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Azamfirei R, Behrens D, Padilla S, Madden K, Goldberg S, Geno M, Manning MJ, Piole M, Madsen E, Maue D, Abu-Sultaneh S, Awojoodu R, Wang NY, Needham DM, Neufeld K, Kudchadkar SR. Delirium Screening in Critically Ill Children: Secondary Analysis of the Multicenter PICU Up! Pilot Trial Dataset, 2019-2020. Pediatr Crit Care Med 2024:00130478-990000000-00350. [PMID: 38832837 DOI: 10.1097/pcc.0000000000003555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
OBJECTIVES To determine the patient-level factors associated with performing daily delirium screening in PICUs with established delirium screening practices. DESIGN A secondary analysis of 2019-2020 prospective data from the baseline phase of the PICU Up! pilot stepped-wedge multicenter trial (NCT03860168). SETTING Six PICUs in the United States. PATIENTS One thousand sixty-four patients who were admitted to a PICU for 3 or more days. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 1064 patients, 74% (95% CI, 71-76%) underwent delirium screening at least once during their PICU stay. On 57% of the 8965 eligible patient days, screening was conducted. The overall prevalence of delirium was 46% across all screened days, and 64% of screened patients experienced delirium at some point during their PICU stay. Factors associated with greater adjusted odds ratio (aOR) of increased daily delirium screening included PICU stay longer than 15 days compared with 1-3 days (aOR 3.36 [95% CI, 2.62-4.30]), invasive mechanical ventilation as opposed to room air (aOR 1.67 [95% CI, 1.32-2.12]), dexmedetomidine infusions (aOR 1.23 [95% CI, 1.04-1.44]) and propofol infusions (aOR 1.55 [95% CI, 1.08-2.23]). Conversely, decreased aOR of daily delirium screening was associated with female gender (aOR 0.78 [95% CI, 0.63-0.96]), and the administration of continuous infusions of opioids (aOR 0.75 [95% CI, 0.63-0.90]) or ketamine (aOR 0.48 [95% CI, 0.29-0.79]). Neither patient age, the presence of family or physical restraints, or benzodiazepine infusions were associated with daily delirium screening rates. CONCLUSIONS In the 2019-2020 PICU UP! cohort, across six PICUs, delirium screening occurred on only 57% of days, despite the presence of established practices. Female gender, patients in the early stages of their PICU stay, and patients not receiving mechanical ventilation were associated with lower odds of daily delirium screening. Our results highlight the need for structured quality improvement processes to both standardize and increase the frequency of delirium screening.
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Affiliation(s)
- Razvan Azamfirei
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- George Emil Palade University of Medicine, Pharmacy, Science, and Technology, Targu Mures, Romania
| | - Deanna Behrens
- Pediatric Critical Care, Advocate Children's Hospital, Park Ridge, IL
| | - Sofia Padilla
- Pediatric Critical Care, Advocate Children's Hospital, Park Ridge, IL
| | - Kate Madden
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Sarah Goldberg
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Megan Geno
- Department of Physical and Occupational Therapy, Boston Children's Hospital, Boston, MA
| | | | - Michelle Piole
- Division of Pediatric Critical Care, SSM Health Cardinal Glennon Children's Hospital, St. Louis, MO
| | - Erik Madsen
- Division of Pediatric Critical Care, SSM Health Cardinal Glennon Children's Hospital, St. Louis, MO
| | - Danielle Maue
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Samer Abu-Sultaneh
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Ronke Awojoodu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nae-Yuh Wang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Departments of Biostatistics and Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Dale M Needham
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Departments of Biostatistics and Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
- Outcomes after Critical Illness and Surgery Group, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Karin Neufeld
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
- Outcomes after Critical Illness and Surgery Group, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pediatrics, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD
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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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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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Balsalobre-Martínez P, Montosa-García R, Marín-Yago A, Baeza-Mirete M, Muñoz-Rubio GM, Rojo-Rojo A. Challenges of the Implementation of a Delirium Rate Scale in a Pediatric Intensive Care Unit: A Qualitative Approach. Healthcare (Basel) 2023; 12:52. [PMID: 38200958 PMCID: PMC10779040 DOI: 10.3390/healthcare12010052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/11/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Delirium in the pediatric population admitted to intensive care is a worrying reality due to its potential complications and the increase in associated costs. This study aims to explore the experiences of nursing staff of a Pediatric Intensive Care Unit after 15 months of starting a program to fight against childhood delirium in their unit. METHODOLOGY A qualitative study was conducted through semi-structured interviews with Pediatric Intensive Care Unit (PICU) Key Informants. The Standards for Reporting Qualitative Research (SRQR) and the consolidated criteria for Reporting Qualitative Research (COREQ) were followed as quality measures for the study. Seven nurses (33% of the eligible population) from the PICU of a referral hospital were interviewed. Text transcripts were analyzed using the Interpretative Description and Qualitative Content Analysis method. RESULTS The interviewees indicated not identifying delirium as an important reality; with great deficiencies observed in what is related to the identification of delirium; identifying CAPD as an unreliable tool in their unit; and not sharing therapeutic objectives in this respect with the medical staff. CONCLUSIONS The nursing staff presented a series of negative attitudes towards the phenomena of delirium in their unit, with gaps in training and in clinical management, and the diagnostic tool used, and did not see it as a priority objective of the unit, partly due to a resistance to change and a latent interprofessional communication conflict. A change at the formative, attitudinal, and relational levels is urgently needed for the success of the program and the well-being of the children in the unit.
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Affiliation(s)
| | - Raquel Montosa-García
- Pediatric Intensive Care Unit, Hospital Universitario Virgen de la Arrixaca, Public Murcian Healthcare System, 30120 Murcia, Spain (A.M.-Y.)
| | - Ana Marín-Yago
- Pediatric Intensive Care Unit, Hospital Universitario Virgen de la Arrixaca, Public Murcian Healthcare System, 30120 Murcia, Spain (A.M.-Y.)
