Risk Factors for the Development of Postoperative Delirium in Pediatric Intensive Care Patients

Effect of intravenous different drugs on the prevention of restlessness during recovery period of pediatric laparoscopic surgery: a randomized control trial

PURPOSE

To explored the impact of dexmedetomidine and esketamine in mitigating restlessness during the postoperative recovery phase following laparoscopic surgery in children.

METHODS

102 individuals aged 1 to 7 years experiencing laparoscopic surgery were randomly allocated into three groups, each accepting 1 μg/kg of dexmedetomidine, 0.3 mg/kg of esketamine, or saline immediately at the end of carbon dioxide pneumoperitoneum. Emergence agitation (EA) occurrence was assessed by PAED scale and 5-point agitation scale. Pain was judged using Face, Legs, Activity, Cry, and Consolability (FLACC) scale. The recovery time, extubation time, and post-anesthesia care unit (PACU) stay time were recorded for all three groups.

RESULTS

Patients administered 1 μg/kg of dexmedetomidine (8.8%) and individuals given 0.3 mg/kg of esketamine (11.8%) showed lower incidences of emergence agitation compared to those receiving saline (35.5%; P = 0.009). There was no statistically significant difference in the time to discharge from the PACU among the three groups of patients (P > 0.05). The recovery time and extubation time were notably extended in the dexmedetomidine group (40.88 ± 12.95 min, 42.50 ± 13.38 min) when compared to the saline group (32.56 ± 13.05 min, 33.29 ± 11.30 min; P = 0.009, P = 0.010).

CONCLUSION

Following CO2 pneumoperitoneum in pediatric laparoscopic surgeries, the intravenous administration of 1 μg/kg dexmedetomidine or 0.3 mg/kg esketamine effectively lowers EA occurrence without extending PACU time.

Psychological Health of the Adolescent Transplant Recipient

BACKGROUND

Solid organ transplant recipients experience a period of unique vulnerability during adolescence, when normative developmental changes intersect with health-related variables to influence psychological health.

METHODS

This article builds on previous reviews of psychological health in solid organ transplant recipients and proposes opportunities for clinical intervention during adolescence.

RESULTS

Transplant recipients often experience neurocognitive changes, particularly with respect to executive functions, that impact health management tasks and autonomous care. Recipients should be monitored for the development of anxiety, depression, and posttraumatic stress symptoms during adolescence, which in turn can negatively impact adherence to immunosuppression. Recent research in posttraumatic growth and resiliency factors may represent a promising avenue of intervention, leveraging normative developmental processes during this time period.

CONCLUSIONS

As pediatric transplant providers, adolescence represents a developmental period for targeted interventions to foster adjustment and adherence and promote a successful transition to adult care.

Postoperative Delirium Screening Characteristics in Pediatric Intestinal, Liver, and Renal Transplant Recipients: Single-Center Retrospective Cohort Study

OBJECTIVES

To describe and compare the results of delirium screening in the immediate post-transplant PICU admission for pediatric intestinal, liver, and renal transplant recipients. We also examined associations with known and suspected risk factors for pediatric delirium (PD).

DESIGN

Retrospective analysis of a single-center cohort, 2016-2022.

SETTING

Twenty-four-bed PICU in a high-volume transplant center.

PATIENTS

All intestinal, liver, and renal transplant recipients under 23 years old admitted between July 2016 and August 2022.

MEASUREMENTS AND MAIN RESULTS

We identified 211 pediatric transplant recipients: intestinal ( n = 36), liver ( n = 78), and renal ( n = 97). Results of the Cornell Assessment for PD during the immediate post-transplant PICU admission were reviewed and patients were categorized into screen positive, screen negative, and unscreened. Corresponding data on known and suspected risk factors for PD were also collected. Data on delirium subtypes were not collected. Screens were available for 156 of 211 patients (74%) who were included in the final analysis. The prevalence of a positive screen by transplant category was: intestine 80% (24/30), liver 75% (47/63), and renal 14% (9/63). A positive screen was associated with younger age, greater duration of mechanical ventilation, and greater PICU length of stay (LOS) in bivariate analysis. In multivariable analysis, age and PICU LOS remained strongly correlated with a positive screen ( p < 0.05). Deep sedation and agitation as categorized by the State Behavioral Scale was associated with a positive screen, as was significant iatrogenic withdrawal symptoms ( p < 0.05). Most patients screened positive by post-transplant days 2 and 3 (58/80 [72%] and 64/80 [80%], respectively).

CONCLUSIONS

In our 2016 to 2022 experience, we found a high prevalence of positive PD screens in pediatric intestinal and liver transplant recipients in the immediate post-transplant PICU admission. A positive screen was associated with younger age and greater PICU LOS.

Association between pediatric postoperative delirium and regional cerebral oxygen saturation: a prospective observational study

BACKGROUND

Postoperative delirium (POD) represents a prevalent and noteworthy complication in the context of pediatric surgical interventions. In recent times, a hypothesis has emerged positing that cerebral ischemia and regional cerebral oxygen desaturation might serve as potential catalysts in the pathogenesis of POD. The primary aim of this study was to methodically examine the potential relationship between POD and regional cerebral oxygen saturation (rSO2) and to assess the predictive and evaluative utility of rSO2 in the context of POD.

