in comparison with those without MV. The overall utilization of dexmedetomidine and ketamine was more frequent, whereas the administration of benzodiazepines was less during the study period. Pediatric intensivists have a distinctive opportunity to collaborate with the liver transplant team to develop comprehensive guidelines for sedation and analgesia, aimed at enhancing the quality of care provided to these patients.
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Affiliation(s)
- Matthew Goldstein
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
| | - Andrew Jergel
- Department of Pediatrics, Pediatric Biostatistics Core at Emory University School of Medicine, Atlanta, Georgia, USA
| | - Saul Karpen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Healthcare of Atlanta, and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Zhulin He
- Department of Pediatrics, Pediatric Biostatistics Core at Emory University School of Medicine, Atlanta, Georgia, USA
| | - Thomas M Austin
- Department of Anesthesiology, Shands Children's Hospital, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Akash Deep
- Paediatric Intensive Care Unit (PICU), King's College Hospital, London, UK
| | - Laura Gilbertson
- Department of Anesthesiology and Pain Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Pradip Kamat
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
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Hardin BG, McCarter A, Hamrick SEG. A Delirium Prevention and Management Initiative: Implementing a Best Practice Recommendation for the NICU. Neonatal Netw 2024; 43:19-34. [PMID: 38267090 DOI: 10.1891/nn-2023-0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Medically complex infants experiencing NICU stays can be difficult to manage, exhibiting refractory agitation, disengagement, or both-all signs of delirium, which can present in a hypoactive, hyperactive, or mixed form. Though documented in other settings, delirium is under-recognized in NICUs. Pediatric studies show that a high percentage of patients with delirium are under the age of 12 months. Delirium is associated with increased ventilation days, hospital days, and costs. It negatively affects neurodevelopment and social interaction. Studies show that pediatric nurses are unprepared to recognize delirium. Our nurse-led multidisciplinary group created a best practice recommendation (BPR) focused on detecting delirium and minimizing risk through thoughtful sedation management, promotion of sleep hygiene and mobility, and facilitation of meaningful caregiver presence. Occasionally, medications, including melatonin and risperidone, are helpful. In 2019, we introduced this BPR to reduce delirium risk in our NICU. Practice changes tied to this initiative correlate with a significant reduction in delirium scores and risk including exposure to deliriogenic medications. A multidisciplinary care bundle correlates with decreased delirium screening scores in NICU patients.
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Zilezinski M, Denninger NE, Tannen A, Kottner J. Non-pharmacological interventions to prevent and manage delirium in critically ill children in neonatal and paediatric intensive care units (NICU/PICU): a scoping review protocol. BMJ Open 2023; 13:e073883. [PMID: 37899161 PMCID: PMC10619068 DOI: 10.1136/bmjopen-2023-073883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 10/10/2023] [Indexed: 10/31/2023] Open
Abstract
INTRODUCTION Delirium is one of the most common forms of acute cerebral dysfunction in critically ill children leading to increased morbidity and mortality. Prevention, identification and management of delirium is an important part of paediatric and neonatological intensive care. This scoping review aims to identify and map evidence on non-pharmacological interventions for paediatric delirium prevention and management in paediatric and neonatal intensive care settings. METHODS AND ANALYSIS This scoping review will be conducted according to the Joanna Briggs Institute methodology for scoping reviews and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Searches will be performed in the databases Medline (via PubMed), CINAHL, Cochrane Library, Ovid (Journals), EMBASE and Web of Science (01/2000-current). Two reviewers will independently review retrieved studies, and relevant information will be extracted using data extraction forms. The results will be presented in tabular format and accompanied by a narrative summary. INCLUSION CRITERIA The review will include references that describe or evaluate non-pharmacological interventions to prevent or manage paediatric delirium. Conference abstracts, editorials, opinion papers and grey literature will be excluded. ETHICS AND DISSEMINATION Due to the nature of research involving humans or unpublished secondary data, approval of an ethics committee are not required. The dissemination of findings is planned via professional networks and publication in an open-access scientific journal.
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Affiliation(s)
- Max Zilezinski
- Institute of Clinical Nursing Science, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Natascha-Elisabeth Denninger
- Department of Primary Care and Health Services Research, Nursing Science and Interprofessional Care, Medical Faculty Heidelberg, Heidelberg University, Heidelberg, Germany
- Institute for Health and Nursing Science, International Graduate Academy, Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Antje Tannen
- Institute of Clinical Nursing Science, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Kottner
- Institute of Clinical Nursing Science, Charité Universitätsmedizin Berlin, Berlin, Germany
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18
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Yoldas TK, Sahutoglu C, Kaynarca O, Bor C. Correlation Between Sociocultural and Economic Factors in Pediatric Patients' Families and Emergence Delirium. Cureus 2023; 15:e46229. [PMID: 37829987 PMCID: PMC10565521 DOI: 10.7759/cureus.46229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Postoperative delirium is a commonly encountered condition that can arise from multiple factors, and its occurrence varies based on the type of surgery in pediatric patients. This study aimed to investigate the occurrence of delirium during the recovery from anesthesia in children undergoing eye surgery and its association with the sociocultural and economic status of their families. METHODS This prospective observational study included children aged 2-12 years who underwent eye surgeries. Demographic data, socioeconomic and educational status of parents, parental separation and cooperation scores, Cravero agitation score, and face, legs, activity, cry, and consolability (FLACC) score (at zero, five, 15, and 30 minutes in the postoperative period) were recorded. Patients who scored 5 on the Cravero agitation scale for at least five minutes were considered to have postoperative delirium. The STROBE checklist was followed for reporting. RESULTS A total of 104 patients were included in the study, of which 65 were male. The mean age of the patients was 6.5±2.9 years, and 42 patients (40.4%) belonged to the preschool age group. The incidence of delirium was found to be 51.9%. Delirium was found to be associated with postoperative pain (p=0.003), age (p=0.001), preoperative anxiety (not cooperative examination score (p=0.047), poor separation score (p=0.006)), presence of a surgical history (p=0.012), and cataract surgery (p=0.007). No evidence was found to demonstrate a link between sociocultural and economic conditions and the development of delirium. CONCLUSIONS This study identified several factors that influenced the occurrence of delirium, including postoperative pain (FLACC≥4), younger age (<6 years), cataract surgery, presence of surgical history, examination score (score 3, not cooperative), and separation score (scores 3-4, poor).
