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Yaregal Melesse D, Teshale Tesema T, Ayinie Mekonnen Z, Chekol WB, Admass BA, Mengie Workie M. Predictors of postoperative delirium in paediatric patients undergoing surgery under general anaesthesia at Amhara Regional State Tertiary Hospitals: a multicenter prospective study. Front Pediatr 2024; 12:1348789. [PMID: 38523839 PMCID: PMC10957644 DOI: 10.3389/fped.2024.1348789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/23/2024] [Indexed: 03/26/2024] Open
Abstract
Introduction Postoperative delirium in paediatric patients is a recognised issue. Nevertheless, in low- and middle-income nations, researchers have had luck in determining its extent and predictors. Identifying predictors of postoperative delirium in paediatric patients having general anaesthesia at Tertiary Hospitals in Ethiopia was the aim of this study. Methods A multicenter, prospective follow up study was conducted from April 15 to June 15, 2023 at the study settings. During the study period a total of 424 paediatric surgical patients treated under general anaesthesia in all study locations, ranging in age from birth to sixteen were candidates for this study. Charts and direct observation of patient's with assessment tool [Cornell Assessment of Pediatric Delirium (CAPD)] were used from each available patient. Binary logistic regression analysis was performed to determine predictors of postoperative delirium in paediatric patients undergoing surgery under general anaesthesia. Results Postoperative delirium occurred in 160 of the 404 paediatric patients who underwent surgery under general anaesthesia. Ophthalmic surgery, corticosteroid use, anticholinergic use, severe postoperative pain, and preoperative anxiety were found to be predictors of postoperative delirium; whereas, sedative medication premedication and paracetamol used for analgesia were found to be protective against postoperative delirium. Inference and recommendation The postoperative delirium in paediatric patients undergoing surgery under general anaesthesia was higher compared to developed countries. Ophthalmic surgery, corticosteroids, anticholinergic medications, postoperative pain, and preoperative anxiety were found to be predictors. The impact of postoperative delirium might be lessened by concentrating on its screening and factor control.
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Affiliation(s)
- Debas Yaregal Melesse
- Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Bradford CV, Fung MY, Wang A, Benefield EC, Bashqoy F, Neely SB, Johnson PN. Delirium Assessment Treatment Strategies in Critically Ill Pediatric Patients: A Pediatric Pharmacy Association Practice-Based Research Network Survey Study. J Pediatr Pharmacol Ther 2023; 28:540-552. [PMID: 38130349 PMCID: PMC10731945 DOI: 10.5863/1551-6776-28.6.540] [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: 11/01/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2023]
Abstract
OBJECTIVES The purpose of this study was to describe overall screening, prevention, and treatments for pediatric delirium at various neonatal intensive care units (NICUs), cardiac intensive care units (CICUs), and pediatric intensive care units (PICUs) from the Pediatric Pharmacy Association (PPA) membership. The primary objective was to identify the number of respondents that had a defined delirium-based protocol. The secondary objectives included identification of delirium assessment tools used, first- and second-line delirium treatment options, and monitoring practices for antipsychotics for delirium management. METHODS A cross-sectional questionnaire was distributed to PPA members from February 8, 2022, to March, 25, 2022. Comparisons between the NICUs, PICUs, and CICUs were conducted by using chi-square tests, with a priori p value of <0.05. RESULTS The questionnaire was completed by 84 respondents at 62 institutions; respondents practiced in the PICU or mixed PICU (n = 48; 57.1%), CICU (n = 13; 15.5%), and NICU (n = 23; 27.4%). Sixty-one respondents (72.6%) noted their units routinely screen for delirium, and there was a significant difference between the respondents of different units that use a delirium scoring tool (p < 0.01). Only 33 respondents (39.3%) had a defined delirium protocol, and there was no difference between units (p = 0.31). The most common agents used for delirium treatment were quetiapine and risperidone. There was variability in the monitoring used between respondents, but the majority (n = 74; 88%) monitor electrocardiograms to assess the corrected QT interval, but practice variability existed. CONCLUSIONS Most respondents did not have a defined delirium protocol. Variations were noted in the treatment options and monitoring for critically ill pediatric patients with delirium.