METHODS

This prospective observational study was conducted at the Children's Hospital, Zhejiang University School of Medicine, Zhejiang, China, spanning the period from November 2020 to March 2021. The research cohort comprised children undergoing surgical procedures within this clinical setting. To measure rSO2 dynamics, cerebral near-infrared spectroscopy (NIRS) was used to monitor rSO2 levels both before and after surgery. In addition, POD was assessed in the paediatric patients according to the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) criteria. The analysis of the association between the rSO2 index and the incidence of POD was carried out through the application of either the independent samples t-test or the nonparametric rank-sum test. To ascertain the threshold value of the adjusted rSO2 index for predictive and evaluative purposes regarding POD in the pediatric population, the Receiver Operating Characteristics (ROC) curve was employed.

RESULTS

A total of 211 cases were included in this study, of which 61 (28.9%) developed POD. Participants suffering delirium had lower preoperative rSO2mean, lower preoperative rSO2min, and lower postoperative rSO2min, higher ∆rSO2mean, higher amount of ∆rSO2mean, lower ∆rSO2min (P < 0.05). Preoperative rSO2mean (AUC = 0.716, 95%CI 0.642-0.790), ∆rSO2mean (AUC = 0.694, 95%CI 0.614-0.774), amount of ∆rSO2mean (AUC = 0.649, 95%CI 0.564-0.734), preoperative rSO2min (AUC = 0.702, 96%CI 0.628-0.777), postoperative rSO2min (AUC = 0.717, 95%CI 0.647-0.787), and ∆rSO2min (AUC = 0.714, 95%CI 0.638-0.790) performed well in sensitivity and specificity, and the best threshold were 62.05%, 1.27%, 2.41%, 55.68%, 57.36%, 1.29%.

CONCLUSIONS

There is a close relationship between pediatric POD and rSO2. rSO2 could be used as an effective predictor of pediatric POD. It might be helpful to measure rSO2 with NIRS for early recognizing POD and making it possible for early intervention.

Attitudes, knowledge and practices concerning delirium among paediatric intensive care unit nurses: a multisite cross-sectional study in Sichuan, China

BACKGROUND

Delirium is an acute mental state associated with poor outcomes. The incidence of delirium is high, especially in the paediatric intensive care unit (PICU). It is important for staff, particularly nurses, to understand delirium and implement interventions to prevent it. We performed a survey with the aim of evaluating and analysing the factors influencing the knowledge, attitudes and behaviour of PICU nurses towards delirium.

METHODS

This cross-sectional descriptive study included 215 PICU nurses in 6 PICUs from five teaching hospitals in Sichuan Province, China. An online survey about the knowledge, attitudes and practices related to delirium care was conducted among PICU nurses used a self-made and validated questionnaire. The data were analysed using descriptive statistics; differences between groups were compared using t tests, ANOVA and rank-sum tests. Variables with a significance level of 0.05 in the univariate analysis were entered into the multivariable regression analysis to identify predictors.

RESULTS

Only 14.4% of the nurses had a good understanding of delirium, and 40.9% had received relevant training. The mean knowledge score was 9.01 ± 3.86, and the overall passing rate of knowledge was 49.8%. The mean attitude and behaviour scores were 40.95 ± 5.62 and 40.33 ± 8.01, respectively. Among the hospitals, different delirium assessments for children and specific training were performed, explaining approximately 10% of the variability in knowledge scores (F = 6.152), approximately 10% of the variability in attitude/belief scores (F = 5.908), and approximately 17% of the variability in practice scores (F = 10.767).

CONCLUSIONS

PICU nurses have poor knowledge of delirium, particularly regarding its clinical manifestations, influencing factors and medications used, and they have adequate attitudes and confidence and good behaviour regarding delirium in children. To better prevent delirium, we suggest that PICU departments routinely assess delirium and conduct delirium training for nurses.

TRIAL REGISTRATION

Not applicable.

Predictors of postoperative delirium in paediatric patients undergoing surgery under general anaesthesia at Amhara Regional State Tertiary Hospitals: a multicenter prospective study

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.

Antipsychotic Drug Prescription in Pediatric Intensive Care Units: A 10-Year U.S. Retrospective Database Study

Delirium recognition during pediatric critical illness may result in the prescription of antipsychotic medication. These medications have unclear efficacy and safety. We sought to describe antipsychotic medication use in pediatric intensive care units (PICUs) contributing to a U.S. national database. This study is an analysis of the Pediatric Health Information System Database between 2008 and 2018, including children admitted to a PICU aged 0 to 18 years, without prior psychiatric diagnoses. Antipsychotics were given in 16,465 (2.3%) of 706,635 PICU admissions at 30 hospitals. Risperidone (39.6%), quetiapine (22.1%), and haloperidol (20.8%) were the most commonly used medications. Median duration of prescription was 4 days (interquartile range: 2-11 days) for atypical antipsychotics, and haloperidol was used a median of 1 day (1-3 days). Trend analysis showed quetiapine use increased over the study period, whereas use of haloperidol and chlorpromazine (typical antipsychotics) decreased ( p  < 0.001). Compared with no antipsychotic administration, use of antipsychotics was associated with comorbidities (81 vs. 65%), mechanical ventilation (57 vs. 36%), longer PICU stay (6 vs. 3 days), and higher mortality (5.7 vs. 2.8%) in univariate analyses. In the multivariable model including demographic and clinical factors, antipsychotic prescription was associated with mortality (odds ratio [OR] = 1.09, 95% confidence interval [CI]: 1.02-1.18). Use of atypical antipsychotics increased over the 10-year period, possibly reflecting increased comfort with their use in pediatric patients. Antipsychotics were more common in patients with comorbidities, mechanical ventilation, and longer PICU stay, and associated with higher mortality in an adjusted model which warrants further study.