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Affiliation(s)
- Tuba K Yoldas
- Anesthesiology and Reanimation, Ege University School of Medicine, İzmir, TUR
| | - Cengiz Sahutoglu
- Anesthesiology and Reanimation, Ege University School of Medicine, İzmir, TUR
| | - Ozgecan Kaynarca
- Anesthesiology and Reanimation, Ege University School of Medicine, İzmir, TUR
| | - Canan Bor
- Anesthesiology and Reanimation, Ege University School of Medicine, İzmir, TUR
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Flagg LK, Mauney JA. Updates and Clinical Implications of Pediatric Delirium. Crit Care Nurs Clin North Am 2023; 35:315-325. [PMID: 37532385 DOI: 10.1016/j.cnc.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
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.
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Affiliation(s)
- Lauren K Flagg
- Yale University School of Nursing, Orange, CT, USA; Yale New Haven Hospital, Pediatric Critical Care, New Haven, CT, USA.
| | - Jennifer A Mauney
- University of Florida College of Nursing, 1225 Center Drive, PO Box 100197, Gainesville, FL 32610, USA
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Sperotto F, Ramelet AS, Daverio M, Mondardini MC, von Borell F, Brenner S, Tibboel D, Ista E, Pokorna P, Amigoni A. Assessment and management of iatrogenic withdrawal syndrome and delirium in pediatric intensive care units across Europe: An ESPNIC survey. Pharmacotherapy 2023; 43:804-815. [PMID: 37203273 DOI: 10.1002/phar.2831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Analgesia and sedation are essential for the care of children in the pediatric intensive care unit (PICU); however, when prolonged, they may be associated with iatrogenic withdrawal syndrome (IWS) and delirium. We sought to evaluate current practices on IWS and delirium assessment and management (including non-pharmacologic strategies as early mobilization) and to investigate associations between the presence of an analgosedation protocol and IWS and delirium monitoring, analgosedation weaning, and early mobilization. METHODS We conducted a multicenter cross-sectional survey-based study collecting data from one experienced physician or nurse per PICU in Europe from January to April 2021. We then investigated differences among PICUs that did or did not follow an analgosedation protocol. RESULTS Among 357 PICUs, 215 (60%) responded across 27 countries. IWS was systematically monitored with a validated scale in 62% of PICUs, mostly using the Withdrawal Assessment Tool-1 (53%). The main first-line treatment for IWS was a rescue bolus with interruption of weaning (41%). Delirium was systematically monitored in 58% of PICUs, mostly with the Cornell Assessment of Pediatric Delirium scale (48%) and the Sophia Observation Scale for Pediatric Delirium (34%). The main reported first-line treatment for delirium was dexmedetomidine (45%) or antipsychotic drugs (40%). Seventy-one percent of PICUs reported to follow an analgosedation protocol. Multivariate analyses adjusted for PICU characteristics showed that PICUs using a protocol were significantly more likely to systematically monitor IWS (odds ratio [OR] 1.92, 95% confidence interval [CI] 1.01-3.67) and delirium (OR 2.00, 95% CI 1.07-3.72), use a protocol for analgosedation weaning (OR 6.38, 95% CI 3.20-12.71) and promote mobilization (OR 3.38, 95% CI 1.63-7.03). CONCLUSIONS Monitoring and management of IWS and delirium are highly variable among European PICUs. The use of an analgosedation protocol was associated with an increased likelihood of monitoring IWS and delirium, performing a structured analgosedation weaning and promoting mobilization. Education on this topic and interprofessional collaborations are highly needed to help reduce the burden of analgosedation-associated adverse outcomes.
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Affiliation(s)
- Francesca Sperotto
- Cardiovascular Critical Care Unit, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine University of Lausanne, Lausanne, Switzerland
| | - Marco Daverio
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Maria Cristina Mondardini
- Pediatric Anesthesia and Intensive Care Unit, Department of Woman's and Child's Health, IRCCS University Hospital of Bologna Policlinico S.Orsola, Bologna, Italy
| | - Florian von Borell
- Department of Pediatrics, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Sebastian Brenner
- Department of Pediatrics, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Dick Tibboel
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Erwin Ista
- Department of Neonatal & Pediatric Intensive Care, Division Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Paula Pokorna
- Department of Neonatal & Pediatric Intensive Care, Division Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
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Ticinesi A, Parise A, Nouvenne A, Cerundolo N, Prati B, Meschi T. The possible role of gut microbiota dysbiosis in the pathophysiology of delirium in older persons. MICROBIOME RESEARCH REPORTS 2023; 2:19. [PMID: 38046817 PMCID: PMC10688815 DOI: 10.20517/mrr.2023.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 03/15/2023] [Accepted: 05/23/2023] [Indexed: 12/05/2023]
Abstract
Delirium is a clinical syndrome characterized by an acute change in attention, awareness and cognition with fluctuating course, frequently observed in older patients during hospitalization for acute medical illness or after surgery. Its pathogenesis is multifactorial and still not completely understood, but there is general consensus on the fact that it results from the interaction between an underlying predisposition, such as neurodegenerative diseases, and an acute stressor acting as a trigger, such as infection or anesthesia. Alterations in brain insulin sensitivity and metabolic function, increased blood-brain barrier permeability, neurotransmitter imbalances, abnormal microglial activation and neuroinflammation have all been involved in the pathophysiology of delirium. Interestingly, all these mechanisms can be regulated by the gut microbiota, as demonstrated in experimental studies investigating the microbiota-gut-brain axis in dementia. Aging is also associated with profound changes in gut microbiota composition and functions, which can influence several aspects of disease pathophysiology in the host. This review provides an overview of the emerging evidence linking age-related gut microbiota dysbiosis with delirium, opening new perspectives for the microbiota as a possible target of interventions aimed at delirium prevention and treatment.