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Affiliation(s)
- Caitlyn V. Bradford
- Department of Pharmacy Practice (CVB), Philadelphia College of Pharmacy, Saint Joseph’s University, Philadelphia, PA
| | - Mon-Yee Fung
- Department of Pharmacy (M-YF), University of Michigan MOTT Children’s Hospital, Ann Arbor, MI
| | - Alexander Wang
- Department of Pharmacy (AW), Children’s National Hospital, Washington, DC
| | | | - Ferras Bashqoy
- Department of Pharmacy (FB), Hassenfeld Children’s Hospital at NYU Langone Health, New York City, NY
| | - Stephen B. Neely
- Department of Pharmacy: Clinical and Administrative Sciences (SBN, PNJ), College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Peter N. Johnson
- Department of Pharmacy: Clinical and Administrative Sciences (SBN, PNJ), College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Abstract
OBJECTIVES Children with chronic critical illness (CCI) are hypothesized to be a high-risk patient population with persistent multiple organ dysfunction and functional morbidities resulting in recurrent or prolonged critical care; however, it is unclear how CCI should be defined. The aim of this scoping review was to evaluate the existing literature for case definitions of pediatric CCI and case definitions of prolonged PICU admission and to explore the methodologies used to derive these definitions. DATA SOURCES Four electronic databases (Ovid Medline, Embase, CINAHL, and Web of Science) from inception to March 3, 2021. STUDY SELECTION We included studies that provided a specific case definition for CCI or prolonged PICU admission. Crowdsourcing was used to screen citations independently and in duplicate. A machine-learning algorithm was developed and validated using 6,284 citations assessed in duplicate by trained crowd reviewers. A hybrid of crowdsourcing and machine-learning methods was used to complete the remaining citation screening. DATA EXTRACTION We extracted details of case definitions, study demographics, participant characteristics, and outcomes assessed. DATA SYNTHESIS Sixty-seven studies were included. Twelve studies (18%) provided a definition for CCI that included concepts of PICU length of stay (n = 12), medical complexity or chronic conditions (n = 9), recurrent admissions (n = 9), technology dependence (n = 5), and uncertain prognosis (n = 1). Definitions were commonly referenced from another source (n = 6) or opinion-based (n = 5). The remaining 55 studies (82%) provided a definition for prolonged PICU admission, most frequently greater than or equal to 14 (n = 11) or greater than or equal to 28 days (n = 10). Most of these definitions were derived by investigator opinion (n = 24) or statistical method (n = 18). CONCLUSIONS Pediatric CCI has been variably defined with regard to the concepts of patient complexity and chronicity of critical illness. A consensus definition is needed to advance this emerging and important area of pediatric critical care research.
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ZHU X, FENG X, LIN J, DING Y. Risk factors of delirium in paediatric intensive care units: A meta-analysis. PLoS One 2022; 17:e0270639. [PMID: 35802701 PMCID: PMC9269883 DOI: 10.1371/journal.pone.0270639] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 06/14/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Delirium is a brain dysfunction syndrome, which children have a higher incidence. At present, there have been more and more studies and reports on delirium in paediatric intensive care unit, but there are some differences in the risk factor results among different studies. To better manage delirium, this study was performed.
Objective
To integrate and clarify the risk factors for delirium in paediatric intensive care unit.
Methods
CNKI, CBMdisc, Wanfang Data Knowledge Service Platform, VIP, PubMed, Embase, Cochrane Library, JBI and PsycInfo were searched for relevant literature. The study subjects were patients in PICU and literature was included according to the PICOS principle. Literature screening and risk of bias assessment were mainly completed by two researchers, and RevMan 5.3 software and Stata software were used for data analysis. The GRADE systerm was used to assess the quality of evidence.