| | - Manuel Baeza-Mirete
- Faculty of Nursing, Catholic University of Murcia (UCAM), 30107 Murcia, Spain
| | - Gloria María Muñoz-Rubio
- Intensive Care Unit, Hospital Universitario Virgen de la Arrixaca, Public Murcian Health System, 30120 Murcia, Spain
| | - Andrés Rojo-Rojo
- Faculty of Nursing, Catholic University of Murcia (UCAM), 30107 Murcia, Spain
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MacDonald I, de Goumoëns V, Marston M, Alvarado S, Favre E, Trombert A, Perez MH, Ramelet AS. Effectiveness, quality and implementation of pain, sedation, delirium, and iatrogenic withdrawal syndrome algorithms in pediatric intensive care: a systematic review and meta-analysis. Front Pediatr 2023; 11:1204622. [PMID: 37397149 PMCID: PMC10313131 DOI: 10.3389/fped.2023.1204622] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/15/2023] [Indexed: 07/04/2023] Open
Abstract
Background Pain, sedation, delirium, and iatrogenic withdrawal syndrome are conditions that often coexist, algorithms can be used to assist healthcare professionals in decision making. However, a comprehensive review is lacking. This systematic review aimed to assess the effectiveness, quality, and implementation of algorithms for the management of pain, sedation, delirium, and iatrogenic withdrawal syndrome in all pediatric intensive care settings. Methods A literature search was conducted on November 29, 2022, in PubMed, Embase, CINAHL and Cochrane Library, ProQuest Dissertations & Theses, and Google Scholar to identify algorithms implemented in pediatric intensive care and published since 2005. Three reviewers independently screened the records for inclusion, verified and extracted data. Included studies were assessed for risk of bias using the JBI checklists, and algorithm quality was assessed using the PROFILE tool (higher % = higher quality). Meta-analyses were performed to compare algorithms to usual care on various outcomes (length of stay, duration and cumulative dose of analgesics and sedatives, length of mechanical ventilation, and incidence of withdrawal). Results From 6,779 records, 32 studies, including 28 algorithms, were included. The majority of algorithms (68%) focused on sedation in combination with other conditions. Risk of bias was low in 28 studies. The average overall quality score of the algorithm was 54%, with 11 (39%) scoring as high quality. Four algorithms used clinical practice guidelines during development. The use of algorithms was found to be effective in reducing length of stay (intensive care and hospital), length of mechanical ventilation, duration of analgesic and sedative medications, cumulative dose of analgesics and sedatives, and incidence of withdrawal. Implementation strategies included education and distribution of materials (95%). Supportive determinants of algorithm implementation included leadership support and buy-in, staff training, and integration into electronic health records. The fidelity to algorithm varied from 8.2% to 100%. Conclusions The review suggests that algorithm-based management of pain, sedation and withdrawal is more effective than usual care in pediatric intensive care settings. There is a need for more rigorous use of evidence in the development of algorithms and the provision of details on the implementation process. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021276053, PROSPERO [CRD42021276053].
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Affiliation(s)
- Ibo MacDonald
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
| | - Véronique de Goumoëns
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
- Bureau d’Echange des Savoirs pour des praTiques exemplaires de soins (BEST) a JBI Center of Excellence, Lausanne, Switzerland
| | - Mark Marston
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Silvia Alvarado
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Eva Favre
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
- Department of Adult Intensive Care, Lausanne University Hospital, Lausanne, Switzerland
| | - Alexia Trombert
- Medical Library, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Maria-Helena Perez
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
- Bureau d’Echange des Savoirs pour des praTiques exemplaires de soins (BEST) a JBI Center of Excellence, Lausanne, Switzerland
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
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Ubeda Tikkanen A, Vova J, Holman L, Chrisman M, Clarkson K, Santiago R, Schonberger L, White K, Badaly D, Gauthier N, Pham TDN, Britt JJ, Crouter SE, Giangregorio M, Nathan M, Akamagwuna UO. Core components of a rehabilitation program in pediatric cardiac disease. Front Pediatr 2023; 11:1104794. [PMID: 37334215 PMCID: PMC10275574 DOI: 10.3389/fped.2023.1104794] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 04/17/2023] [Indexed: 06/20/2023] Open
Abstract
There is increasing effort in both the inpatient and outpatient setting to improve care, function, and quality of life for children with congenital heart disease, and to decrease complications. As the mortality rates of surgical procedures for congenital heart disease decrease, improvement in perioperative morbidity and quality of life have become key metrics of quality of care. Quality of life and function in patients with congenital heart disease can be affected by multiple factors: the underlying heart condition, cardiac surgery, complications, and medical treatment. Some of the functional areas affected are motor abilities, exercise capacity, feeding, speech, cognition, and psychosocial adjustment. Rehabilitation interventions aim to enhance and restore functional ability and quality of life for those with physical impairments or disabilities. Interventions such as exercise training have been extensively evaluated in adults with acquired heart disease, and rehabilitation interventions for pediatric patients with congenital heart disease have similar potential to improve perioperative morbidity and quality of life. However, literature regarding the pediatric population is limited. We have gathered a multidisciplinary team of experts from major institutions to create evidence- and practice-based guidelines for pediatric cardiac rehabilitation programs in both inpatient and outpatient settings. To improve the quality of life of pediatric patients with congenital heart disease, we propose the use of individualized multidisciplinary rehabilitation programs that include: medical management; neuropsychology; nursing care; rehabilitation equipment; physical, occupational, speech, and feeding therapies; and exercise training.
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Affiliation(s)
- Ana Ubeda Tikkanen
- Department of Pediatric Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, United States
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA, United States
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, MA, United States
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States
| | - Joshua Vova
- Department of Physiatry, Children’s Healthcare of Atlanta, Atlanta, GA, United States
| | - Lainie Holman
- Department Pediatric Physical Medicine and Rehabilitation, Cleveland Clinic, Cleveland, OH, United States
| | - Maddie Chrisman
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Kristin Clarkson
- Department of Pediatric Physical Medicine and Rehabilitation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Rachel Santiago
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, MA, United States
| | - Lisa Schonberger
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, MA, United States
| | - Kelsey White
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, MA, United States
| | - Daryaneh Badaly
- Learning and Development Center, Child Mind Institute, New York, NY, United States
| | - Naomi Gauthier
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Tam Dan N. Pham
- Department of Pediatric Cardiology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Jolie J. Britt
- Department of Pediatric Cardiology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Scott E. Crouter
- Department of Kinesiology, Recreation, and Sport Studies, The University of Tennessee Knoxville, Knoxville, IL, United States
| | - Maeve Giangregorio
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA, United States
| | - Unoma O. Akamagwuna
- Department Pediatric Physical Medicine and Rehabilitation, Texas Children's Hospital, Houston, TX, United States
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, TX, United States
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Moraes LHA, Maropo VLB, Zoboli I, Falcão MC, de Carvalho WB. Severe irritability in a critically ill preterm infant: a case of delirium at the neonatal intensive care unit. Dement Neuropsychol 2023; 17:e20220046. [PMID: 37223840 PMCID: PMC10202332 DOI: 10.1590/1980-5764-dn-2022-0046] [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: 05/18/2022] [Revised: 07/26/2022] [Accepted: 08/17/2022] [Indexed: 05/25/2023] Open
Abstract
Delirium is a common disorder in intensive care units, being associated with greater morbidity and mortality. However, in neonatal intensive care units, delirium is rarely diagnosed, due to the low familiarity of the neonatologist with the subject and the difficulties in the applicability of diagnostic questionnaires. This case report aimed to assess the presence of this disorder in this group of patients and identify the difficulties encountered in the diagnosis and treatment. We report the case of a premature newborn with necrotizing enterocolitis during hospitalization and underwent three surgical approaches. The newborn exhibited intense irritability, having received high doses of fentanyl, dexmedetomidine, clonidine, ketamine, phenytoin, and methadone, without the control of the symptoms. A diagnosis of delirium was then made and treatment with quetiapine was started, with a complete reversal of the symptoms. This is the first case reported in Brazil and the first describing the withdrawal of the quetiapine.