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Affiliation(s)
- Andrea Ticinesi
- Microbiome Research Hub, University of Parma, Parma 43124, Italy
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma 43126, Italy
| | - Alberto Parise
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma 43126, Italy
| | - Antonio Nouvenne
- Microbiome Research Hub, University of Parma, Parma 43124, Italy
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma 43126, Italy
| | - Nicoletta Cerundolo
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma 43126, Italy
| | - Beatrice Prati
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma 43126, Italy
| | - Tiziana Meschi
- Microbiome Research Hub, University of Parma, Parma 43124, Italy
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
- Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Parma 43126, Italy
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Köditz H, Drouche A, Dennhardt N, Schmidt M, Schultz M, Schultz B. Depth of anesthesia, temperature, and postoperative delirium in children and adolescents undergoing cardiac surgery. BMC Anesthesiol 2023; 23:148. [PMID: 37131120 PMCID: PMC10152600 DOI: 10.1186/s12871-023-02102-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 04/20/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND After pediatric cardiosurgical interventions, postoperative delirium can occur, which can be associated with undesirable consequences during and after the hospital stay. It is therefore important to avoid any factors causing delirium as far as possible. Electroencephalogram (EEG) monitoring can be used during anesthesia to individually adjust dosages of hypnotically acting drugs. It is necessary to gain knowledge about the relationship between intraoperative EEG and postoperative delirium in children. METHODS In a dataset comprising 89 children (53 male, 36 female; median age: 0.99 (interquartile range: 0.51, 4.89) years) undergoing cardiac surgery involving use of a heart-lung machine, relationships between depth of anesthesia as measured by EEG (EEG index: Narcotrend Index (NI)), sevoflurane dosage, and body temperature were analyzed. A Cornell Assessment of Pediatric Delirium (CAP-D) score ≥ 9 indicated delirium. RESULTS The EEG could be used in patients of all age groups for patient monitoring during anesthesia. In the context of induced hypothermia, EEG monitoring supported individually adjusted sevoflurane dosing. The NI was significantly correlated with the body temperature; decreasing temperature was accompanied by a decreasing NI. A CAP-D score ≥ 9 was documented in 61 patients (68.5%); 28 patients (31.5%) had a CAP-D < 9. Delirious patients with an intubation time ≤ 24 h showed a moderate negative correlation between minimum NI (NImin) and CAP-D (rho = -0.41, 95% CI: -0.70 - -0.01, p = 0.046), i.e., CAP-D decreased with increasing NImin. In the analysis of all patients' data, NImin and CAP-D showed a weak negative correlation (rho = -0.21, 95% CI: -0.40 - 0.01, p = 0.064). On average, the youngest patients had the highest CAP-D scores (p = 0.002). Patients with burst suppression / suppression EEG had a longer median intubation time in the intensive care unit than patients without such EEG (p = 0.023). There was no relationship between minimum temperature and CAP-D score. CONCLUSIONS The EEG can be used to individually adjust sevoflurane dosing during hypothermia. Of the patients extubated within 24 h and classified as delirious, patients with deeper levels of anesthesia had more severe delirium symptoms than patients with lighter levels of anesthesia.
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Affiliation(s)
- H Köditz
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - A Drouche
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - N Dennhardt
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - M Schmidt
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - M Schultz
- Medical University of Vienna, Vienna, Austria
| | - Barbara Schultz
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany.
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Quirós-Mata M, Delaney J, Russell R, Sabapathy C, Stankova J, Traube C. Delirium in a patient with trisomy 21 undergoing chemotherapy for high-risk acute lymphoblastic leukemia. Pediatr Blood Cancer 2023; 70:e30176. [PMID: 36583483 DOI: 10.1002/pbc.30176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 12/03/2022] [Accepted: 12/05/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Monica Quirós-Mata
- Division of Hematology-Oncology, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Joanne Delaney
- Division of Hematology-Oncology, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Ruth Russell
- Division of Psychiatry, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Christine Sabapathy
- Division of Hematology-Oncology, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jitka Stankova
- Division of Hematology-Oncology, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Chani Traube
- Division of Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, New York, USA
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Luccarelli J, Kalluri AS, Thom RP, Hazen EP, Pinsky E, McCoy TH. The occurrence of delirium diagnosis among youth hospitalizations in the United States: A Kids' Inpatient Database analysis. Acta Psychiatr Scand 2023; 147:481-492. [PMID: 35794791 PMCID: PMC9816352 DOI: 10.1111/acps.13473] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/21/2022] [Accepted: 07/03/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Delirium is an acute neuropsychiatric condition associated with increased morbidity and mortality. There is increasing recognition of delirium as a substantial health burden in younger patients, although few studies have characterized its occurrence. This study analyzes the occurrence of delirium diagnosis, its comorbidities, and cost among youth hospitalized in the United States. METHODS The Kids' Inpatient Database, a national all-payers sample of pediatric hospitalizations in general hospitals, was examined for the year 2019. Hospitalizations with a discharge diagnosis of delirium among patients aged 1-20 years were included in the analysis. RESULTS Delirium was diagnosed in 43,138 hospitalizations (95% CI: 41,170-45,106), or 2.3% of studied hospitalizations. Delirium was diagnosed in a broad range of illnesses, with suicide and self-inflicted injury as the most common primary discharge diagnosis among patients with delirium. In-hospital mortality was seven times greater in hospitalizations caring a delirium diagnosis. The diagnosis of delirium was associated with an adjusted increased hospital cost of $8648 per hospitalization, or $373 million in aggregate cost. CONCLUSIONS Based on a large national claims database, delirium was diagnosed in youth at a lower rate than expected based on prospective studies. The relative absence of delirium diagnosis in claims data may reflect underdiagnosis, a failure to code, and/or a lower rate of delirium in general hospitals compared with other settings. Further research is needed to better characterize the incidence and prevalence of delirium in young people in the hospital setting.