Results
A total of 10 studies were included, all in English, involving 4343 children. Within the GRADE system, 4 indicators were scored A, 1 indicators were scored B, and 3 indicators were scored C regarding evidence levels. Three studies analysed the influence of developmental delay on the occurrence of delirium in PICU, total sample size of which was 1823, and the results showed that the combined effect was statistically significant [OR = 3.34, 95%CI(2.46–4.53), Z = 7.75, P<0.001]; Five studies analysed the effects of mechanical ventilation on the occurrence of delirium in PICU, sample size of which was 1562, and the results showed that the combined effect was statistically significant [OR = 4.11, 95%CI(3.13–5.40), Z = 10.16, P<0.001]; Two studies analysed the effects of benzodiazepines on children developing delirium, sample size of which was 1635, and the results showed that the combined effect was statistically significant [OR = 5.05, 95%CI(3.65–6.97), Z = 9.83, P<0.001]; Two studies analysed the effects of anticholinergic drug use on children developing delirium in PICU, sample size of which was 1703, and the results suggested the combined effect was statistically significant [OR = 5.04, 95%CI (3.62–7.00), Z = 9.63, P<0.001]; Two studies compared the same age period, sample size of which was 1724 and the results showed that children 2–5 years old has a 48% incidence rate of delirium relative to children younger than 2 years old, and the combined effect was statistically significant [OR = 0.48, 95%CI(0.25–0.92), Z = 2.22, P = 0.030], children 5–13 years old has a 39% incidence rate of delirium relative to children younger than 2 years old, and the combined effect was statistically significant [OR = 0.39, 95%CI(0.26–0.59), Z = 4.43, P<0.001]. Two studies analysed the effects of PICU LOS on children developing delirium and the combined effect of PICU LOS on the occurrence of delirium in children in PICU was statistically significant [OR = 1.10, 95%CI(1.05–1.15), Z = 4.07, P<0.001].
Conclusion
Developmental delay, mechanical ventilation, benzodiazepine use, anticholinergic use, age and PICU length of stay are independent risk factors for delirium in children in PICU. However, only a few articles were included in this study, which may lead to a certain bias and affect the analysing results. More large-sample, multicentre studies should be conducted to further explore and clarify the independent influencing factors of delirium in children in PICU and to provide guidance for clinical practice.
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Affiliation(s)
- Xuelian ZHU
- Department of Orthopedics, Wuxi Children’s Hospital, Wuxi, China
| | - Xiaoyan FENG
- Nursing Department, Wuxi Children’s Hospital, Wuxi, China
- * E-mail:
| | - Jia LIN
- PICU, Wuxi Children’s Hospital, Wuxi, China
| | - Yanhong DING
- Department of Orthopedics, Wuxi Children’s Hospital, Wuxi, China
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Mattsson J, Meijers J, Björling G. Challenges in Nursing Care of Children With Substance Withdrawal Syndrome in the PICU. SAGE Open Nurs 2022; 8:23779608221117382. [PMID: 35959413 PMCID: PMC9358588 DOI: 10.1177/23779608221117382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/27/2022] [Accepted: 07/16/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction Substance withdrawal is one of the most common advert events in the Pediatric Intensive Care Unit (PICU), as the administration of potent opiates and sedative drugs is frequently performed several times each day. Objectives The present study explored the challenges in nursing care of children with substance withdrawal syndrome in the PICU. Method The study has an explorative and descriptive semi-structured qualitative interview design, with a strategic selection of informants. It was conducted at one out of three pediatric intensive care units in Sweden. Results Three different main themes were identified describing the different challenges regarding withdrawal symptoms: monitor the child’s interest, work with structured support, and understand the observation. Conclusions There is a discrepancy between the medical perspective and the nursing care perspective regarding children in PICU suffering from withdrawal syndrome. The lack of joint guidelines, language, and nursing diagnoses may lead to subjective evaluations and increase suffering for these children.
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Affiliation(s)
- Janet Mattsson
- Department of Learning, Informatics, Management and Ethics, LIME, Karolinska Institutet, Stockholm, Sweden
- Children’s Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Johannes Meijers
- Children’s Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Gunilla Björling
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Faculty of Nursing, Kilimanjaro Christian Medical University College, Moshi, Tanzania
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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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Koth AM, Chan T, Tjoeng YL, Watson RS, Dervan LA. Delirium in a Tertiary Pediatric Cardiac Intensive Care Unit: Risk Factors and Outcomes. J Intensive Care Med 2021; 37:1328-1335. [PMID: 34898312 DOI: 10.1177/08850666211066892] [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: 11/16/2022]
Abstract
OBJECTIVE Delirium is an increasingly recognized hospital complication associated with poorer outcomes in critically ill children. We aimed to evaluate risk factors for screening positive for delirium in children admitted to a pediatric cardiac intensive care unit (CICU) and to examine the association between duration of positive screening and in-hospital outcomes. STUDY DESIGN Retrospective cohort study in a single-center quaternary pediatric hospital CICU evaluating children admitted from March 2014-October 2016 and screened for delirium using the Cornell Assessment of Pediatric Delirium. Statistical analysis used multivariable logistic and linear regression. RESULTS Among 942 patients with screening data (98% of all admissions), 67% of patients screened positive for delirium. On univariate analysis, screening positive was associated with younger age, single ventricle anatomy, duration of mechanical ventilation, continuous renal replacement therapy, extracorporeal life support, and surgical complexity, as well as higher average total daily doses of benzodiazepines, opioids, and dexmedetomidine. On multivariable analysis, screening positive for delirium was independently associated with age <2 years, duration of mechanical ventilation, and greater than the median daily doses of benzodiazepine and opioid. In addition to these factors, duration of screening positive was also independently associated with higher STAT category (3-5) or medical admission, organ failure, acute kidney injury (AKI), and higher dexmedetomidine exposure. Duration of positive delirium screening was associated with both increased CICU and hospital length of stay (each additional day of positive screening was associated with a 3% longer CICU stay [95% CI = 1%-6%] and 2% longer hospital stay [95% CI = 0%-4%]). CONCLUSIONS Screening positive for delirium is common in the pediatric CICU and is independently associated with prolonged intensive care unit (ICU) and hospital stay. Longer duration of mechanical ventilation and higher sedative doses are independent risk factors for screening positive for delirium. Efforts aimed at reducing these exposures may decrease the burden of delirium in this population.