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Affiliation(s)
- Lucas Hirano Arruda Moraes
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, Pós-Graduação em Ciências da Saúde, São Paulo SP, Brazil
| | - Vanessa Lisbethe Bezerra Maropo
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, Residente de Neonatologia, São Paulo SP, Brazil
| | - Ivete Zoboli
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança e do Adolescente, Grupo de Dor e Cuidados Paliativos, São Paulo SP, Brazil
| | - Mário Cícero Falcão
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, São Paulo SP, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança e do Adolescente, Centro de Terapia Intensiva Neonatal 2, São Paulo SP, Brazil
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Nonpulmonary Treatments for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S45-S60. [PMID: 36661435 DOI: 10.1097/pcc.0000000000003158] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To provide an updated review of the literature on nonpulmonary treatments for pediatric acute respiratory distress syndrome (PARDS) from the Second Pediatric Acute Lung Injury Consensus Conference. DATA SOURCES MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION Searches were limited to children with PARDS or hypoxic respiratory failure focused on nonpulmonary adjunctive therapies (sedation, delirium management, neuromuscular blockade, nutrition, fluid management, transfusion, sleep management, and rehabilitation). DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Twenty-five studies were identified for full-text extraction. Five clinical practice recommendations were generated, related to neuromuscular blockade, nutrition, fluid management, and transfusion. Thirteen good practice statements were generated on the use of sedation, iatrogenic withdrawal syndrome, delirium, sleep management, rehabilitation, and additional information on neuromuscular blockade and nutrition. Three research statements were generated to promote further investigation in nonpulmonary therapies for PARDS. CONCLUSIONS These recommendations and statements about nonpulmonary treatments in PARDS are intended to promote optimization and consistency of care for patients with PARDS and identify areas of uncertainty requiring further investigation.
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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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10
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Recommendations for analgesia and sedation in critically ill children admitted to intensive care unit. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2022. [PMCID: PMC8853329 DOI: 10.1186/s44158-022-00036-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We aim to develop evidence-based recommendations for intensivists caring for children admitted to intensive care units and requiring analgesia and sedation. A panel of national paediatric intensivists expert in the field of analgesia and sedation and other specialists (a paediatrician, a neuropsychiatrist, a psychologist, a neurologist, a pharmacologist, an anaesthesiologist, two critical care nurses, a methodologist) started in 2018, a 2-year process. Three meetings and one electronic-based discussion were dedicated to the development of the recommendations (presentation of the project, selection of research questions, overview of text related to the research questions, discussion of recommendations). A telematic anonymous consultation was adopted to reach the final agreement on recommendations. A formal conflict-of-interest declaration was obtained from all the authors. Eight areas of direct interest and one additional topic were considered to identify the best available evidence and to develop the recommendations using the Evidence-to-Decision framework according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. For each recommendation, the level of evidence, the strength of the recommendation, the benefits, the harms and the risks, the benefit/harm balance, the intentional vagueness, the values judgement, the exclusions, the difference of the opinions, the knowledge gaps, and the research opportunities were reported. The panel produced 17 recommendations. Nine were evaluated as strong, 3 as moderate, and 5 as weak. Conclusion: a panel of national experts achieved consensus regarding recommendations for the best care in terms of analgesia and sedation in critically ill children.
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11
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MacDonald I, Perez MH, Amiet V, Trombert A, Ramelet AS. Quality of clinical practice guidelines and recommendations for the management of pain, sedation, delirium and iatrogenic withdrawal in pediatric intensive care: a systematic review protocol. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2021-001293. [PMID: 36053608 PMCID: PMC8852722 DOI: 10.1136/bmjpo-2021-001293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/16/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Inadequate management of pain and sedation in critically ill children can cause unnecessary suffering and agitation, but also delirium and iatrogenic withdrawal. It is, therefore, important to address these four interrelated conditions together. Some clinical practice guidelines (CPGs) are available for the management of pain and sedation, and a few for delirium and iatrogenic withdrawal in the paediatric intensive care unit; none address the four conditions altogether. Critical appraisal of the quality of CPGs is necessary for their recommendations to be adopted into clinical practice. The aim of this systematic review is to identify and appraise the quality of CPGs and recommendations for management of either pain, sedation, delirium and iatrogenic withdrawal. METHODS AND ANALYSIS Researchers will conduct a systematic review in electronic databases (Medline ALL (Ovid), Embase.com, CINAHL with Full Text (EBSCO), JBI EBP Database (Ovid)), guideline repositories and websites of professional societies to identify CPGs published from 2010 to date. They will then combine index and free terms describing CPGs with pain, sedation, delirium and withdrawal. The researchers will include CPGs if they can be applied in the paediatric intensive care population (newborns to 18 years old) and include recommendation(s) for assessment of at least one of the four conditions. Two independent reviewers will screen for eligibility, complete data extraction and quality assessments using the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the AGREE Recommendation Excellence instruments. Researchers will report characteristics, content and recommendations from CPGs in tabulated forms. ETHICS AND DISSEMINATION Ethical approval is not required for this systematic review. Results will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42021274364.
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Affiliation(s)
- Ibo MacDonald
- University Institute of Higher Education and Research in Healthcare, University of Lausanne Faculty of Biology and Medicine, Lausanne, Switzerland
| | - Marie-Hélène Perez
- Department of Woman Mother and Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Vivianne Amiet
- Department of Woman Mother and Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Alexia Trombert
- Medical Library, Lausanne University Hospital, Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- University Institute of Higher Education and Research in Healthcare, University of Lausanne Faculty of Biology and Medicine, Lausanne, Switzerland .,Department of Woman Mother and Child, Lausanne University Hospital, Lausanne, Switzerland
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12
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van Dijk M, Ista E. Four-in-One: A Comprehensive Checklist for the Assessment of Pain, Undersedation, Iatrogenic Withdrawal and Delirium in the PICU: A Delphi Study. Front Pediatr 2022; 10:887689. [PMID: 35769214 PMCID: PMC9234388 DOI: 10.3389/fped.2022.887689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/21/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Children's pain, undersedation, iatrogenic withdrawal syndrome and delirium often have overlapping symptoms, which makes it difficult to decide why a child in the PICU is not comfortable. Validated assessment tools for these conditions are available, but regular assessment with multiple instruments may be too time-consuming. Therefore, we aimed to develop a new holistic instrument-the mosaIC checklist-that incorporates the assessment of the four conditions. MATERIALS AND METHODS We conducted a two-rounds international Delphi study among experts working in PICUs worldwide to find cues that in combination or separately are relevant for the four conditions. RESULTS In the first Delphi round, 38 of the 48 enrolled participants (79%) completed a questionnaire; in the second round 32 of 48 (67%). Eventually, 46 cues in eight categories (e.g., facial, vocal/verbal, body movements, sleep /behavioral state, posture/muscle tone, agitation, physiological and contextual) were found relevant. Thirty-three (72%) were considered relevant for pain, 24 for undersedation (52%), 35 for iatrogenic withdrawal syndrome (76%) and 28 (61%) for pediatric delirium. Thirteen cues (28%) were considered relevant for all four conditions; 11's (24%) for only one condition. CONCLUSION This Delphi study is the first step in developing a 4-in-1 comprehensive checklist to assess pain, undersedation, iatrogenic withdrawal syndrome and delirium in a holistic manner. Further validation is needed before the checklist can be applied in practice. Application of the mosaIC checklist could help determine what condition is most likely to cause a child's discomfort-and at the same time help reduce the PICU staff's registration burden.
