Patterns of Delirium in a Pediatric Intensive Care Unit and Associations With Noise Pollution

Recognition and Management of Delirium in the Neonatal Intensive Care Unit: Case Series From a Single-Center Level 4 Intensive Care Unit

Delirium often goes unrecognized in neonates and children because of lack of experience in evaluating behavior and cognition, insufficient awareness of the prevalence, and nondistinctive symptoms in this population. Although there are increasing reports of the presence of delirium in neonates, there are few data to guide the pharmacologic treatment in this population. In this retrospective single-center case series, we present our experience using quetiapine to treat delirium in 9 medically complex neonates. Based on an extensive literature review, expert opinion, and institutional experience, we propose an approach for monitoring and treating delirium in neonates and infants.

Unveiling the Immune Landscape of Delirium through Single-Cell RNA Sequencing and Machine Learning: Towards Precision Diagnosis and Therapy

BACKGROUND

Postoperative delirium (POD) poses significant clinical challenges regarding its diagnosis and treatment. Identifying biomarkers that can predict and diagnose POD is crucial for improving patient outcomes.

METHODS

To explore potential biomarkers for POD, we conducted bulk RNA sequencing (bulk-seq) on peripheral blood samples from POD patients and healthy controls. The expression levels of genes downstream of the phosphatidylinositol 3-kinase/protein kinase B (PI3K-Akt) signalling pathway were analysed. We then validated the expression of these genes using quantitative real-time polymerase chain reaction (RT-qPCR) in an independent cohort of 30 healthy controls and 30 POD patients. Receiver operating characteristic (ROC) analysis and six machine learning models were used to evaluate the predictive and diagnostic value of these genes. Additionally, single-cell RNA sequencing (scRNA-seq) was performed to validate gene expression in specific subsets of peripheral blood mononuclear cells (PBMCs), including T-cells, B-cells, natural killer (NK) cells, dendritic cells (DCs), and monocytes.

RESULTS

Bulk-seq revealed increased expression of genes downstream of the PI3K-Akt signalling pathway, specifically CHRM2, IL6, NOS3, NGF, and IL6R, in the peripheral blood of POD patients compared to healthy controls. Conversely, the expression of IGF1 was significantly decreased. RT-qPCR validation confirmed these findings. ROC analysis and machine learning models indicated that these genes are useful for predicting and diagnosing POD. scRNA-seq further validated the expression of these genes in specific PBMC subsets, including T-cells, B-cells, NK cells, DCs, and monocytes, with results consistent with the bulk-seq and RT-qPCR data.

CONCLUSIONS

The abnormal activation of the PI3K-Akt signalling pathway in T-cells, B-cells, NK cells, DCs, and monocytes may serve as potential biomarkers for predicting and diagnosing POD. These findings could inform the development of novel therapeutic strategies for managing POD.

Recognition and Management of Delirium in the Neonatal Intensive Care Unit: Case Series From a Single-Center Level IV Intensive Care Unit

Delirium often goes unrecognized in neonates and children because of lack of experience in evaluating behavior and cognition, insufficient awareness of the prevalence, and nondistinctive symptoms in this population. Although there are increasing reports of the presence of delirium in neonates, there are little data to guide the pharmacologic treatment in this population. In this retrospective single-center case series, we present our experience using quetiapine to treat delirium in 9 medically complex neonates. Based on an extensive literature review, expert opinion, and institutional experience, we propose an approach for monitoring and treating delirium in neonates and infants.

Nursing Care of a Child With Delirium Receiving Venoarterial Extracorporeal Membrane Oxygenation: A Case Report

INTRODUCTION

Children receiving extracorporeal membrane oxygenation are prone to delirium. This case report describes the nursing care of a child with delirium who received venoarterial extracorporeal membrane oxygenation. Relevant interventions and precautions are also discussed.