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Affiliation(s)
- Andrew M Koth
- Division of Pediatric Critical Care Medicine, 271845Department of Pediatrics, University of Washington, Seattle, WA, USA.,The Heart Center, 7274Seattle Children's Hospital, Seattle, WA, USA
| | - Titus Chan
- Division of Pediatric Critical Care Medicine, 271845Department of Pediatrics, University of Washington, Seattle, WA, USA.,The Heart Center, 7274Seattle Children's Hospital, Seattle, WA, USA.,Center for Integrative Brain Research, 7274Seattle Children's Hospital, Seattle, WA, USA
| | - Yuen Lie Tjoeng
- Division of Pediatric Critical Care Medicine, 271845Department of Pediatrics, University of Washington, Seattle, WA, USA.,The Heart Center, 7274Seattle Children's Hospital, Seattle, WA, USA
| | - R Scott Watson
- Division of Pediatric Critical Care Medicine, 271845Department of Pediatrics, University of Washington, Seattle, WA, USA.,Center for Child Health, Behavior, and Development, 145793Seattle Children's Research Institute, Seattle, WA, USA
| | - Leslie A Dervan
- Division of Pediatric Critical Care Medicine, 271845Department of Pediatrics, University of Washington, Seattle, WA, USA.,Center for Clinical and Translational Research, 145793Seattle Children's Research Institute, Seattle, WA, USA
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Martinez EE, Dang H, Franks J, Callif CG, Tasker RC, Madden K, Mehta NM. Association Between Anticholinergic Drug Burden and Adequacy of Enteral Nutrition in Critically Ill, Mechanically Ventilated Pediatric Patients. Pediatr Crit Care Med 2021; 22:1083-1087. [PMID: 34560773 DOI: 10.1097/pcc.0000000000002840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Enteral nutrition delivery is limited by intolerance and interruptions in critically ill children. Anticholinergic properties of frequently administered medications may contribute to altered gastric motility and enteral nutrition intolerance in this population. We examined the association between the anticholinergic burden of administered medications using the Anticholinergic Drug Scale and adequacy of enteral nutrition delivery. DESIGN Secondary analysis of data from a previously characterized PICU cohort. SETTING Multidisciplinary PICU in a quaternary academic medical center. PATIENTS Younger than or equal to 18 years, on mechanical ventilation and received enteral nutrition within the first 3 days of PICU admission. MEASUREMENTS AND MAIN RESULTS Daily Anticholinergic Drug Scale score, demographic data, and clinical data were obtained from the primary study. Percent enteral energy adequacy ([kcal delivered ÷ kcal prescribed] × 100) during the first 3 days of PICU admission was calculated. Forty-two patients received enteral nutrition, with median age (interquartile range) 5 years (1.09-12.54 yr), and 62% were male. Median Anticholinergic Drug Scale score was inversely correlated with energy adequacy, with a median 9% decline in energy adequacy per 1-point increase in Anticholinergic Drug Scale score (coefficient, -9.3; 95% CI, -13.43 to -5.27; R2 = 0.35; p < 0.0001). Median hours of enteral nutrition interruptions directly correlated with Anticholinergic Drug Scale score (coefficient, 1.5; 95% CI, 0.531-2.54; R2 = 0.19; p = 0.004). Severity score was greater in patients with less than or equal to 25% enteral energy adequacy and directly correlated with median Anticholinergic Drug Scale score. CONCLUSIONS Anticholinergic burden from medications administered in the PICU is a potentially modifiable factor for suboptimal enteral nutrition delivery.