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Affiliation(s)
- Monique van Dijk
- Pediatric Intensive Care Unit, Department of Pediatric Surgery, Erasmus University Medical Center, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Internal Medicine, Section Nursing Science, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Erwin Ista
- Pediatric Intensive Care Unit, Department of Pediatric Surgery, Erasmus University Medical Center, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Internal Medicine, Section Nursing Science, Erasmus University Medical Center, Rotterdam, Netherlands
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13
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Ubeda Tikkanen A, Kudchadkar SR, Goldberg SW, Suskauer SJ. Acquired Brain Injury in the Pediatric Intensive Care Unit: Special Considerations for Delirium Protocols. J Pediatr Intensive Care 2021; 10:243-247. [PMID: 34745696 DOI: 10.1055/s-0040-1719045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 09/30/2020] [Indexed: 10/23/2022] Open
Abstract
The goal of this article was to highlight the overlapping nature of symptoms of delirium and acquired brain injury (ABI) in children and similarities and differences in treatment, with a focus on literature supporting an adverse effect of antipsychotic medications on recovery from brain injury. An interdisciplinary approach to education regarding overlap between symptoms of delirium and ABI is important for pediatric intensive care settings, particularly at this time when standardized procedures for delirium screening and management are being increasingly employed. Development of treatment protocols specific to children with ABI that combine both nonpharmacologic and pharmacologic strategies will reduce the risk of reliance on treatment strategies that are less preferred and optimize care for this population.
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Affiliation(s)
- Ana Ubeda Tikkanen
- Department of Pediatric Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts, United States.,Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, United States.,Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, United States.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, United States
| | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Sarah W Goldberg
- Division of Pediatric Cardiology, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Stacy J Suskauer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Kennedy Krieger Institute, Baltimore, Maryland, United States
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14
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A Systematic Review and Pooled Prevalence of Delirium in Critically Ill Children. Crit Care Med 2021; 50:317-328. [PMID: 34387241 DOI: 10.1097/ccm.0000000000005260] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Pediatric delirium is a neuropsychiatric disorder with disrupted cerebral functioning due to underlying disease and/or critical care treatment. Pediatric delirium can be classified as hypoactive, hyperactive, and mixed. This systematic review was conducted to estimate the pooled prevalence of pediatric delirium using validated assessment tools in children (Cornell Assessment of Pediatric Delirium, Pediatric Confusion Assessment Method for the ICU, PreSchool Confusion Assessment Method for the ICU, Pediatric Confusion Assessment Method for the ICU Severity Scale, and Sophia Observation Withdrawal Symptoms Pediatric Delirium scale), identify modifiable and nonmodifiable risk factors, and explore the association of pediatric delirium with clinical outcomes. DATA SOURCES A systematic search of PubMed, EMBASE, and CINAHL databases was undertaken for full articles pertaining to pediatric delirium prevalence. STUDY SELECTION No language or date barriers were set. Studies were included where the following eligibility criteria were met: study design aimed to estimate pediatric delirium prevalence arising from treatment in the intensive care setting, using a validated tool. Only randomized controlled trials, cross-sectional studies, or cohort studies allowing an estimate of the prevalence of pediatric delirium were included. DATA EXTRACTION Data were extracted by the primary researcher (D.S.) and accuracy checked by coauthors. DATA SYNTHESIS A narrative synthesis and pooled prevalence meta-analysis were undertaken. CONCLUSIONS Pediatric delirium, as determined by the Cornell Assessment of Pediatric Delirium score, is estimated to occur in 34% of critical care admissions. Eight of 11 studies reporting on subtype identified hypoactive delirium as most prevalent (46-81%) with each of the three remaining reporting either hyperactive (44%), mixed (57%), or equal percentages of hypoactive and mixed delirium (43%) as most prevalent. The development of pediatric delirium is associated with cumulative doses of benzodiazepines, opioids, the number of sedative classes used, deep sedation, and cardiothoracic surgery. Increased time mechanically ventilated, length of stay, mortality, healthcare costs, and associations with decreased quality of life after discharge were also found. Multi-institutional and longitudinal studies are required to better determine the natural history, true prevalence, long-term outcomes, management strategies, and financial implications of pediatric delirium.
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Dokken M, Rustøen T, Diep LM, Fagermoen FE, Huse RI, A. Rosland G, Egerod I, Bentsen GK. Iatrogenic withdrawal syndrome frequently occurs in paediatric intensive care without algorithm for tapering of analgosedation. Acta Anaesthesiol Scand 2021; 65:928-935. [PMID: 33728643 DOI: 10.1111/aas.13818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/03/2021] [Accepted: 03/06/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Analgesics and sedatives are key elements to reduce physiological and psychological stress associated with treatment in paediatric intensive care. Prolonged drug use may induce tolerance and development of iatrogenic withdrawal syndrome (IWS) during the tapering phase. Our primary aim was to describe the prevalence of IWS among critically ill ventilated patients in two Norwegian paediatric intensive care units (PICUs), and secondary to investigate what motivated bedside nurses to administer additional drug doses. METHODS Mechanically ventilated patients (n = 40) from newborn to eighteen years of age, with continuous infusions of opioids and benzodiazepines for 5 days or more, were included consecutively from May 2016 to June 2018. By using Withdrawal Assessment Tool-1 (WAT-1) twice daily we recorded the prevalence of IWS. Additionally, we recorded signs and symptoms that led bedside nurses to administration extra bolus medication. RESULTS Peak WAT-1 score indicated an IWS prevalence of 95% in this selected group. The first days of the tapering phase were most critical for IWS. The most frequent symptoms triggering administration of additional bolus doses were agitation/restlessness, and thiopental and propofol were the bolus drugs used most frequently. CONCLUSIONS IWS affected 95% of the children having received infusions of opioids and benzodiazepines for 5 days or more in PICUs without a tapering protocol for these drugs. This calls for implementation and testing of such weaning protocols.
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Affiliation(s)
- Mette Dokken
- Division of Emergencies and Critical Care Paediatric Intensive Care Section Oslo University Hospital ‐ Rikshospitalet Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Tone Rustøen
- Division of Emergencies and Critical Care Department of Research and Development Oslo University Hospital Oslo Norway
- Department of Nursing Science Faculty of Medicine Institute of Health and Society University of Oslo Oslo Norway
| | - Lien M. Diep
- Department of Biostatistic and Epidemiology Oslo University Hospital Oslo Norway
| | - Frode E. Fagermoen
- Division of Emergencies and Critical Care Department of Anesthesiology Oslo University Hospital ‐ Rikshospitalet Oslo Norway
| | - Rakel I. Huse
- Division of Emergencies and Critical Care Paediatric Intensive Care Section Oslo University Hospital ‐ Rikshospitalet Oslo Norway
| | - Gudny A. Rosland
- Division of Emergencies and Critical Care Paediatric Intensive Care Section Oslo University Hospital ‐ Rikshospitalet Oslo Norway
| | - Ingrid Egerod
- Intensive Care Department University of CopenhagenRigshospitalet Copenhagen Denmark
| | - Gunnar K. Bentsen
- Division of Emergencies and Critical Care Department of Anesthesiology Oslo University Hospital ‐ Rikshospitalet Oslo Norway
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16
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Egbuta C, Mason KP. Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit. J Clin Med 2021; 10:1847. [PMID: 33922824 PMCID: PMC8122992 DOI: 10.3390/jcm10091847] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022] Open
Abstract
Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.