CLINICAL FINDINGS

A 6-year-old girl was admitted to the pediatric intensive care unit with a 2-day history of vomiting and fever. The child underwent cannulation for venoarterial extracorporeal membrane oxygenation.

DIAGNOSIS

The child was diagnosed with acute fulminant myocarditis, cardiac shock, and ventricular arrhythmia.

INTERVENTIONS

On the third day of extracorporeal membrane oxygenation, bedside nurses began using the Cornell Assessment of Pediatric Delirium to assess the child for delirium symptoms. The team of physicians and nurses incorporated a nonpharmacologic delirium management bundle into pediatric daily care. Delirium screening, analgesia and sedation management, sleep promotion, and family participation were implemented.

OUTCOMES

During the 18 days of pediatric intensive care unit hospitalization, the child had 6 days of delirium: 1.5 days of hypoactive delirium, 1.5 days of hyperactive delirium, and 3 days of mixed delirium. The child was successfully discharged home on hospital day 22.

CONCLUSION

Caring for a child with delirium receiving venoarterial extracorporeal membrane oxygenation required multidimensional nursing capabilities to prevent and reduce delirium while ensuring safe extracorporeal membrane oxygenation. This report may assist critical care nurses caring for children under similar circumstances.

Early Rehabilitation in Critically ill Children: A Two Center Implementation Study

OBJECTIVES

To implement an early rehabilitation bundle in two Canadian PICUs.

DESIGN AND SETTING

Implementation study in the PICUs at McMaster Children's Hospital (site 1) and London Health Sciences (site 2).

PATIENTS

All children under 18 years old admitted to the PICU were eligible for the intervention.

INTERVENTIONS

A bundle consisting of: 1) analgesia-first sedation; 2) delirium monitoring and prevention; and 3) early mobilization.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were the duration of implementation, bundle compliance, process of care, safety, and the factors influencing implementation. Secondary endpoints were the impact of the bundle on clinical outcomes such as pain, delirium, iatrogenic withdrawal, ventilator-free days, length of stay, and mortality. Implementation occurred over 26 months (August 2018 to October 2020). Data were collected on 1,036 patients representing 4,065 patient days. Bundle compliance was optimized within 6 months of roll-out. Goal setting for mobilization and level of arousal improved significantly (p < 0.01). Benzodiazepine, opioid, and dexmedetomidine use decreased in site 1 by 23.2% (95% CI, 30.8-15.5%), 26.1% (95% CI, 34.8-17.4%), and 9.2% (95% CI, 18.2-0.2%) patient exposure days, respectively, while at site 2, only dexmedetomidine exposure decreased significantly by 10.5% patient days (95% CI, 19.8-1.1%). Patient comfort, safety, and nursing workload were not adversely affected. There was no significant impact of the bundle on the rate of delirium, ventilator-free days, length of PICU stay, or mortality. Key facilitators to implementation included institutional support, unit-wide practice guidelines, dedicated PICU educators, easily accessible resources, and family engagement.

CONCLUSIONS

A rehabilitation bundle can improve processes of care and reduce patient sedative exposure without increasing patient discomfort, nursing workload, or harm. We did not observe an impact on short-term clinical outcomes. The efficacy of a PICU-rehabilitation bundle requires ongoing study. Lessons learned in this study provide evidence to inform rehabilitation implementation in the PICU setting.

Sleep quantity and quality of critically ill children perceived by caregivers and bedside nursing staff: a pilot study

STUDY OBJECTIVES

Sleep is crucial for healing but often impaired in the pediatric intensive care unit due to environmental disruptions. Caregivers and bedside nursing staff are often most aware of these factors and the impact on patient sleep, but studies have not yet compared their perceptions.

METHODS

Caregivers and bedside nursing staff of pediatric patients staying a second night in the pediatric intensive care unit were asked to complete a survey regarding environmental factors (ie, temperature, light, sound, nursing staff room entries), sleep quality, and sleep quantity (ie, sleep duration, number of naps) of the pediatric patient. Caregivers were asked similar questions about their child's sleep at home.