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Affiliation(s)
- James Luccarelli
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114
- Department of Psychiatry, McLean Hospital, Belmont, MA 02478
- Harvard Medical School, Boston, MA 02115
| | - Aditya S. Kalluri
- Harvard Medical School, Boston, MA 02115
- Boston Combined Residency Program in Pediatrics, Boston, MA 02115
| | - Robyn P. Thom
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114
- Harvard Medical School, Boston, MA 02115
- Lurie Center for Autism, Lexington, MA 02421
| | - Eric P. Hazen
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114
- Harvard Medical School, Boston, MA 02115
| | - Elizabeth Pinsky
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114
- Harvard Medical School, Boston, MA 02115
| | - Thomas H. McCoy
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114
- Harvard Medical School, Boston, MA 02115
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Affiliation(s)
- Joel Kian Boon Lim
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore
| | - Vicknesan Jeyan Marimuttu
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore
- Child and Adolescent Mental Wellness Service, Department of Psychological Medicine, KK Women's and Children's Hospital, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore
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Mondardini MC, Sperotto F, Daverio M, Amigoni A. Analgesia and sedation in critically ill pediatric patients: an update from the recent guidelines and point of view. Eur J Pediatr 2023; 182:2013-2026. [PMID: 36892607 DOI: 10.1007/s00431-023-04905-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 02/14/2023] [Accepted: 02/26/2023] [Indexed: 03/10/2023]
Abstract
In the last decades, the advancement of knowledge in analgesia and sedation for critically ill pediatric patients has been conspicuous and relevant. Many recommendations have changed to ensure patients' comfort during their intensive care unit (ICU) stay and prevent and treat sedation-related complications, as well as improve functional recovery and clinical outcomes. The key aspects of the analgosedation management in pediatrics have been recently reviewed in two consensus-based documents. However, there remains a lot to be researched and understood. With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field. Conclusion: With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field. What is Known: • Critically ill pediatric patients receiving intensive care required analgesia and sedation to attenuate painful and stressful stimuli. •Optimal management of analgosedation is a challenge often burdened with complications such as tolerance, iatrogenic withdrawal syndrome, delirium, and possible adverse outcomes. What is New: •The new insights on the analgosedation treatment for critically ill pediatric patients delineated in the recent guidelines are summarized to identify strategies for changes in clinical practice. •Research gaps and potential for quality improvement projects are also highlighted.
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Affiliation(s)
- Maria Cristina Mondardini
- Pediatric Anesthesia and Intensive Care Unit, Department of Woman's and Child's Health, IRCCS University Hospital of Bologna Policlinico S. Orsola, Bologna, Italy
| | - Francesca Sperotto
- Cardiovascular Critical Care Unit, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marco Daverio
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy.
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Sood S, Ganatra HA, Perez Marques F, Langner TR. Complications during mechanical ventilation-A pediatric intensive care perspective. Front Med (Lausanne) 2023; 10:1016316. [PMID: 36817772 PMCID: PMC9928727 DOI: 10.3389/fmed.2023.1016316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/16/2023] [Indexed: 02/04/2023] Open
Abstract
Mechanical ventilation is a common procedure performed in pediatric intensive care units, with over 20% of patients requiring invasive ventilator support. The most common indication for endotracheal intubation and ventilation in the pediatric population is respiratory failure either due to respiratory embarrassment or neurologic pathology. Despite the use of ventilation modes that are lung protective in the pediatric population, complications of mechanical ventilation occur frequently. These include atelectasis, post-extubation stridor, perioral tissue damage, ventilator associated pneumonia, mucus plugging, pneumothorax, pneumomediastinum, and ICU neuromyopathy. The purpose of this review is to discuss the risk factors, presentation and management of complications associated with mechanical ventilation in the pediatric population.
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Moradi J, Mikhail M, Lee LA, Traube C, Sarti AJ, Choong K. Lived Experiences of Delirium in Critically Ill Children: A Qualitative Study. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1758695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AbstractThe aim of this study was to understand the lived experiences of delirium in critically ill children. We conducted phenomenological qualitative interviews with critically ill pediatric survivors aged 0 to 18 years who had experienced delirium, along with their family caregivers and health care providers, from pediatric intensive care units in two tertiary care children's hospitals in Canada. Cases were identified if they had a Cornell Assessment of Pediatric Delirium (CAPD) score of ≥ 9 for at least 48 hours. Thirteen interviews were conducted, representing 10 index patients with delirium (age range: 7 weeks to 17 years). Participants shared experiences that were divided into themes of delirium symptoms, the impact of delirium, and their experience with the care of delirium. Within each theme, subthemes were identified. Symptoms of delirium included hallucinations, fluctuating symptoms, and lack of eye contact. Children were often described as “not himself/herself.” Delirium had long-lasting impact on patients; memories remained prominent even after the hospital stay. Family members and health care providers often felt helpless and ill-prepared to manage delirium. The delirium experience had significant impact on loved ones, causing persistent and vicarious suffering after the critical illness course. Family members and health care providers prioritized nonpharmacological strategies, family presence, and education as key strategies for delirium management. The lived experience of delirium in both infants and older children is physically, psychologically, and emotionally distressing. Given the traumatic long-term consequences, there is an urgent need to target delirium education, management, and prevention to improve long-term outcomes in PICU survivors and their families.