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Affiliation(s)
| | - Keira P. Mason
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA;
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Isaac L, van den Hoogen NJ, Habib S, Trang T. Maternal and iatrogenic neonatal opioid withdrawal syndrome: Differences and similarities in recognition, management, and consequences. J Neurosci Res 2021; 100:373-395. [PMID: 33675100 DOI: 10.1002/jnr.24811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/01/2021] [Indexed: 11/12/2022]
Abstract
Opioids are potent analgesics used to manage pain in both young and old, but the increased use in the pregnant population has significant individual and societal implications. Infants dependent on opioids, either through maternal or iatrogenic exposure, undergo neonatal opioid withdrawal syndrome (NOWS), where they may experience withdrawal symptoms ranging from mild to severe. We present a detailed and original review of NOWS caused by maternal opioid exposure (mNOWS) and iatrogenic opioid intake (iNOWS). While these two entities have been assessed entirely separately, recognition and treatment of the clinical manifestations of NOWS overlap. Neonatal risk factors such as age, genetic predisposition, drug type, and clinical factors like type of opioid, cumulative dose of opioid exposure, and disease status affect the incidence of both mNOWS and iNOWS, as well as their severity. Recognition of withdrawal is dependent on clinical assessment of symptoms, and the use of clinical assessment tools designed to determine the need for pharmacotherapy. Treatment of NOWS relies on a combination of non-pharmacological therapies and pharmacological options. Long-term consequences of opioids and NOWS continue to generate controversy, with some evidence of anatomic brain changes, but conflicting animal and human clinical evidence of significant cognitive or behavioral impacts on school-age children. We highlight the current knowledge on clinically relevant recognition, treatment, and consequences of NOWS, and identify new advances in clinical management of the neonate. This review brings a unique clinical perspective and critically analyzes gaps between the clinical problem and our preclinical understanding of NOWS.
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Affiliation(s)
- Lisa Isaac
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nynke J van den Hoogen
- Comparative Biology and Experimental Medicine, Physiology and Pharmacology, Hotchkiss Brain Institute, University of Calgary, Toronto, ON, Canada
| | - Sharifa Habib
- Department of Neonatology, Hospital for Sick Children, Toronto, ON, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Tuan Trang
- Comparative Biology and Experimental Medicine, Physiology and Pharmacology, Hotchkiss Brain Institute, University of Calgary, Toronto, ON, Canada
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18
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Geven BM, Maaskant JM, Ward CS, van Woensel JBM. Dexmedetomidine and Iatrogenic Withdrawal Syndrome in Critically Ill Children. Crit Care Nurse 2021; 41:e17-e23. [PMID: 33560432 DOI: 10.4037/ccn2021462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Iatrogenic withdrawal syndrome is a well-known adverse effect of sedatives and analgesics commonly used in patients receiving mechanical ventilation in the pediatric intensive care unit, with an incidence of up to 64.6%. When standard sedative and analgesic treatment is inadequate, dexmedetomidine may be added. The effect of supplemental dexmedetomidine on iatrogenic withdrawal syndrome is unclear. OBJECTIVE To explore the potentially preventive effect of dexmedetomidine, used as a supplement to standard morphine and midazolam regimens, on the development of iatrogenic withdrawal syndrome in patients receiving mechanical ventilation in the pediatric intensive care unit. METHODS This retrospective observational study used data from patients on a 10-bed general pediatric intensive care unit. Iatrogenic withdrawal syndrome was measured using the Sophia Observation withdrawal Symptoms-scale. RESULTS In a sample of 102 patients, the cumulative dose of dexmedetomidine had no preventive effect on the development of iatrogenic withdrawal syndrome (P = .19). After correction for the imbalance in the baseline characteristics between patients who did and did not receive dexmedetomidine, the cumulative dose of midazolam was found to be a significant risk factor for iatrogenic withdrawal syndrome (P < .03). CONCLUSION In this study, supplemental dexmedetomidine had no preventive effect on iatrogenic withdrawal syndrome in patients receiving sedative treatment in the pediatric intensive care unit. The cumulative dose of midazolam was a significant risk factor for iatrogenic withdrawal syndrome.
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Affiliation(s)
- Barbara M Geven
- Barbara M. Geven is a pediatric intensive care nurse and clinical epidemiologist, Amsterdam UMC/Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands
| | - Jolanda M Maaskant
- Jolanda M. Maaskant is a senior nurse researcher and clinical epidemiologist, Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam UMC/University of Amsterdam
| | - Catherine S Ward
- Catherine S. Ward is a general and pediatric anesthesiologist, Amsterdam UMC/Emma Children's Hospital
| | - Job B M van Woensel
- Job B.M. van Woensel is medical director of the pediatric intensive care unit, Amsterdam UMC/Emma Children's Hospital
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Abstract
OBJECTIVES The objective of this study was to determine the prevalence of ICU delirium in children less than 18 years old that underwent cardiac surgery within the last 30 days. The secondary aim of the study was to identify risk factors associated with ICU delirium in postoperative pediatric cardiac surgical patients. DESIGN A 1-day, multicenter point-prevalence study of delirium in pediatric postoperative cardiac surgery patients. SETTING Twenty-seven pediatric cardiac and general critical care units caring for postoperative pediatric cardiac surgery patients in North America. PATIENTS All children less than 18 years old hospitalized in the cardiac critical care units at 06:00 on a randomly selected, study day. INTERVENTIONS Eligible children were screened for delirium using the Cornell Assessment of Pediatric Delirium by the study team in collaboration with the bedside nurse. MEASUREMENT AND MAIN RESULTS Overall, 181 patients were enrolled and 40% (n = 73) screened positive for delirium. There were no statistically significant differences in patient demographic information, severity of defect or surgical procedure, past medical history, or postoperative day between patients screening positive or negative for delirium. Our bivariate analysis found those patients screening positive had a longer duration of mechanical ventilation (12.8 vs 5.1 d; p = 0.02); required more vasoactive support (55% vs 26%; p = 0.0009); and had a higher number of invasive catheters (4 vs 3 catheters; p = 0.001). Delirium-positive patients received more total opioid exposure (1.80 vs 0.36 mg/kg/d of morphine equivalents; p < 0.001), did not have an ambulation or physical therapy schedule (p = 0.02), had not been out of bed in the previous 24 hours (p < 0.0002), and parents were not at the bedside at time of data collection (p = 0.008). In the mixed-effects logistic regression analysis of modifiable risk factors, the following variables were associated with a positive delirium screen: 1) pain score, per point increase (odds ratio, 1.3; 1.06-1.60); 2) total opioid exposure, per mg/kg/d increase (odds ratio, 1.35; 1.06-1.73); 3) SBS less than 0 (odds ratio, 4.01; 1.21-13.27); 4) pain medication or sedative administered in the previous 4 hours (odds ratio, 3.49; 1.32-9.28); 5) no progressive physical therapy or ambulation schedule in their medical record (odds ratio, 4.40; 1.41-13.68); and 6) parents not at bedside at time of data collection (odds ratio, 2.31; 1.01-5.31). CONCLUSIONS We found delirium to be a common problem after cardiac surgery with several important modifiable risk factors.