RESULTS

The caregivers and nursing staff of 31 pediatric patients participated in this pilot study. There was no significant difference between caregiver and nursing staff ratings of sleep quality, sleep duration, number of naps, room temperature, sound, or light (P > .05 for all). Nursing staff did report significantly more room entries than caregivers (P = .01). Compared to sleep at home, caregivers reported sleep in the hospital to be of lower quality (P = .009) with more frequent room entries (P = .01).

CONCLUSIONS

Caregivers rate their child's sleep in the pediatric intensive care unit as lower quality than sleep at home. Caregivers and bedside nursing staff largely agree about pediatric patient sleep quality and quantity as well as environmental factors. This agreement may facilitate further research and interventions at improving sleep in the pediatric intensive care unit.

CITATION

Witte MA, Lloyd RM, McGree M, Kawai Y. Sleep quantity and quality of critically ill children perceived by caregivers and bedside nursing staff: a pilot study. J Clin Sleep Med. 2023;19(12):2027-2033.

Lived Experiences of Delirium in Critically Ill Children: A Qualitative Study

The aim of this study was to understand the lived experiences of delirium in critically ill children. We conducted phenomenological qualitative interviews with critically ill pediatric survivors aged 0 to 18 years who had experienced delirium, along with their family caregivers and health care providers, from pediatric intensive care units in two tertiary care children's hospitals in Canada. Cases were identified if they had a Cornell Assessment of Pediatric Delirium (CAPD) score of ≥ 9 for at least 48 hours. Thirteen interviews were conducted, representing 10 index patients with delirium (age range: 7 weeks to 17 years). Participants shared experiences that were divided into themes of delirium symptoms, the impact of delirium, and their experience with the care of delirium. Within each theme, subthemes were identified. Symptoms of delirium included hallucinations, fluctuating symptoms, and lack of eye contact. Children were often described as “not himself/herself.” Delirium had long-lasting impact on patients; memories remained prominent even after the hospital stay. Family members and health care providers often felt helpless and ill-prepared to manage delirium. The delirium experience had significant impact on loved ones, causing persistent and vicarious suffering after the critical illness course. Family members and health care providers prioritized nonpharmacological strategies, family presence, and education as key strategies for delirium management. The lived experience of delirium in both infants and older children is physically, psychologically, and emotionally distressing. Given the traumatic long-term consequences, there is an urgent need to target delirium education, management, and prevention to improve long-term outcomes in PICU survivors and their families.

Trial Registration number: NCT04168515.

Modified ABCDEF-Bundles for Critically Ill Pediatric Patients - What Could They Look Like?

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.

Use of Musical Intervention in the Pediatric Intensive Care Unit of a Developing Country: A Pilot Pre–Post Study

Music is frequently used in different clinical settings, and it is implemented as a complementary, low-cost and useful intervention to reduce pain, anxiety and to improve relaxation. This pilot pre–post study aimed to examine the feasibility and preliminary effectiveness of a specific musical intervention in patients ≤16 years admitted to the Pediatric Intensive Care Unit (PICU) of an Iraqi hospital. The COMFORT Behavior Scale (CBS) was used by nurses to assess the level of sedation. Fifty-nine children were enrolled during the study period (March 2020–August 2021). CBS was lowered by 2.2 (95% CI: 1.9 to 2.6) points after 30 min, and by 3.3 (95% CI: 2.9 to 3.6) points after 60 min from music initiation. Thirty minutes after music initiation, heart rate decreased by 6.3 (95% CI: 4.5 to 8.1) beats per minute, whereas at 60 min, heart rate decreased by 9.1 (95% CI: 7.2 to 10.9) beats per minute. No clinically significant variations were detected in the other vital signs (blood pressure, respiratory rate and oxygen saturation). These findings support the feasibility of musical intervention in a developing country. CBS and heart rate variation may be worth following up in larger and conclusive studies.