Trial Registration number: NCT04168515.
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Affiliation(s)
- Jasmin Moradi
- Department of Pediatric Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Mirriam Mikhail
- Department of Pediatrics, Toronto Sick Children's Hospital, Toronto, Ontario, Canada
| | - Laurie A. Lee
- Alberta Children's Hospital, University of Calgary, Pediatric Critical Care, Calgary, AB, Canada
| | - Chani Traube
- Department of Pediatric Critical Care, Weill Cornell Medical College, New York, New York, United States
| | - Aimee J. Sarti
- Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Karen Choong
- Department of Pediatric Critical Care, McMaster University, Hamilton, Ontario, Canada
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The clinical implications of climate change for mental health. Nat Hum Behav 2022; 6:1474-1481. [DOI: 10.1038/s41562-022-01477-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/10/2022] [Indexed: 11/18/2022]
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Improving Delirium Assessments in Vanderbilt Pediatric and Pediatric Cardiovascular Intensive Care Units. Pediatr Qual Saf 2022; 7:e577. [PMID: 35919397 PMCID: PMC9278948 DOI: 10.1097/pq9.0000000000000577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 06/10/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction: Delirium is a disturbance of attention and awareness that represents a change from baseline mental status. Accurate diagnosis of delirium is of paramount importance to improving the management of pediatric delirium in the intensive care unit. Despite ongoing education, inconsistencies in delirium assessments occur. Here, we aimed to determine the extent of the problem and increase compliance with delirium assessments. Methods: We collected preintervention data to assess baseline compliance of delirium assessments in the Pediatric Intensive Care Unit (PICU) and Pediatric Cardiac Intensive Care Unit (PCICU) at Monroe Carell Jr Children’s Hospital at Vanderbilt in November 2020. We executed 2 Plan-Do-Study-Act cycles with different interventions and collected data after each and approximately 1 year after the interventions. The first intervention consisted of virtual lectures on delirium assessments for the nursing staff. The second intervention included an educational handout and a new electronic medical record documentation tool. Results: Five hundred five individual nurse-patient encounters were assessed and collected throughout the project. The mean compliance of delirium documentation before the interventions was 52.5%. Target compliance after interventions was 70%. Mean compliance was 70% after cycle 1, 78% after cycle 2, and 86% in March 2022. Conclusions: Using pre- and postintervention data from chart reviews and nurse interviews regarding delirium screenings, we found that interventions targeting nurse education and EMR flowsheet improved compliance with delirium assessment and documentation in the PICU and PCICU. Future work should focus on assessing the clinical implications of this project in diagnosing and treating delirium.
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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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Traube C, Tucci M, Nellis ME, Avery KL, McQuillen PS, Fitzgerald JC, Muszynski JA, Cholette JM, Schwarz AJ, Stalets EL, Quaid MA, Hanson SJ, Lacroix J, Reeder RW, Spinella PC. Transfusion-Associated Delirium in Children: No Difference Between Short Storage Versus Standard Issue RBCs. Crit Care Med 2022; 50:173-182. [PMID: 35100190 PMCID: PMC8820396 DOI: 10.1097/ccm.0000000000005393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Primary objective is to determine if transfusion of short storage RBCs compared with standard issue RBCs reduced risk of delirium/coma in critically ill children. Secondary objective is to assess if RBC transfusion was independently associated with delirium/coma. DESIGN This study was performed in two stages. First, we compared patients receiving either short storage or standard RBCs in a multi-institutional prospective randomized controlled trial. Then, we compared all transfused patients in the randomized controlled trial with a single-center cohort of nontransfused patients matched for confounders of delirium/coma. SETTING Twenty academic PICUs who participated in the Age of Transfused Blood in Critically Ill Children trial. PATIENTS Children 3 days to 16 years old who were transfused RBCs within the first 7 days of admission. INTERVENTIONS Subjects were randomized to either short storage RBC study arm (defined as RBCs stored for up to seven days) or standard issue RBC study arm. In addition, subjects were screened for delirium prior to transfusion and every 12 hours after transfusion for up to 3 days. MEASUREMENTS AND MAIN RESULTS Primary outcome measure was development of delirium/coma within 3 days of initial transfusion. Additional outcome measures were dose-response relationship between volume of RBCs transfused and delirium/coma, and comparison of delirium/coma rates between transfused patients and individually matched nontransfused patients. We included 146 subjects in the stage I analysis; 69 were randomized to short storage RBCs and 77 to standard issue. There was no significant difference in delirium/coma development between study arms (79.5% vs 70.1%; p = 0.184). In the stage II analysis, adjusted odds for delirium in the transfused cohort was more than eight-fold higher than in the nontransfused matched cohort, even after controlling for hemoglobin (adjusted odds ratio, 8.9; CI, 2.8-28.4; p < 0.001). CONCLUSIONS RBC transfusions (and not anemia) are independently associated with increased odds of subsequent delirium/coma. However, storage age of RBCs does not affect delirium risk.