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Conrad P, Meyer S, Whiting J, Connor JA. Iatrogenic withdrawal syndrome in specialty pediatric critical care. Appl Nurs Res 2020; 55:151284. [DOI: 10.1016/j.apnr.2020.151284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/01/2020] [Accepted: 05/07/2020] [Indexed: 11/28/2022]
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21
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Anticholinergic Burden in Children, Adults and Older Adults in Slovenia: A Nationwide Database Study. Sci Rep 2020; 10:9337. [PMID: 32518392 PMCID: PMC7283335 DOI: 10.1038/s41598-020-65989-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/17/2020] [Indexed: 11/11/2022] Open
Abstract
Anticholinergic burden has been widely studied in specific patient populations with specific conditions. However, the prevalence in the general population is poorly understood. This retrospective cross-sectional study was a nationwide database analysis of outpatient prescriptions of anticholinergic medications. The study was based on Slovenian health claims data of all outpatient prescriptions in 2018. Anticholinergic burden was evaluated using the Anticholinergic Cognitive Burden scale. Three age groups were analysed: children (≤18 years), adults (19–64 years) and older adults (≥65 years). Anticholinergic medications were prescribed to 29.8% of the participants; 7.6% were exposed to a clinically significant anticholinergic burden. The proportion of patients exposed to anticholinergic burden was highest in older adults (43.2%), followed by adults (25.8%) and children (20.7%). The most frequently prescribed medications with the highest anticholinergic activity were antipsychotics and medications for urinary diseases (42.8% and 40.2%, respectively). Medications with second highest activity were mostly antiepileptics (87.3%). Medications with possible anticholinergic activity included diverse therapeutic groups. Anticholinergic burden is highest in older adults but is also considerable among adults and children. Medications with anticholinergic activity belong to diverse therapeutic groups. Further research is needed on safe use of these medications in all age groups.
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Abstract
Supplemental Digital Content is available in the text. Trauma ICU patients may require high and/or prolonged doses of opioids and/or benzodiazepines as part of their treatment. These medications may contribute to drug physical dependence, a response manifested by withdrawal syndrome. We aimed to identify risk factors, symptoms, and clinical variables associated with probable withdrawal syndrome.
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Dechnik A, Traube C. Delirium in hospitalised children. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:312-321. [PMID: 32087768 DOI: 10.1016/s2352-4642(19)30377-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 09/29/2019] [Accepted: 10/21/2019] [Indexed: 01/15/2023]
Abstract
Delirium is a syndrome characterised by an acute and fluctuating alteration in cognition and awareness. It occurs frequently in children with serious medical illness, and is associated with adverse outcomes such as increased length of hospital stay, duration of mechanical ventilation, hospital costs, and mortality. Delirium-especially the hypoactive subtype-is often overlooked by paediatric practitioners, but can be reduced by mitigating risks and effectively managed if detected early. Non-modifiable risk factors of delirium include young age (age <2 years), cognitive or neurological disabilities, need for invasive mechanical ventilation, severe underlying illness and pre-existing chronic conditions, and poor nutritional status. Routine bedside screening using validated tools can enable early detection of delirium. To reduce delirium in hospitalised children, health-care providers should optimise the hospital environment (eg, by reducing sleep disruption and keeping the child stimulated during the day), improve pain management, and decrease sedation (particularly use of benzodiazepines).
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Affiliation(s)
- Andzelika Dechnik
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Chani Traube
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA.
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Goulooze SC, Ista E, van Dijk M, Hankemeier T, Tibboel D, Knibbe CAJ, Krekels EHJ. Supervised Multidimensional Item Response Theory Modeling of Pediatric Iatrogenic Withdrawal Symptoms. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2019; 8:904-912. [PMID: 31612647 PMCID: PMC6930857 DOI: 10.1002/psp4.12469] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/14/2019] [Indexed: 01/22/2023]
Abstract
Item‐level data from composite scales can be analyzed with pharmacometric item response theory (IRT) models to improve the quantification of disease severity compared with the use of total composite scores. However, regular IRT models assume unidimensionality, which is violated in the scale measuring iatrogenic withdrawal in children because some items are also affected by pain, undersedation, or delirium. Here, we compare regular IRT modelling of pediatric iatrogenic withdrawal symptom data with two new analysis approaches in which the latent variable is guided towards the condition of interest using numerical withdrawal severity scored by nurses as a “supervising variable:” supervised IRT (sIRT) and supervised multi‐dimensional (smIRT) modelling. In this example, in which the items scores are affected by multiple conditions, regular IRT modeling is worse to quantify disease severity than the total composite score, whereas improved performance compared with the composite score is observed for the sIRT and smIRT models.
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Affiliation(s)
- Sebastiaan C Goulooze
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Erwin Ista
- Intensive Care and Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Monique van Dijk
- Intensive Care and Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Thomas Hankemeier
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Dick Tibboel
- Intensive Care and Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Catherijne A J Knibbe
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.,Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Elke H J Krekels
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
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Rodríguez-Rubio M, Álvarez-Rojas E, de la Oliva P. The diagnosis of delirium in pediatric intensive care: A burdensome yet essential task. Med Intensiva 2019; 44:128. [PMID: 31097217 DOI: 10.1016/j.medin.2019.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 04/07/2019] [Indexed: 10/26/2022]
Affiliation(s)
- M Rodríguez-Rubio
- Servicio de Cuidados Intensivos Pediátricos, Hospital Universitario La Paz, Madrid, España; Departamento de Pediatría, Universidad Autónoma de Madrid, Madrid, España.
| | - E Álvarez-Rojas
- Servicio de Cuidados Intensivos Pediátricos, Hospital Universitario La Paz, Madrid, España
| | - P de la Oliva
- Servicio de Cuidados Intensivos Pediátricos, Hospital Universitario La Paz, Madrid, España; Departamento de Pediatría, Universidad Autónoma de Madrid, Madrid, España
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Castro REVD, Sousa CDC, de Magalhães-Barbosa MC, Prata-Barbosa A, Cheniaux E. Ranitidine-Induced Delirium in a 7-Year-Old Girl: A Case Report. Pediatrics 2019; 143:peds.2018-2428. [PMID: 30635349 DOI: 10.1542/peds.2018-2428] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2018] [Indexed: 11/24/2022] Open
Abstract
Ranitidine is a histamine-2 blocker commonly prescribed in PICUs for the prophylaxis of gastrointestinal bleeding and stress ulcers. However, it can be associated to central nervous system side effects, such as delirium, in adults. We present the first case of a child presenting delirium possibly caused by anticholinergic toxidrome secondary to the use of ranitidine, resolving after drug discontinuation. With this case report, we reinforce that a wide variety of clinical conditions can trigger delirium and that the best therapeutic approach is to minimize risk factors.