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Affiliation(s)
- Enid E Martinez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Hongxing Dang
- Department of Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jennifer Franks
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Charles G Callif
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Robert C Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Kate Madden
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Center for Nutrition, Boston Children's Hospital, Boston, MA
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Liviskie C, McPherson C, Luecke C. Assessment and Management of Delirium in the Pediatric Intensive Care Unit: A Review. J Pediatr Intensive Care 2021; 12:94-105. [PMID: 37082469 PMCID: PMC10113017 DOI: 10.1055/s-0041-1730918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/31/2021] [Indexed: 10/21/2022] Open
Abstract
AbstractMany critically ill patients suffer from delirium which is associated with significant morbidity and mortality. There is a paucity of data about the incidence, symptoms, or treatment of delirium in the pediatric intensive care unit (PICU). Risk factors for delirium are common in the PICU including central nervous system immaturity, developmental delay, mechanical ventilation, and use of anticholinergic agents, corticosteroids, vasopressors, opioids, or benzodiazepines. Hypoactive delirium is the most common subtype in pediatric patients; however, hyperactive delirium has also been reported. Various screening tools are validated in the pediatric population, with the Cornell Assessment of Pediatric Delirium (CAPD) applicable to the largest age range and able to detect signs and symptoms consistent with both hypo- and hyperactive delirium. Treatment of delirium should always include identification and reversal of the underlying etiology, reserving pharmacologic management for those patients without symptom resolution, or with significant impact to medical care. Atypical antipsychotics (olanzapine, quetiapine, and risperidone) should be used first-line in patients requiring pharmacologic treatment owing to their apparent efficacy and low incidence of reported adverse effects. The choice of atypical antipsychotic should be based on adverse effect profile, available dosage forms, and consideration of medication interactions. Intravenous haloperidol may be a potential treatment option in patients unable to tolerate oral medications and with significant symptoms. However, given the high incidence of serious adverse effects with intravenous haloperidol, routine use should be avoided. Dexmedetomidine should be used when sedation is needed and when clinically appropriate, given the positive impact on delirium. Additional well-designed trials assessing screening and treatment of PICU delirium are needed.
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Affiliation(s)
- Caren Liviskie
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, Missouri, United States
| | - Christopher McPherson
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, Missouri, United States
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Caitlyn Luecke
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, Missouri, United States
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Soundararajan K, Balchandra P. Staff Awareness of Anti-Cholinergic Burden (ACB) - A Qualitative Cross-Sectional Study in a Tertiary Care Hospital. Cureus 2021; 13:e14141. [PMID: 33927943 PMCID: PMC8075820 DOI: 10.7759/cureus.14141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction and hypothesis Anticholinergics are commonly used for a variety of conditions including urinary incontinence. Many studies show the ill effects of anticholinergics on cognition resulting in increased morbidity and mortality. However, the interaction of anticholinergic medications and cumulative anti-cholinergic burden (ACB) of different medications are not well known in general population and amongst health care professionals. Our aim is to study the extent of current awareness of ACB amongst health care professionals which plays a crucial role in educating patients and avoiding these morbidities. Methods A single centre cross-sectional study of 50 health care professionals who participated voluntarily. A questionnaire was designed to assess the knowledge, beliefs and attitudes towards anticholinergic burden and participants were also asked to choose the ACB score for 17 commonly used medications. Results A total of 74% participants admitted to have no understanding of the term ACB, 48% participants prescribe anticholinergics in their daily role, 44% knew that cognition was adversely affected by anticholinergics, and 16% participants were aware of scoring system. Only 16% participants routinely counsel women of cognitive side effects when anticholinergics are started. 86% reported that they would avoid prescribing medications which might affect cognition if possible. If given choice as a patient, 94% would avoid these medications if they were informed of the specific side effects like impaired cognition, physical decline, falls, hospital admissions and increased mortality. Conclusion Anticholinergic burden (ACB) is a serious phenomenon associated with increased morbidity and mortality in the general population as well as elderly population. It is evident from this study that the knowledge and awareness of ACB in our health care staff are still lacking.