Non-pharmacological interventions to prevent and manage delirium in critically ill children in neonatal and paediatric intensive care units (NICU/PICU): a scoping review protocol

INTRODUCTION

Delirium is one of the most common forms of acute cerebral dysfunction in critically ill children leading to increased morbidity and mortality. Prevention, identification and management of delirium is an important part of paediatric and neonatological intensive care. This scoping review aims to identify and map evidence on non-pharmacological interventions for paediatric delirium prevention and management in paediatric and neonatal intensive care settings.

METHODS AND ANALYSIS

This scoping review will be conducted according to the Joanna Briggs Institute methodology for scoping reviews and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Searches will be performed in the databases Medline (via PubMed), CINAHL, Cochrane Library, Ovid (Journals), EMBASE and Web of Science (01/2000-current). Two reviewers will independently review retrieved studies, and relevant information will be extracted using data extraction forms. The results will be presented in tabular format and accompanied by a narrative summary.

INCLUSION CRITERIA

The review will include references that describe or evaluate non-pharmacological interventions to prevent or manage paediatric delirium. Conference abstracts, editorials, opinion papers and grey literature will be excluded.

ETHICS AND DISSEMINATION

Due to the nature of research involving humans or unpublished secondary data, approval of an ethics committee are not required. The dissemination of findings is planned via professional networks and publication in an open-access scientific journal.

Risk factors of delirium in a paediatric intensive care unit: A prospective case series study

BACKGROUND

Delirium is one of the most common complications in critically ill children. Once delirium occurs, it will cause physical and psychological distress in children and increase the length of their ICU stay and hospitalization costs. Understanding the risk factors for delirium in critically ill children can help develop targeted nursing interventions to reduce the incidence of delirium.

AIMS

To investigate the incidence and the risk factors of delirium in the paediatric intensive care unit (PICU).

STUDY DESIGN

We performed a prospective observational study in critically ill patients in the PICU between February and July 2020. Delirium was diagnosed by the Cornell Assessment of Paediatric Delirium (CAPD) and the Richmond Agitation Sedation Scale and analysed via univariate analysis and multivariate logistic regression to determine the independent risk factors of delirium in critically ill children.

RESULTS

The study enrolled 315 patients ranging in age from 1-202 (65.3-54.3) months, with 56.2% (n = 177) being male. The incidence of delirium was 29.2% (n = 92) according to CAPD criteria. Among them, 33 cases (35.9%) were of hyperactive delirium, 16 cases (17.4%) were of hypoactive delirium, and 43 cases (46.7%) were of mixed delirium. By using stepwise logistic regression, the independent risk factors of delirium included mechanical ventilation (odds ratio [OR], 11.470; 95% confidence interval [CI], 4.283-30.721), nervous system disease (OR, 5.596; 95%CI, 2.445 to 12.809), developmental delay (OR, 5.157; 95% CI, 1.990-13.363), benzodiazepine (OR, 3.359; 95% CI 1.278-8.832), number of catheters (OR, 1.918; 95% CI, 1.425 to 2.582), and age (OR, 0.985; 95% confidence interval CI, 0.976-0.993).

CONCLUSIONS

Delirium is a common complication in the PICU. The independent risk factors include mechanical ventilation, nervous system disease, developmental delay, benzodiazepines, higher number of catheters, and younger age. This study may help develop intervention strategies to reduce the incidence of delirium in critically ill children by targeting modifiable risk factors.

RELEVANCE TO CLINICAL PRACTICE

Recommendations for practice include paying attention to high-risk children in the ICU who are prone to delirium, removing influencing factors as soon as possible, and providing targeted nursing interventions.

Correlation Between Sociocultural and Economic Factors in Pediatric Patients' Families and Emergence Delirium

BACKGROUND

Postoperative delirium is a commonly encountered condition that can arise from multiple factors, and its occurrence varies based on the type of surgery in pediatric patients. This study aimed to investigate the occurrence of delirium during the recovery from anesthesia in children undergoing eye surgery and its association with the sociocultural and economic status of their families.

METHODS

This prospective observational study included children aged 2-12 years who underwent eye surgeries. Demographic data, socioeconomic and educational status of parents, parental separation and cooperation scores, Cravero agitation score, and face, legs, activity, cry, and consolability (FLACC) score (at zero, five, 15, and 30 minutes in the postoperative period) were recorded. Patients who scored 5 on the Cravero agitation scale for at least five minutes were considered to have postoperative delirium. The STROBE checklist was followed for reporting.