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Affiliation(s)
- Chani Traube
- Division of Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | - Marisa Tucci
- Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | - Marianne E Nellis
- Division of Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | - K Leslie Avery
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL
| | - Patrick S McQuillen
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Jill M Cholette
- Department of Pediatrics, University of Rochester, Golisano Children's Hospital, Rochester, NY
| | | | - Erika L Stalets
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Maureen A Quaid
- Department of Pediatrics, Advocate Children's Hospital, Park Ridge, IL
| | - Sheila J Hanson
- Department of Pediatrics and Children's Wisconsin, Critical Care Section, Medical College of Wisconsin, Milwaukee, WI
| | - Jacques Lacroix
- Division of Pediatric Critical Care, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Philip C Spinella
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
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Engel J, von Borell F, Baumgartner I, Kumpf M, Hofbeck M, Michel J, Neunhoeffer F. Modified ABCDEF-Bundles for Critically Ill Pediatric Patients - What Could They Look Like? Front Pediatr 2022; 10:886334. [PMID: 35586826 PMCID: PMC9108250 DOI: 10.3389/fped.2022.886334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/11/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND SIGNIFICANCE Advances in pediatric intensive care have led to markedly improved survival rates in critically ill children. Approximately 70% of those children survive with varying forms of complex chronic diseases or impairment/disabilities. Length of stay, length of mechanical ventilation and number of interventions per patient are increasing with rising complexity of underlying diseases, leading to increasing pain, agitation, withdrawal symptoms, delirium, immobility, and sleep disruption. The ICU-Liberation Collaborative of the Society of Critical Care Medicine has developed a number of preventative measures for prevention, early detection, or treatment of physical and psychiatric/psychological sequelae of oftentimes traumatic intensive care medicine. These so called ABCDEF-Bundles consist of elements for (A) assessment, prevention and management of pain, (B) spontaneous awakening and breathing trials (SAT/SBT), (C) choice of analgesia and sedation, (D) assessment, prevention and management of delirium, (E) early mobility and exercise and (F) family engagement and empowerment. For adult patients in critical care medicine, research shows significant effects of bundle-implementation on survival, mechanical ventilation, coma, delirium and post-ICU discharge disposition. Research regarding PICS in children and possible preventative or therapeutic intervention is insufficient as yet. This narrative review provides available information for modification and further research on the ABCDEF-Bundles for use in critically ill children. MATERIAL AND METHODS A narrative review of existing literature was used. RESULTS One obvious distinction to adult patients is the wide range of different developmental stages of children and the even closer relationship between patient and family. Evidence for pediatric ABCDEF-Bundles is insufficient and input can only be collected from literature regarding different subsections and topics. CONCLUSION In addition to efforts to improve analgesia, sedation and weaning protocols with the aim of prevention, early detection and effective treatment of withdrawal symptoms or delirium, efforts are focused on adjusting ABCDEF bundle for the entire pediatric age group and on strengthening families' decision-making power, understanding parents as a resource for their child and involving them early in the care of their children.
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Affiliation(s)
- Juliane Engel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Florian von Borell
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Isabella Baumgartner
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Jörg Michel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
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Siegel EJ, Groves AM, Silver G, Hojsak J, Lim CA, Traube C. Delirium in the NICU: A Point Prevalence Study. Hosp Pediatr 2021; 11:e321-e326. [PMID: 34711646 DOI: 10.1542/hpeds.2020-005736] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Delirium is a well-described complication of critical illness, with occurrence rates of >25% in the PICU, and associated morbidity. Infants in the NICU are likely at risk. There have been no previous screening studies to quantify delirium rates in the neonatal population. We hypothesized that delirium was prevalent in term neonates in the NICU. In this pilot study, our objective was to estimate prevalence using a validated pediatric delirium screening tool, which has not yet been tested in NICUs. METHODS In this point prevalence study, all term or term-corrected infants admitted to the NICU on designated study days were screened for delirium using the Cornell Assessment of Pediatric Delirium. RESULTS A total of 149 infants were eligible for screening over 8 study days. A total of 147 (98.6%) were successfully screened with the Cornell Assessment of Pediatric Delirium. Overall, 22.4% (n = 33) screened positive for delirium. Delirium was more commonly detected in children on invasive mechanical ventilation (67% vs 17%, P < .01) and those with underlying neurologic disorders (64% vs 13%, P < .01). A multivariate logistic regression revealed that neurologic disability and mechanical ventilation were both independently associated with a positive delirium screen (aOR: 12.3, CI: 4.5-33.6 and aOR: 9.3, CI: 2.5-34.6, respectively). CONCLUSIONS Our results indicate that delirium likely occurs frequently in term-equivalent infants in the NICU. Further research is necessary to establish feasibility, validity, and interrater reliability of delirium screening in this population.