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Affiliation(s)
- Kamalaveni Soundararajan
- Obstetrics and Gynaecology, Hull University Teaching Hospitals NHS Trust, Kingston upon Hull, GBR
| | - Pooja Balchandra
- Obstetrics and Gynaecology, Hull University Teaching Hospitals NHS Trust, Kingston upon Hull, GBR
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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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12
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Miller M, Barbe N, Poulsen RJ, Coffey BJ. Overcoming Complications in Management of a Difficult-to-Treat Adolescent with Schizoaffective Disorder. J Child Adolesc Psychopharmacol 2020; 30:526-530. [PMID: 32931309 DOI: 10.1089/cap.2020.29190.bjc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Michelle Miller
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA.,Jackson Behavioral Health Hospital, Miami, Florida, USA
| | - Nadege Barbe
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA.,Jackson Behavioral Health Hospital, Miami, Florida, USA
| | - Raul J Poulsen
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA.,Jackson Behavioral Health Hospital, Miami, Florida, USA
| | - Barbara J Coffey
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA.,Jackson Behavioral Health Hospital, Miami, Florida, USA
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13
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The authors reply. Pediatr Crit Care Med 2020; 21:925-926. [PMID: 33009315 DOI: 10.1097/pcc.0000000000002498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Kalvas LB, Harrison TM. State of the science in pediatric ICU delirium: An integrative review. Res Nurs Health 2020; 43:341-355. [PMID: 32632985 PMCID: PMC8006059 DOI: 10.1002/nur.22054] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/23/2020] [Indexed: 11/08/2022]
Abstract
Delirium is a complication of critical illness associated with poor outcomes. Although widely studied in adults, comparatively little is understood about delirium in pediatric intensive care units (ICUs). The purpose of this integrative review is to determine the extent and nature of current evidence, identify gaps in the literature, and outline future areas for investigation of pediatric ICU delirium. Eligible articles included research reports of delirium in pediatric ICU samples published in English since 2009. After an extensive literature search and consideration for inclusion/exclusion criteria, 22 articles were chosen for review. Delirium was highly prevalent in the ICU. Delirium episodes developed early in hospitalization, lasted several days, and consisted of hypoactive or mixed motor subtypes. Frequently identified independent risk factors included young age, developmental delay, mechanical ventilation, and benzodiazepine exposure. Pediatric delirium was independently associated with increased length of stay, costs, and mortality. The long-term cognitive, psychological, and functional morbidities associated with pediatric delirium remain largely unknown. Few researchers have implemented interventions to prevent or manage delirium. There was little evidence for the efficacy or safety of pharmacological management. Multicomponent delirium bundles may significantly decrease delirium incidence. Key quality issues among studies included variation in delirium screening, low levels of evidence (i.e., observational studies), and limited ability to determine intervention efficacy in quasi-experimental designs. Although the quantity and quality of pediatric delirium research has rapidly increased, further studies are needed to understand the long-term effects of pediatric delirium and determine the efficacy and safety of interventions for prevention and management.
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Affiliation(s)
- Laura Beth Kalvas
- Graduate Fellow at The Ohio State University College of Nursing, Columbus, OH
| | - Tondi M. Harrison
- Associate Professor at The Ohio State University College of Nursing, Columbus, OH
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15
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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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16
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Abstract
OBJECTIVES To describe the relationships between anticholinergic drug exposure, cholinesterase enzyme activity, inflammation, and the development of postoperative delirium in children. DESIGN Single-center prospective cohort study. SETTING Twenty-two bed PICU in a tertiary-care academic medical center in Germany. PATIENTS A consecutive cohort of children admitted after major elective surgery. INTERVENTIONS Children were screened for delirium bid over 5 consecutive postoperative days. Acetylcholinesterase and butyrylcholinesterase plasma activity levels were measured prior to surgery and once daily during the 5 day study period. Number of anticholinergic drugs and Anticholinergic Drug Scale score were calculated for each patient. MEASUREMENTS AND MAIN RESULTS Ninety-three children (age range, 0-17 yr) were included. The number of anticholinergic drugs as well as the Anticholinergic Drug Scale score were significantly correlated with development of postoperative delirium, independently of disease severity. Baseline cholinesterase enzyme levels did not differ between patients who did and did not develop postoperative delirium. Butyrylcholinesterase levels, but not acetylcholinesterase levels, dropped by 33% postoperatively, independent of the presence of postoperative delirium. Postoperative butyrylcholinesterase levels were inversely related to number of anticholinergic drugs, Anticholinergic Drug Scale score, and C-reactive protein levels. CONCLUSIONS Anticholinergic drug exposure was related to development of postoperative delirium in this cohort, with demonstration of a dose-response relationship. As there are alternative options available for many of these medications, it may be reasonable to avoid anticholinergic exposure in the PICU whenever possible.