RESULTS

A total of 104 patients were included in the study, of which 65 were male. The mean age of the patients was 6.5±2.9 years, and 42 patients (40.4%) belonged to the preschool age group. The incidence of delirium was found to be 51.9%. Delirium was found to be associated with postoperative pain (p=0.003), age (p=0.001), preoperative anxiety (not cooperative examination score (p=0.047), poor separation score (p=0.006)), presence of a surgical history (p=0.012), and cataract surgery (p=0.007). No evidence was found to demonstrate a link between sociocultural and economic conditions and the development of delirium.

CONCLUSIONS

This study identified several factors that influenced the occurrence of delirium, including postoperative pain (FLACC≥4), younger age (<6 years), cataract surgery, presence of surgical history, examination score (score 3, not cooperative), and separation score (scores 3-4, poor).

Factors Associated With Delirium in Children: A Systematic Review and Meta-Analysis

OBJECTIVES

Pediatric delirium (PD) is a neuropsychiatric syndrome caused by a complex interplay between predisposing factors (e.g., age, cognitive impairment), acute illness, and environmental triggers. PD is associated with substantial morbidity and mortality. The objective of this study is to systematically review and evaluate factors associated with PD in hospitalized pediatric patients.

DATA SOURCES

A systematic search of PubMed, Embase, Ovid Medline, Web- of-Science, Cochrane, CIHNAL, and Google Scholar databases was conducted for relevant studies (1990-2022).

STUDY SELECTION

We included studies that compared pediatric patients with and without delirium. Reviews, editorials, congress abstracts, or studies that did not report factors for PD were excluded. No restrictions were imposed on language.

DATA EXTRACTION

Title and abstract were independently screened by two reviewers. Individual characteristics, study design, and outcomes were independently extracted.

DATA SYNTHESIS

Categorical dichotomous data were summarized across groups using Mantel-Haenszel odds ratios (ORs) with 95% 95% CIs. Either fixed-effect or random effects models were used as indicated by the results of a heterogeneity test. Of 1,846 abstracts, 24 studies were included. We identified 54 factors studied in univariate analyses, and 27 of these were associated with PD in multivariable analyses. In pooled analyses, greater odds of PD were associated with developmental delay (OR 3.98; 95% CI 1.54-10.26), need for mechanical ventilation (OR 6.02; 95% CI 4.43-8.19), use of physical restraints (OR 4.67; 95% CI 1.82-11.96), and receipt of either benzodiazepines (OR 4.10; 95% CI 2.48-6.80), opiates (OR 2.88; 95% CI 1.89-4.37), steroids (OR 2.02; 95% CI 1.47-2.77), or vasoactive medication (OR 3.68; 95% CI 1.17-11.60).

CONCLUSIONS

In this meta-analysis, we identified seven factors associated with greater odds of developing delirium during pediatric critical illness.

[Risk factors for delirium after sedation in children with convulsion and establishment of a nomogram model for predicting the risk of delirium]

OBJECTIVES

To investigate the risk factors for delirium after sedation in children with convulsion, and to establish a nomogram model for predicting the risk of delirium.

METHODS

A total of 373 children with convulsion who were hospitalized in the pediatric ward of the Second Affiliated Hospital of Air Force Medical University from August 2020 to January 2022 were prospectively enrolled. There were 245 children in the modeling group and 128 children in the validation group. A multivariate logistic regression analysis was used to identify independent predictive factors for delirium after sedation and establish a nomogram model for predicting the risk of this disorder based on these factors. The calibration curve, the receiver operating characteristic curve, and the decision curve analysis were used to evaluate the accuracy, discriminatory ability, and clinical application value of this model, respectively.

RESULTS

The incidence of delirium after sedation was 22.3% (83/373) in the children with convulsion. The multivariate logistic regression analysis showed that age>5 years (OR=0.401, P<0.05) was a protective factor against delirium after sedation in these children, while presence of infection (OR=3.020, P<0.05), admission to the pediatric intensive care unit (OR=3.126, P<0.05), use of benzodiazepines (OR=5.219, P<0.05), history of status convulsion (OR=2.623, P<0.05), and history of delirium episodes (OR=3.119, P<0.05) were risk factors for delirium. The H-L deviation test of the nomogram prediction model showed a good degree of fit (χ2=9.494, P=0.302). Internal and external validation showed that the mean absolute errors between the actual and predicted values of the calibration curve were 0.030 and 0.018, respectively, and the areas under the receiver operating characteristic curve were 0.777 and 0.775, respectively. The decision curve analysis showed that the model provided significant net clinical benefit when the predicted risk threshold was >0.01.

CONCLUSIONS

Age, presence of infection, admission to the pediatric intensive care unit, use of benzodiazepines, history of status convulsion, and history of delirium episodes are closely associated with the development of delirium after sedation in children with convulsion. The nomogram model for predicting this disorder that is established based on these factors has relatively high accuracy, discriminatory ability, and clinical application value.

A prospective cohort study of emergence delirium and its clinical correlates in a pediatric intensive care unit in North India

BACKGROUND

Delirium is a common occurrence in medically compromised adults, but, research is limited in the pediatric population especially from low- and middle-income countries such as India.