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Affiliation(s)
- Roberta Esteves Vieira de Castro
- Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil; .,Hospital Vitória, Americas Medical City, Rio de Janeiro, Brazil
| | | | | | | | - Elie Cheniaux
- Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.,Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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D'Souza G, Wren AA, Almgren C, Ross AC, Marshall A, Golianu B. Pharmacological Strategies for Decreasing Opioid Therapy and Management of Side Effects from Chronic Use. CHILDREN 2018; 5:children5120163. [PMID: 30563157 PMCID: PMC6306833 DOI: 10.3390/children5120163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/27/2018] [Accepted: 12/03/2018] [Indexed: 12/04/2022]
Abstract
As awareness increases about the side effects of opioids and risks of misuse, opioid use and appropriate weaning of opioid therapies have become topics of significant clinical relevance among pediatric populations. Critically ill hospitalized neonates, children, and adolescents routinely receive opioids for analgesia and sedation as part of their hospitalization, for both acute and chronic illnesses. Opioids are frequently administered to manage pain symptoms, reduce anxiety and agitation, and diminish physiological stress responses. Opioids are also regularly prescribed to youth with chronic pain. These medications may be prescribed during the initial phase of a diagnostic workup, during an emergency room visit; as an inpatient, or on an outpatient basis. Following treatment for underlying pain conditions, it can be challenging to appropriately wean and discontinue opioid therapies. Weaning opioid therapy requires special expertise and care to avoid symptoms of increased pain, withdrawal, and agitation. To address this challenge, there have been enhanced efforts to implement opioid-reduction during pharmacological therapies for pediatric pain management. Effective pain management therapies and their outcomes in pediatrics are outside the scope of this paper. The aims of this paper were to: (1) Review the current practice of opioid-reduction during pharmacological therapies; and (2) highlight concrete opioid weaning strategies and management of opioid withdrawal.
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Affiliation(s)
- Genevieve D'Souza
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA 94304, USA.
| | - Anava A Wren
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Stanford University, Palo Alto, CA 94304, USA.
| | - Christina Almgren
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA 94304, USA.
| | - Alexandra C Ross
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA 94304, USA.
| | - Amanda Marshall
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA 94304, USA.
| | - Brenda Golianu
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA 94304, USA.
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Ista E, van Beusekom B, van Rosmalen J, Kneyber MCJ, Lemson J, Brouwers A, Dieleman GC, Dierckx B, de Hoog M, Tibboel D, van Dijk M. Validation of the SOS-PD scale for assessment of pediatric delirium: a multicenter study. Crit Care 2018; 22:309. [PMID: 30458826 PMCID: PMC6247513 DOI: 10.1186/s13054-018-2238-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 10/15/2018] [Indexed: 11/13/2022] Open
Abstract
Backgrounds Reports of increasing incidence rates of delirium in critically ill children are reason for concern. We evaluated the measurement properties of the pediatric delirium component (PD-scale) of the Sophia Observation Withdrawal Symptoms scale Pediatric Delirium scale (SOS-PD scale). Methods In a multicenter prospective observational study in four Dutch pediatric ICUs (PICUs), patients aged ≥ 3 months and admitted for ≥ 48 h were assessed with the PD-scale thrice daily. Criterion validity was assessed: if the PD-scale score was ≥ 4, a child psychiatrist clinically assessed the presence or absence of PD according to the Diagnostic and statistical manual of mental disorders (DSM)-IV. In addition, the child psychiatrist assessed a randomly selected group to establish the false-negative rate. The construct validity was assessed by calculating the Pearson coefficient (rp) for correlation between the PD-scale and Cornell Assessment Pediatric Delirium (CAP-D) scores. Interrater reliability was determined by comparing paired nurse-researcher PD-scale assessments and calculating the intraclass correlation coefficient (ICC). Results Four hundred eighty-five patients with a median age of 27.0 months (IQR 8–102) were included, of whom 48 patients were diagnosed with delirium by the child psychiatrist. The PD-scale had overall sensitivity of 92.3% and specificity of 96.5% compared to the psychiatrist diagnosis for a cutoff score ≥4 points. The rp between the PD-scale and the CAP-D was 0.89 (CI 95%, 0.82–0.93; p < 0.001). The ICC of 75 paired nurse-researcher observations was 0.99 (95% CI, 0.98–0.99). Conclusions The PD-scale has good reliability and validity for early screening of PD in critically ill children. It can be validly and reliably used by nurses to this aim. Electronic supplementary material The online version of this article (10.1186/s13054-018-2238-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Erwin Ista
- Intensive Care Unit, Departments of Pediatrics and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Office Sb-2704, P.O. Box 2060, 3000 CB, Rotterdam, The Netherlands.
| | - Babette van Beusekom
- Department of Child and Adolescent Psychiatry and Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Martin C J Kneyber
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Critical Care, Anaesthesiology, Peri - operative & Emergency medicine (CAPE), University of Groningen, Groningen, The Netherlands
| | - Joris Lemson
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arno Brouwers
- Department of Pediatrics, Division Pediatric Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Gwen C Dieleman
- Department of Child and Adolescent Psychiatry and Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Bram Dierckx
- Department of Child and Adolescent Psychiatry and Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Matthijs de Hoog
- Intensive Care Unit, Departments of Pediatrics and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Office Sb-2704, P.O. Box 2060, 3000 CB, Rotterdam, The Netherlands
| | - Dick Tibboel
- Intensive Care Unit, Departments of Pediatrics and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Office Sb-2704, P.O. Box 2060, 3000 CB, Rotterdam, The Netherlands
| | - Monique van Dijk
- Intensive Care Unit, Departments of Pediatrics and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Office Sb-2704, P.O. Box 2060, 3000 CB, Rotterdam, The Netherlands
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Risk Factors for the Development of Postoperative Delirium in Pediatric Intensive Care Patients. Pediatr Crit Care Med 2018; 19:e514-e521. [PMID: 30059477 DOI: 10.1097/pcc.0000000000001681] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To determine and quantify risk factors for postoperative pediatric delirium. DESIGN Single-center prospective cohort study. SETTING Twenty-two bed PICU in a tertiary care academic medical center in Germany. PATIENTS All children admitted after major elective surgery (n = 93; 0-17 yr). INTERVENTIONS After awakening, children were screened for delirium using the Cornell Assessment of Pediatric Delirium bid over a period of 5 days. Demographic and clinical data were collected from the initiation of general anesthesia. MEASUREMENTS AND MAIN RESULTS A total of 61 patients (66%) were delirious. Younger children developed delirium more frequently, and the symptoms were more pronounced. The number of preceding operations did not influence the risk of delirium. Total IV anesthesia had a lower risk than inhalational anesthesia (p < 0.05). Duration of anesthesia was similar in all groups. Patients with delirium had a longer duration of mechanical ventilation in the PICU (p < 0.001). Significant differences in cumulative doses of various medications (e.g., sedatives, analgesics, and anticholinergics) were noted between groups; these differences were independent of disease severity. Invasive catheters and respiratory devices (p < 0.01) as well as infections (p < 0.001) increased risk of delirium. CONCLUSIONS A high prevalence of delirium was noted in the PICU, and several perioperative risk factors were identified. Our data may be a base for development of strategies to prevent and treat postoperative delirium in children.