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17
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Measuring Central Cholinergic Inhibition As a Risk Factor for Delirium Remains a Challenge. Pediatr Crit Care Med 2020; 21:590-591. [PMID: 32483024 DOI: 10.1097/pcc.0000000000002252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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18
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Madden K, Callif CG, Tasker RC. Exposure to Anticholinergic Medications in Pediatric Severe Sepsis and Feasibility of Delirium Screening. J Pediatr Intensive Care 2020; 9:271-276. [PMID: 33133743 DOI: 10.1055/s-0040-1712144] [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: 01/13/2020] [Accepted: 04/17/2020] [Indexed: 10/24/2022] Open
Abstract
In sepsis, anticholinergic dysregulation may result in encephalopathy or delirium during severe illness, either as a result of central inflammation or because of exposure to medications with anticholinergic activity. In this retrospective study, we determined the magnitude of anticholinergic drug exposure in 75 children with severe sepsis. We found that exposure over the first 5 days was high-median (interquartile range) daily anticholinergic drug scale score 4 (2-5)-and associated with higher vasoactive scores and death. We conclude that anticholinergic drug exposure is significant in severe sepsis, which means it may be a modifiable factor that should be studied further.
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Affiliation(s)
- Kate Madden
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Charles G Callif
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Robert C Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, United States.,Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, United States
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19
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Abstract
Purpose of Review We briefly review post-intensive care syndrome (PICS) and the morbidities associated with critical illness that led to the intensive care unit (ICU) liberation movement. We review each element of the ICU liberation bundle, including pediatric support data, as well as tips and strategies for implementation in a pediatric ICU (PICU) setting. Recent Findings Numerous studies have found children have cognitive, physical, and psychiatric deficits after a PICU stay. The effects of the full ICU liberation bundle in children have not been published, but in adults, bundle implementation (even partial) resulted in significant improvement in survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition. Summary Although initially described in adults, children also suffer from PICS. The ICU liberation bundle is feasible in children and may ameliorate the effects of a PICU stay. Further studies are needed to characterize the benefits of the ICU liberation bundle in children.
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Affiliation(s)
- Alice Walz
- 1Department of Pediatrics, Medical University of South Carolina, Charleston, SC USA
| | - Marguerite Orsi Canter
- Department of Pediatrics, NYU Winthrop Hospital, Long Island School of Medicine, Mineola, NY USA
| | - Kristina Betters
- 3Department of Pediatrics, Vanderbilt University School of Medicine, Doctors Office Tower 5114, 2200 Children's Way, Nashville, TN 37232 USA
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20
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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: 25] [Impact Index Per Article: 6.3] [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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Ricardo Ramírez C, Álvarez Gómez M, Franco Vásquez JG. In reply to: «The diagnosis of delirium in pediatric intensive care: A burdensome yet essential task». Med Intensiva 2019; 44:129-130. [PMID: 31164246 DOI: 10.1016/j.medin.2019.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 05/02/2019] [Accepted: 05/05/2019] [Indexed: 11/30/2022]
Affiliation(s)
- C Ricardo Ramírez
- Grupo de Investigación en Psiquiatría de Enlace, Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - M Álvarez Gómez
- Grupo de Investigación en Cuidado, Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - J G Franco Vásquez
- Grupo de Investigación en Psiquiatría de Enlace, Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
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22
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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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23
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Fernández-Carrión F, González-Salas E, Silver G, Traube C. Translation and Cultural Adaptation of Cornell Assessment of Pediatric Delirium to Spanish. Pediatr Crit Care Med 2019; 20:400-402. [PMID: 30951003 DOI: 10.1097/pcc.0000000000001853] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Francisco Fernández-Carrión
- Pediatric Intensive Care Unit, Universitary Hospital, Salamanca, Spain Department of Child and Adolescent Psychiatry, Weill Cornell Medical College, New York, NY Pediatric Critical Care Medicine, Weill Cornell Medical College, New York, NY
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