The diagnosis and treatment of delirium in children

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.

Evaluation of Pediatric Delirium Awareness and Management in Pediatric Intensive Care Units in Turkey

Delirium has been associated with prolonged pediatric intensive care unit (PICU) stay and mechanical ventilation times as well as high hospital costs and mortality rates. This work aimed to examine pediatric delirium awareness and delirium management in Turkey. A total of 19 physicians responsible for their respective PICUs completed the survey. Most of the units (57.9%) did not use any assessment tool. Varying measures were applied in different units to reduce the prevalence of delirium. The number of units that continuously measured noise was very low (15.8%). Eye mask and earpiece usage rates were also very low. In pharmacological treatment, haloperidol, dexmedetomidine, benzodiazepines, and atypical antipsychotics were the most preferred options. Some units have reached a sufficient level of pediatric delirium awareness and management. However, insufficiencies in delirium awareness and management remain in general.

Delirium in Children: Identification, Prevention, and Management

Delirium in children is an often underrecognized but serious complication of hospitalization. Delirium in this age group has been described as behaviors such as refractory agitation and restlessness, visual or auditory hallucinations, children being "not themselves," and a lethargic state. Often, children with delirium are at risk for harming themselves by dislodging tubes, falling, or refusing care. Pediatric nurses must recognize and intervene to prevent and treat delirium in hospitalized children because the delirium may be an indicator of worsening clinical status and is associated with high mortality and morbidity in children of all ages and with posttraumatic stress disorder. Pediatric nurses are uniquely positioned to design care interventions to both reduce risk for delirium and treat active delirium. Many treatment recommendations are nonpharmacological and are part of excellent nursing care.

Delirium among children and adolescents in an urban sub-Saharan African setting

OBJECTIVES

The purpose of this study is to describe the demographic and clinical profile, mortality rates, and effectiveness of a multifaceted treatment approach in hospitalized children and adolescents with delirium referred to psychiatry.

METHODS

We report a series of 23 children and adolescents prospectively diagnosed with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, delirium after referral to a consultation-liaison psychiatry service based in a large, regional, dedicated children's hospital in South Africa.

RESULTS

Children and adolescents with delirium referred to psychiatrists appear to represent a subgroup of delirious patients with a high risk of mortality, an underrepresentation of hypoactive cases, and complex, multifactorial, and often uncertain etiologies. A significant minority of these cases may be managed without the use of psychotropic medications. Uncontrolled data provide supportive evidence for the moderate effectiveness of both haloperidol and risperidone in childhood delirium when explicit criteria guiding the use of antipsychotic medications are utilized.

CONCLUSIONS

Delirium is an important and underresearched disorder in children and adolescents. Although the evidence base for the use of antipsychotic medications in childhood delirium remains relatively slim, tentative threshold criteria for the use of such medications are suggested by this study. Controlled studies comparing different antipsychotic medications with each other and with nonpharmacological strategies are urgently required.