AIMS

This study aimed to evaluate the emergence of delirium in children aged 5-18 years admitted to a pediatric intensive care unit (PICU) of a tertiary care hospital in North India. Other objectives included delineating the clinical characteristics of delirium and its clinical correlates.

METHODOLOGY

It was a prospective cohort study in which all admitted children during a calendar year were assessed and those fulfilling the inclusion criteria were enrolled for study. The Pediatric Confusion Assessment Method Intensive Care Unit (p-CAM-ICU) scale was used to diagnose delirium.

RESULTS

ut of 305 total admissions to the PICU, 105 children were included. More than two third were male (68.6%) with a median age of 11 years. The incidence of delirium was 11.4% and median duration of delirium was 2 days. Majority of the children had hypoactive delirium (58.3%), followed by hyperactive (25%) and mixed type (16.7%). Metabolic or respiratory acidosis at baseline was significantly associated with delirium (p = 0.030). Presence of delirium led to significant prolongation of PICU stay (p < 0.001).

CONCLUSION

The emergence of delirium elicited in this study is on the lower side incomparison to previous studies. Several etiological factors for delirium are preventable and hence protocols and guidelines for management are required.

Risk factors for postoperative delirium in children with congenital heart disease: a prospective nested case-control study

OBJECTIVES

To study the risk factors for postoperative delirium (POD) in children with congenital heart disease.

METHODS

A prospective nested case-control study was performed on children with congenital heart disease who underwent surgery in Fuwai Hospital, Chinese Academy of Medical Sciences, from December 2020 to June 2021. The clinical data were compared between the POD group (n=114) and non-POD group (n=102). A multivariate unconditional logistic regression analysis was used to investigate the risk factors for POD in children with congenital heart disease.

RESULTS

The multivariate logistic regression analysis showed that age (OR=0.951, P<0.001), gender (OR=2.127, P=0.049), number of invasive catheters per day (OR=1.490, P=0.017), degree of postoperative pain (OR=5.856, P<0.001), and preoperative parental anxiety level (OR=1.025, P=0.010) were independent risk factors for POD in children with congenital heart disease.

CONCLUSIONS

The risk of POD increases in children with congenital heart disease who are younger, male, have higher number of invasive catheters per day, higher degree of postoperative pain, or higher preoperative parental anxiety level.

Implementation of a Delirium Bundle for Pediatric Intensive Care Patients

BACKGROUND AND OBJECTIVE

Delirium represents the most common form of acute cerebral dysfunction in critical illness. The prevention, recognition, and treatment of delirium must become the focus of modern pediatric intensive care, as delirium can lead to increased morbidity and mortality. The aim of this study is to evaluate the impact of a delirium bundle consisting of mainly non-pharmacological measures.

MATERIAL AND METHODS

This is a pre-/post-implementation study in an interdisciplinary pediatric intensive care unit of a tertiary care university hospital. In the pre-implementation period, pediatric intensive care delirium was monitored using the Sophia Observation withdrawal Symptoms and Pediatric Delirium scale. After introduction of a delirium bundle consisting of non-pharmacological prevention and treatment measures a period of 4 months was interposed to train the PICU staff and ensure that the delirium bundle was implemented consistently before evaluating the effects in the post-implementation period. Data collection included prevalence of delirium and withdrawal, length of PICU stay, duration of mechanical ventilation, and cumulative dose of sedatives and analgesics.

RESULTS

A total of 792 critically ill children aged 0-18 years were included in this study. An overall delirium prevalence of 30% was recorded in the pre-implementation group and 26% in the post-implementation group (p = 0.13). A significant reduction in the prevalence of pediatric delirium from was achieved in the subgroup of patients under 5 years of age (27.9 vs. 35.8%, p = 0.04) and in patients after surgery for congenital heart disease (28.2 vs. 39.5%, p = 0.04). Young age, length of PICU stay, and iatrogenic withdrawal syndrome were found to be risk factors for developing delirium.

CONCLUSIONS

Based on a validated delirium monitoring, our study gives new information regarding the prevalence of pediatric delirium and the characteristics of intensive care patients at risk for this significant complication. Especially young patients and patients after surgery for congenital heart disease seem to benefit from the implementation of non-pharmacological delirium bundles. Based on our findings, it is important to promote change in pediatric intensive care-toward a comprehensive approach to prevent delirium in critically ill children as best as possible.

Acquired Brain Injury in the Pediatric Intensive Care Unit: Special Considerations for Delirium Protocols

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.

Incidence and Factors Associated with Delirium in Children in a Single Pediatric Intensive Care Unit in Brazil

PURPOSE

To identify the incidence of delirium in a Pediatric Intensive Care Unit (PICU); to determine the factors associated with the occurrence of delirium and the agreement between two scales used for detection of pediatric delirium in critically ill children.

DESIGNS AND METHOD

Descriptive longitudinal study carried out in a PICU. The sample consisted of 65 critically ill children admitted to the PICU, with more than 24 h of hospitalization, excluding children with neurological or cognitive impairment, hearing and visual impairment, chronic encephalopathy and declining consent to participate in the study. Two scales were applied, the Cornell Assessment of Pediatric Delirium (CAPD) and the Sophia Observation Withdrawal Symptoms - Pediatric Delirium Scale (SOS_PD). Descriptive and inferential statistical analysis, with a 5% significance level was performed.