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Affiliation(s)
- Elana J Siegel
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alan M Groves
- Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Gabrielle Silver
- Weill Cornell Medical College, Cornell University, New York, New York
| | - Joanne Hojsak
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - C Anthoney Lim
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Chani Traube
- Weill Cornell Medical College, Cornell University, New York, New York
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36
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Aksu Uzunhan T, Maraş Genç H, Kutlubay B, Kalın S, Bektaş G, Yapıcı Ö, Çıracı S, Sözen HG, Şevketoğlu E, Palabıyık F, Gör Z, Çakar NE, Kara B. Cytotoxic lesions of the corpus callosum in children: Etiology, clinical and radiological features, and prognosis. Brain Dev 2021; 43:919-930. [PMID: 34120800 DOI: 10.1016/j.braindev.2021.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/15/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Cytotoxic lesions of the corpus callosum (CLOCCs) are secondary lesions associated with entities like infection manifested by restricted diffusion on diffusion-weighted cranial magnetic resonance imaging. Our objectives are to evaluate the clinic-radiological spectrum of pediatric patients with cytotoxic lesions of the corpus callosum (CC). METHODS Children (0-18 years) admitted between February 2017 and May 2020 with splenial lesions showing diffusion restriction on MRI, either isolated or within involvement of other parts of the brain, were included retrospectively. The primary lesions of the CC (e.g. acute disseminated encephalomyelitis, acute ischemic infarction, and glioblastoma multiforme) were excluded. CLOCCs were divided into infection-associated, metabolic disorder-associated, and trauma-associated lesions, as well as CLOCCs involving other entities. Data were collected from the medical databases. RESULTS Forty-one patients were determined to have CLOCCs. Twenty-five (61%) were infection-associated, nine (22%) were trauma-associated, and three (7%) were metabolic disorder-associated cases, including 2 inherited disorders of metabolism. There were four (10%) patients with other entities, three with epilepsy, and one had an apparent life-threatening event. Six patients had a known etiology among the infection-associated group; one had multisystem inflammatory syndrome caused by COVID-19 and one had been infected by COVID-19 without any complications. All the infection-associated patients with isolated splenial lesions recovered totally, although six patients required intensive care hospitalization. Four trauma-associated patients had sequela lesions. CONCLUSIONS CLOCCs are associated with a spectrum of diseases, including the new coronavirus, COVID-19 infection. Infection-associated CLOCCs has the best prognosis, although severe cases may occur. Sequelae are possible based on the etiology.
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Affiliation(s)
- Tuğçe Aksu Uzunhan
- Department of Pediatric Neurology, Prof Dr Cemil Taşcıoğlu City Hospital, University of Health Sciences, İstanbul, Turkey.
| | - Hülya Maraş Genç
- Department of Pediatric Neurology, Ümraniye Training and Research Hospital, University of Health Sciences, İstanbul, Turkey
| | - Büşra Kutlubay
- Department of Pediatric Neurology, Ümraniye Training and Research Hospital, University of Health Sciences, İstanbul, Turkey
| | - Sevinç Kalın
- Department of Pediatric Radiology, Ümraniye Training and Research Hospital, University of Health Sciences, İstanbul, Turkey
| | - Gonca Bektaş
- Department of Pediatric Neurology, Bakırköy Dr Sadi Konuk Training and Research Hospital, University of Health Sciences, İstanbul, Turkey
| | - Özge Yapıcı
- Department of Pediatric Radiology, Prof Dr Cemil Taşcıoğlu City Hospital, University of Health Sciences, İstanbul, Turkey
| | - Saliha Çıracı
- Department of Pediatric Radiology, Ümraniye Training and Research Hospital, University of Health Sciences, İstanbul, Turkey
| | - Hatice Gülhan Sözen
- Department of Pediatric Neurology, Ümraniye Training and Research Hospital, University of Health Sciences, İstanbul, Turkey
| | - Esra Şevketoğlu
- Department of Pediatric Intensive Care, Bakırköy Dr Sadi Konuk Training and Research Hospital, University of Health Sciences, İstanbul, Turkey
| | - Figen Palabıyık
- Department of Pediatric Radiology, Bakırköy Dr Sadi Konuk Training and Research Hospital, University of Health Sciences, İstanbul, Turkey
| | - Zeynep Gör
- Department of Pediatrics, Bitlis Tatvan Government Hospital, Bitlis, Turkey
| | - Nafiye Emel Çakar
- Department of Pediatric Metabolism, Prof Dr Cemil Taşcıoğlu City Hospital, University of Health Sciences, İstanbul, Turkey
| | - Bülent Kara
- Department of Pediatric Neurology, Kocaeli University Hospital, University of Health Sciences, İstanbul, Turkey
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37
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Shildt N, Traube C, Dealmeida M, Dave I, Gillespie S, Moore W, Long LD, Kamat PP. "Difficult to Sedate": Successful Implementation of a Benzodiazepine-Sparing Analgosedation-Protocol in Mechanically Ventilated Children. CHILDREN-BASEL 2021; 8:children8050348. [PMID: 33924822 PMCID: PMC8146538 DOI: 10.3390/children8050348] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 11/25/2022]
Abstract
We sought to evaluate the success rate of a benzodiazepine-sparing analgosedation protocol (ASP) in mechanically ventilated children and determine the effect of compliance with ASP on in-hospital outcome measures. In this single center study from a quaternary pediatric intensive care unit, our objective was to evaluate the ASP protocol, which included opiate and dexmedetomidine infusions and was used as first-line sedation for all intubated patients. In this study we included 424 patients. Sixty-nine percent (n = 293) were successfully sedated with the ASP. Thirty-one percent (n = 131) deviated from the ASP and received benzodiazepine infusions. Children sedated with the ASP had decrease in opiate withdrawal (OR 0.16, 0.08–0.32), decreased duration of mechanical ventilation (adjusted mean duration 1.81 vs. 3.39 days, p = 0.018), and decreased PICU length of stay (adjusted mean 3.15 vs. 4.7 days, p = 0.011), when compared to the cohort of children who received continuous benzodiazepine infusions. Using ASP, we report that 69% of mechanically ventilated children were successfully managed with no requirement for continuous benzodiazepine infusions. The 69% who were successfully managed with ASP included infants, severely ill patients, and children with chromosomal disorders and developmental disabilities. Use of ASP was associated with decreased need for methadone use, decreased duration of mechanical ventilation, and decreased ICU and hospital length of stay.
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Affiliation(s)
- Nataly Shildt
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA; (N.S.); (M.D.)
- Division of Pediatric Critical Care Medicine, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Chani Traube
- Department of Pediatrics, Weill Cornell Medical College, New York, NY 10065, USA;
| | - Mary Dealmeida
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA; (N.S.); (M.D.)
| | - Ishaan Dave
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA; (I.D.); (S.G.)
| | - Scott Gillespie
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA; (I.D.); (S.G.)
| | - Whitney Moore
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA;
| | | | - Pradip P. Kamat
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA; (N.S.); (M.D.)