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Anticholinergic Medication Burden in Pediatric Prolonged Critical Illness: A Potentially Modifiable Risk Factor for Delirium. Pediatr Crit Care Med 2018; 19:917-924. [PMID: 30284995 PMCID: PMC6170145 DOI: 10.1097/pcc.0000000000001658] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES It is important to describe and understand the prevalence and risk factors for the syndrome of delirium in critical illness. Since anticholinergic medication may contribute to the development of delirium in the PICU, we have sought to quantify anticholinergic medication exposure in patients with prolonged admission. We have used Anticholinergic Drug Scale scores to quantify the magnitude or extent of this burden. DESIGN Retrospective cohort study, January 2011 to December 2015. SETTING Single academic medical center PICU. PATIENTS Children under 18 years old with a PICU admission of 15 days or longer, requiring mechanical ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Daily Anticholinergic Drug Scale scores for the first 15 days of admission, in each of 88 subjects (total of 1,320 PICU days), were collected and assessed in relation to demographic data, severity of illness, and medication use. Median (interquartile range) of daily Anticholinergic Drug Scale score was 5 (interquartile range, 3-7). Anticholinergic Drug Scale score was not associated with age, sex, medical history, presenting Severity of Illness score, PICU length of stay, ventilator hours, or hospital mortality. Medications most frequently associated with high Anticholinergic Drug Scale score were low potency anticholinergic drugs such as morphine, midazolam, vancomycin, steroids, and furosemide, with the exception of ranitidine (Anticholinergic Drug Scale score 2). Patients receiving high doses of midazolam infusion had significantly higher Anticholinergic Drug Scale scores compared with those receiving lower or no midazolam dosing. CONCLUSIONS A high number of medications with anticholinergic effects are administered to PICU patients receiving prolonged mechanical ventilation. These exposures are much higher than those reported in adult intensive care patients. Since anticholinergic drug exposure is associated with delirium, further study of this exposure in PICU patients is needed.
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Parent's experiences of their child's withdrawal syndrome: a driver for reciprocal nurse-parent partnership in withdrawal assessment. Intensive Crit Care Nurs 2018; 50:71-78. [PMID: 30224222 DOI: 10.1016/j.iccn.2018.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 08/29/2018] [Accepted: 09/04/2018] [Indexed: 11/20/2022]
Abstract
Withdrawal assessment in critically ill children is complicated by the reliance on non-specific behaviours and compounded when the child's typical behaviours are unknown. The existing approach to withdrawal assessment assumes that nurses elicit the parents' view of the child's behaviours. OBJECTIVE AND RESEARCH METHODOLOGY This qualitative study explored parents' perspectives of their child's withdrawal and preferences for involvement and participation in withdrawal assessment. Parents of eleven children were interviewed after their child had completed sedation weaning during recovery from critical illness. Data were analysed using thematic analysis. SETTING A large children's hospital in the Northwest of England. FINDINGS Parents experienced varying degrees of partnership in the context of withdrawal assessment and identified information deficits which contributed to their distress of parenting a child with withdrawal syndrome. Most parents were eager to participate in withdrawal assessment and reported instances where their knowledge enabled a personalised interpretation of their child's behaviours. Reflecting on the reciprocal nature of the information deficits resulted in the development of a model for nurse-parent collaboration in withdrawal assessment. CONCLUSION Facilitating nurse-parent collaboration in withdrawal assessment may have reciprocal benefits by moderating parental stress and aiding the assessment and management of withdrawal syndrome.
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Affiliation(s)
- Chani Traube
- Department of Pediatric Critical Care, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY; Department of Child Psychiatry, Weill Cornell Medical College, New York, NY
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Abstract
PURPOSE OF REVIEW This review seeks to provide an update on the diagnosis, management, and outcome of pediatric delirium. RECENT FINDINGS Care of patients with delirium depends on correct diagnosis and treatment of its underlying cause. A variety of instruments are available to aid diagnosis. Management of delirium currently depends on atypical antipsychotics, while avoiding agents that may precipitate or exacerbate it. While most critically ill children survive delirium, many children die or have worsening function after their illness. The longer the duration of delirium, the more severe its subsequent problems including postintensive care syndrome and posttraumatic stress disorder. Possible serious long-term consequences emphasize the importance of efforts to improve diagnosis and outcome in critically ill children suffering from delirium.
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Affiliation(s)
- Susan Beckwitt Turkel
- Keck School of Medicine of University of Southern California, Departments of Psychiatry and Pediatrics, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA, 90027, USA.
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Ista E, Te Beest H, van Rosmalen J, de Hoog M, Tibboel D, van Beusekom B, van Dijk M. Sophia Observation withdrawal Symptoms-Paediatric Delirium scale: A tool for early screening of delirium in the PICU. Aust Crit Care 2017; 31:266-273. [PMID: 28843537 DOI: 10.1016/j.aucc.2017.07.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 06/29/2017] [Accepted: 07/26/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Delirium in critically ill children is a severe neuropsychiatric disorder which has gained increased attention from clinicians. Early identification of delirium is essential for successful management. The Sophia Observation withdrawal Symptoms-Paediatric Delirium (SOS-PD) scale was developed to detect Paediatric Delirium (PD) at an early stage. OBJECTIVE The aim of this study was to determine the measurement properties of the PD component of the SOS-PD scale in critically ill children. METHODS A prospective, observational study was performed in patients aged 3 months or older and admitted for more than 48h. These patients were assessed with the SOS-PD scale three times a day. If the SOS-PD total score was 4 or higher in two consecutive observations, the child psychiatrist was consulted to assess the diagnosis of PD using the Diagnostic and Statistical Manual-IV criteria as the "gold standard". The child psychiatrist was blinded to outcomes of the SOS-PD. The interrater reliability of the SOS-PD between the care-giving nurse and a researcher was calculated with the intraclass correlation coefficient (ICC). RESULTS A total of 2088 assessments were performed in 146 children (median age 49 months; IQR 13-140). The ICC of 16 paired nurse-researcher observations was 0.90 (95% CI 0.70-0.96). We compared 63 diagnoses of the child psychiatrist versus SOS-PD assessments in 14 patients, in 13 of whom the diagnosis of PD was confirmed. The sensitivity was 96.8% (95% CI 80.4-99.5%) and the specificity was 92.0% (95% CI 59.7-98.9%). CONCLUSIONS The SOS-PD scale shows promising validity for early screening of PD. Further evidence should be obtained from an international multicentre study.
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Affiliation(s)
- Erwin Ista
- Intensive Care Unit, Departments of Pediatrics and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Harma Te Beest
- Intensive Care Unit, Departments of Pediatrics and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Matthijs de Hoog
- Intensive Care Unit, Departments of Pediatrics and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dick Tibboel
- Intensive Care Unit, Departments of Pediatrics and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Babette van Beusekom
- Department of Child and Adolescent Psychiatry and Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Monique van Dijk
- Intensive Care Unit, Departments of Pediatrics and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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We Can Not Compartmentalize Our Patients! Overlapping Symptoms of Iatrogenic Withdrawal Syndrome, Pediatric Delirium, and Anticholinergic Toxidrome. Pediatr Crit Care Med 2017; 18:603-604. [PMID: 28574912 DOI: 10.1097/pcc.0000000000001163] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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