RESULTS

Delirium was identified in 7.7% of children, with duration of the disorder of about 2 days. A very good agreement (Kappa = 1; p-value <0.001) between the two scales was identified. CAPD presented positive predictive value of 80.0%. There was a statistical association between the occurrence of delirium and age less than 2 years (p = 0.060); female gender (p = 0.057); use of mechanical pulmonary ventilation (p = 0.034); antiemetics (p = 0.002); anticholinergics (p = 0.044), and changes in serum sodium and potassium (p = 0.053).

CONCLUSION

Demographic, clinical, and pharmacological conditions were associated with the occurrence of delirium.

PRACTICE IMPLICATIONS

Routine monitoring is the first step to any delirium prevention strategies, so delirium screening by the bedside nurse must be valued through a commitment to education and training.

A Systematic Review and Pooled Prevalence of Delirium in Critically Ill Children

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.

Development and validation of a postoperative delirium prediction model for pediatric patients: A prospective, observational, single-center study

Postoperative delirium is a serious complication that relates to poor outcomes. A risk prediction model could help the staff screen for children at high risk for postoperative delirium. Our study aimed to establish a postoperative delirium prediction model for pediatric patients and to verify the sensitivity and specificity of this model.Data were collected from a total of 1134 children (0-16yr) after major elective surgery between February 2020 to June 2020. Demographic and clinical data were collected to explore the risk factors. Multivariate logistic regression analysis was used to develop the model, and we assessed the predictive ability of the model by using the area under the receiver operating characteristics curve (AUROC). Further data were collected from another 100 patients in October 2020 to validate the model.Prevalence of postoperative delirium in this sample was 11.1%. The model consisted of 5 predictors, namely, age, developmental delay, type of surgery, pain, and dexmedetomidine. The AUROC was 0.889 (P < .001, 95% confidence interval (CI):0.857-0.921), with sensitivity and specificity of 0.754 and 0.867, and the Youden of 0.621. The model verification results showed the sensitivity of 0.667, the specificity of 0.955.Children undergoing surgery are at risk for developing delirium during the postoperative period, young age, developmental delay, otorhinolaryngology surgery, pain, and exposure to dexmedetomidine were associated with increased odds of delirium. Our study established a postoperative delirium prediction model for pediatric patients, which may be a base for development of strategies to prevent and treat postoperative delirium in children.

The diagnostic threshold of Cornell assessment of pediatric delirium in detection of postoperative delirium in pediatric surgical patients

Background

Cornell assessment of pediatric delirium (CAPD) showed advantage in diagnosis of pediatric delirium in Chinese critically ill patients. But its performance in surgical patients is still unclear. The present study was designed to validate the diagnostic performance of CAPD in surgical pediatric patients.

Methods

This is a prospective validation study. Pediatric patients who underwent selective surgery and general anesthesia were enrolled. Primary outcome was the incidence of delirium within postoperative three days. CAPD Chinese version was used to evaluate if the patient had delirium one time per day. At the meantime, a psychiatrist employed Diagnostic and Statistical Manual of Mental Disorders fifth edition to diagnose delirium, which was the “gold standard”, and the result was considered as reference standard. Sensitivity, specificity and area under receiver operating characteristic (ROC) curve were calculated to investigate the performance of CAPD.

Results

A total of 170 patients were enrolled. Median age was 4 years old. As diagnosed by psychiatrist, 23 (13.5 %) patients experienced at least one episode of delirium during the follow-up period. When diagnostic threshold was set at 9, CAPD showed the optimal sensitivity (87.0 %, 95 %CI 65.3 %-96.6 %) and specificity (98.0 %, 95 %CI 93.7 %-99.5 %) in comparison with other diagnostic thresholds. ROC analysis showed that CAPD was a good delirium assessment instrument with area under curve of 0.911 (95 % CI 0.812 to 1.000, P < 0.001). Agreement between CAPD and reference standard was 0.849 (Kappa coefficient, P < 0.001).

Conclusions

This study found that Cornell assessment of pediatric delirium could be used as an effective instrument in diagnosis of delirium in pediatric surgical patients.

Trial registration

www.chictr.org.cn Identifier: ChiCTR-DDD-17,012,231, August 3, 2017.

Prevalence of ICU Delirium in Postoperative Pediatric Cardiac Surgery Patients

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.

The LiberAction Project: Implementation of a Pediatric Liberation Bundle to Screen Delirium, Reduce Benzodiazepine Sedation, and Provide Early Mobilization in a Human Resource-Limited Pediatric Intensive Care Unit