- Division of Pediatric Critical Care Medicine, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
- Correspondence: ; Tel.: +404-277-8010
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38
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Di Nardo M, Boldrini F, Broccati F, Cancani F, Satta T, Stoppa F, Genuini L, Zampini G, Perdichizzi S, Bottari G, Fischer M, Gawronski O, Bonetti A, Piermarini I, Recchiuti V, Leone P, Rossi A, Tabarini P, Biasucci D, Villani A, Raponi M, Cecchetti C, Choong K. The LiberAction Project: Implementation of a Pediatric Liberation Bundle to Screen Delirium, Reduce Benzodiazepine Sedation, and Provide Early Mobilization in a Human Resource-Limited Pediatric Intensive Care Unit. Front Pediatr 2021; 9:788997. [PMID: 34956989 PMCID: PMC8692861 DOI: 10.3389/fped.2021.788997] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/08/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Delirium, bed immobilization, and heavy sedation are among the major contributors of pediatric post-intensive care syndrome. Recently, the Society of Critical Care Medicine has proposed the implementation of daily interventions to minimize the incidence of these morbidities and optimize children functional outcomes and quality of life. Unfortunately, these interventions require important clinical and economical efforts which prevent their use in many pediatric intensive care units (PICU). Aim: First, to evaluate the feasibility and safety of a PICU bundle implementation prioritizing delirium screening and treatment, early mobilization (<72 h from PICU admission) and benzodiazepine-limited sedation in a human resource-limited PICU. Second, to evaluate the incidence of delirium and describe the early mobilization practices and sedative drugs used during the pre- and post-implementation periods. Third, to describe the barriers and adverse events encountered during early mobilization. Methods: This observational study was structured in a pre- (15th November 2019-30th June 2020) and post-implementation period (1st July 2020-31st December 2020). All patients admitted in PICU for more than 72 h during the pre and post-implementation period were included in the study. Patients were excluded if early mobilization was contraindicated. During the pre-implementation period, a rehabilitation program including delirium screening and treatment, early mobilization and benzodiazepine-sparing sedation guidelines was developed and all PICU staff trained. During the post-implementation period, delirium screening with the Connell Assessment of Pediatric Delirium scale was implemented at bedside. Early mobilization was performed using a structured tiered protocol and a new sedation protocol, limiting the use of benzodiazepine, was adopted. Results: Two hundred and twenty-five children were enrolled in the study, 137 in the pre-implementation period and 88 in the post-implementation period. Adherence to delirium screening, benzodiazepine-limited sedation and early mobilization was 90.9, 81.1, and 70.4%, respectively. Incidence of delirium was 23% in the post-implementation period. The median cumulative dose of benzodiazepines corrected for the total number of sedation days (mg/kg/sedation days) was significantly lower in the post-implementation period compared with the pre-implementation period: [0.83 (IQR: 0.53-1.31) vs. 0.74 (IQR: 0.55-1.16), p = 0.0001]. The median cumulative doses of fentanyl, remifentanil, and morphine corrected for the total number of sedation days were lower in the post-implementation period, but these differences were not significant. The median number of mobilizations per patient and the duration of each mobilization significantly increased in the post-implementation period [3.00 (IQR: 2.0-4.0) vs. 7.00 (IQR: 3.0-12.0); p = 0.004 and 4 min (IQR: 3.50-4.50) vs. 5.50 min (IQR: 5.25-6.5); p < 0.0001, respectively]. Barriers to early mobilization were: disease severity and bed rest orders (55%), lack of physicians' order (20%), lack of human resources (20%), and lack of adequate devices for patient mobilization (5%). No adverse events related to early mobilization were reported in both periods. Duration of mechanical ventilation and PICU length of stay was significantly lower in the post-implementation period as well as the occurrence of iatrogenic withdrawal syndrome. Conclusion: This study showed that the implementation of a PICU liberation bundle prioritizing delirium screening and treatment, benzodiazepine-limited sedation and early mobilization was feasible and safe even in a human resource-limited PICU. Further pediatric studies are needed to evaluate the clinical impact of delirium, benzodiazepine-limited sedation and early mobilization protocols on patients' long-term functional outcomes and on hospital finances.
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Affiliation(s)
- Matteo Di Nardo
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Francesca Boldrini
- Unit of Clinical Psychology, Department of Neurological Sciences, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Francesca Broccati
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Federica Cancani
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Tiziana Satta
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Francesca Stoppa
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Leonardo Genuini
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Giorgio Zampini
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Salvatore Perdichizzi
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Gabriella Bottari
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Maximilian Fischer
- Pediatric Emergency Unit, Department of Medical and Surgical Sciences (DIMEC), St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Orsola Gawronski
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Annamaria Bonetti
- Functional Rehab Unit, Neurorehabilitation and Robotics Department, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Irene Piermarini
- Respiratory Physiotherapy, Pediatric Pulmonology and Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics (DPUO), Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Veronica Recchiuti
- Functional Rehab Unit, Neurorehabilitation and Robotics Department, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Paola Leone
- Respiratory Physiotherapy, Pediatric Pulmonology and Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics (DPUO), Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Angela Rossi
- Unit of Clinical Psychology, Department of Neurological Sciences, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Paola Tabarini
- Unit of Clinical Psychology, Department of Neurological Sciences, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Daniele Biasucci
- Department of Emergency, Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario "A. Gemelli" Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Alberto Villani
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Massimiliano Raponi
- Medical Directorate, Bambino Gesu' Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Corrado Cecchetti
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Karen Choong
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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