Background: Delirium, bed immobilization, and heavy sedation are among the major contributors of pediatric post-intensive care syndrome. Recently, the Society of Critical Care Medicine has proposed the implementation of daily interventions to minimize the incidence of these morbidities and optimize children functional outcomes and quality of life. Unfortunately, these interventions require important clinical and economical efforts which prevent their use in many pediatric intensive care units (PICU). Aim: First, to evaluate the feasibility and safety of a PICU bundle implementation prioritizing delirium screening and treatment, early mobilization (<72 h from PICU admission) and benzodiazepine-limited sedation in a human resource-limited PICU. Second, to evaluate the incidence of delirium and describe the early mobilization practices and sedative drugs used during the pre- and post-implementation periods. Third, to describe the barriers and adverse events encountered during early mobilization. Methods: This observational study was structured in a pre- (15th November 2019-30th June 2020) and post-implementation period (1st July 2020-31st December 2020). All patients admitted in PICU for more than 72 h during the pre and post-implementation period were included in the study. Patients were excluded if early mobilization was contraindicated. During the pre-implementation period, a rehabilitation program including delirium screening and treatment, early mobilization and benzodiazepine-sparing sedation guidelines was developed and all PICU staff trained. During the post-implementation period, delirium screening with the Connell Assessment of Pediatric Delirium scale was implemented at bedside. Early mobilization was performed using a structured tiered protocol and a new sedation protocol, limiting the use of benzodiazepine, was adopted. Results: Two hundred and twenty-five children were enrolled in the study, 137 in the pre-implementation period and 88 in the post-implementation period. Adherence to delirium screening, benzodiazepine-limited sedation and early mobilization was 90.9, 81.1, and 70.4%, respectively. Incidence of delirium was 23% in the post-implementation period. The median cumulative dose of benzodiazepines corrected for the total number of sedation days (mg/kg/sedation days) was significantly lower in the post-implementation period compared with the pre-implementation period: [0.83 (IQR: 0.53-1.31) vs. 0.74 (IQR: 0.55-1.16), p = 0.0001]. The median cumulative doses of fentanyl, remifentanil, and morphine corrected for the total number of sedation days were lower in the post-implementation period, but these differences were not significant. The median number of mobilizations per patient and the duration of each mobilization significantly increased in the post-implementation period [3.00 (IQR: 2.0-4.0) vs. 7.00 (IQR: 3.0-12.0); p = 0.004 and 4 min (IQR: 3.50-4.50) vs. 5.50 min (IQR: 5.25-6.5); p < 0.0001, respectively]. Barriers to early mobilization were: disease severity and bed rest orders (55%), lack of physicians' order (20%), lack of human resources (20%), and lack of adequate devices for patient mobilization (5%). No adverse events related to early mobilization were reported in both periods. Duration of mechanical ventilation and PICU length of stay was significantly lower in the post-implementation period as well as the occurrence of iatrogenic withdrawal syndrome. Conclusion: This study showed that the implementation of a PICU liberation bundle prioritizing delirium screening and treatment, benzodiazepine-limited sedation and early mobilization was feasible and safe even in a human resource-limited PICU. Further pediatric studies are needed to evaluate the clinical impact of delirium, benzodiazepine-limited sedation and early mobilization protocols on patients' long-term functional outcomes and on hospital finances.

Pediatric delirium: epidemiology and outcomes

PURPOSE OF REVIEW

Delirium is a frequent complication of serious medical illness in children. The purpose of this review is to highlight recent data on the epidemiology and outcomes related to pediatric delirium, and discuss prevention strategies.

RECENT FINDINGS

Delirium rates in the pediatric ICU are greater than 25%. Delirium in children is associated with prolonged mechanical ventilation and hospital length of stay, increased costs, and excess mortality. Pediatric delirium may affect postdischarge cognition and quality of life. Recent initiatives targeting universal screening, early mobilization, and minimization of benzodiazepine-based sedation have shown reduction in delirium prevalence.

SUMMARY

Widespread screening is needed in critically ill children to detect and mitigate delirium. The identification of modifiable risk factors has provided an opportunity for delirium prevention. Large-scale longitudinal studies are needed to investigate the long-term sequelae of delirium in children.

Publication bias in pediatric emergence delirium: a cross-sectional analysis of ClinicalTrials.gov and ClinicalTrialsRegister.eu

OBJECTIVES

Emergence delirium (ED) is a frequent and potentially serious complication of general anaesthesia in children. Although there are various treatment strategies, no general management recommendations can be made. Selective reporting of study results may impair clinical decision-making. We, therefore, analysed whether the results of completed registered clinical studies in patients with paediatric ED are publicly available or remain unpublished.

DESIGN

Cross-sectional analysis.

SETTING

ClinicalTrials.gov and ClinicalTrialsRegister.eu.

PARTICIPANTS AND OUTCOME MEASURES

We determined the proportion of published and unpublished studies registered at ClinicalTrials.gov and ClinicalTrialsRegister.eu that were marked as completed by 1st September 2018. The major trial and literature databases were used to search for publications. In addition, the study investigators were contacted directly. For published trials, time to publication was calculated as the difference in months between study completion date and publication date.

RESULTS

Of the 44 registered studies on paediatric ED, only 24 (54%) were published by September 2019. Published trials contained data from n=2556 patients, whereas n=1644 patients were enrolled in unpublished trials. Median time to publication was 19 months. Studies completed in recent years were published faster, but still only 9 of 24 trials were published within 12 months of completion.

CONCLUSION

There is a distinct publication gap in clinical research in paediatric ED that may have an impact on meta-analyses and clinical practice.

State of the science in pediatric ICU delirium: An integrative review

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.

Cholinesterases and Anticholinergic Medications in Postoperative Pediatric Delirium

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.

Delirium and Developmental Disability: Improving Specificity of a Pediatric Delirium Screen

OBJECTIVES

Children with developmental disabilities are at high risk for developing delirium when critically ill. However, existing pediatric delirium screening tools were designed for children with typical development. The objective of this study was to improve the specificity of the Cornell Assessment for Pediatric Delirium, to allow for accurate detection of delirium in developmentally delayed children admitted to the PICU. We hypothesized that the Cornell Assessment for Pediatric Delirium, when combined with fluctuation in level of awareness as measured by the Richmond Agitation-Sedation Scale, would be valid and reliable for the diagnosis of delirium in developmentally delayed children.

DESIGN

Prospective observational double-blind cohort study.

SETTING

Tertiary care academic PICU.

PATIENTS

Children with moderate to severe developmental delay.

INTERVENTIONS

Each child was evaluated by the bedside nurse with the Cornell Assessment for Pediatric Delirium once every 12 hours and the Richmond Agitation-Sedation Scale every 4 hours. Cornell Assessment for Pediatric Delirium (score ≥ 9) + Richmond Agitation-Sedation Scale fluctuation (change in Richmond Agitation-Sedation Scale score of at least 2 points during a 24-hr period) was compared with the criterion standard psychiatric evaluation for diagnosis of delirium.

MEASUREMENTS AND MAIN RESULTS

Forty children participated; 94 independent paired assessments were completed. The psychiatrists' diagnostic evaluations were compared with the detection of delirium by the Cornell Assessment for Pediatric Delirium and Richmond Agitation-Sedation Scale. Specificity of the Cornell Assessment for Pediatric Delirium + Richmond Agitation-Sedation Scale fluctuation was 97% (CI, 90-100%), positive predictive value of Cornell Assessment for Pediatric Delirium + Richmond Agitation-Sedation Scale fluctuation was 89% (CI, 65-99%); and negative predictive value remained acceptable at 87% (95% CI, 77-94%). In addition, to confirm interrater reliability of the criterion standard, 11 assessments were performed by two or more psychiatrists in a blinded fashion. There was perfect agreement (κ = 1), indicating reliability in psychiatric diagnosis of delirium in developmentally delayed children.

CONCLUSION

When used in conjunction with Richmond Agitation-Sedation Scale score fluctuation, the Cornell Assessment for Pediatric Delirium is a sensitive and specific tool for the detection of delirium in children with developmental delay. This allows for reliable delirium screening in this hard-to-assess population.

Evaluation of an updated sedation protocol to reduce benzodiazepines in a pediatric intensive care unit

Aim: Midazolam like other benzodiazepines is supposed to be neurotoxic in small children and to represent a risk factor for the development of delirium. The aim of this study was to evaluate whether a modified analgesia and sedation protocol is feasible and effective to reduce the requirement of midazolam in neonates and young infants after cardiac surgery.Methods: Patients aged 6 months or younger who underwent surgery for congenital heart disease with cardiopulmonary bypass were enrolled and divided into a pre-modification group (January-December 2016) and after adjusting our sedation protocol into a post-modification group (January-December 2018). We assessed the doses of midazolam, morphine and clonidine as well as sedation scores according to our nurse-driven sedation protocol every 8 h until 120 h after cardiac surgery. During weaning from analgesia and sedation, children were monitored regarding withdrawal symptoms and pediatric delirium.Results: Sixty-five patients were included (33 patients in the pre-modification group, 32 patients in the post-modification group). The number of patients receiving midazolam and the cumulative dose of midazolam could be successfully reduced. The sedation scores were still within the desired target range for adequate sedation without any negative side effects.Conclusions: It is feasible and safe to reduce the use of midazolam in infants after cardiac surgery maintaining sedation goals based on a modified nurse-driven analgesia and sedation protocol.

Gamma-hydroxybutyrate: is it a feasible alternative to midazolam in long-term mechanically ventilated children?

Aim: Benzodiazepines like midazolam are commonly used for long-term sedation of critically ill children requiring mechanical ventilation. Tolerance to midazolam may occur in these patients resulting in a ceiling effect with insufficient or missing sedative response to increases of midazolam infusion or bolus application. The aim of this study was to evaluate the feasibility of a drug rotation protocol replacing continuous infusion of midazolam with gamma-hydroxybutyrate (GHB) to counteract midazolam tolerance. Methods: This retrospective, observational study was conducted in a 14-bed pediatric intensive care unit of a tertiary referral center. Thirty-three mechanically ventilated children with tolerance to midazolam who received continuous infusion of GHB were included. Success of drug rotation from midazolam to GHB was defined as adequate sedation with GHB and subsequent reduction of required doses of midazolam. Results: In our cohort, drug rotation for at least 2 days could be successfully performed in 10 out of 34 children resulting in subsequent reduction of required doses of midazolam. Drug rotation to GHB failed in 24 patients due to insufficient sedation resulting in a premature termination of the protocol. In these children, dosing of midazolam could not be reduced following drug rotation. We could not identify factors which predict success or failure of drug rotation from midazolam to GHB. Conclusions: The data from our single-center study suggest that drug rotation from midazolam to GHB may be worth trying in children with midazolam tolerance during long-term sedation, but physicians should be aware of possible treatment failure.