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Åkerman S, Axelin A, Traube C, Frithiof R, Thernström Blomqvist Y. Adapting the Cornell assessment of pediatric delirium for Swedish context: translation, cultural validation and inter-rater reliability. BMC Pediatr 2024; 24:413. [PMID: 38926708 PMCID: PMC11202322 DOI: 10.1186/s12887-024-04886-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Pediatric delirium causes prolonged hospital stays, increased costs, and distress for children and caregivers. Currently, there is no delirium screening tool available in Sweden that has been translated, culturally validated, and tested for reliability. This study aimed to translate, culturally adapt, and assess the suitability of the Cornell Assessment of Pediatric Delirium (CAPD) for implementation in Swedish healthcare settings. METHODS The CAPD was translated and culturally adapted to Swedish context following the ten-step process recommended by the International Society for Pharmacoeconomics and Outcomes Task Force for Translation and Cultural Adaptation. The Swedish CAPD was tested in the pediatric intensive care unit of Uppsala University Hospital, a tertiary hospital in Sweden. Inter-rater reliability was tested using intraclass correlation coefficient (ICC), with both Registered Nurses (RNs) and Assistant Nurses (ANs) conducting parallel measurements using the Swedish CAPD. A reliability score of ICC > 0.75 was considered indicative of good reliability. RESULTS After translation of the CAPD into Swedish, 10 RNs participated in the cultural adaptation process. Issues related to word choice, education, and instructions were addressed. Wording improvements were made to ensure accurate interpretation. Supplementary training sessions were organized to strengthen users' proficiency with the Swedish CAPD. Additional instructions were provided to enhance clarity and usability. Inter-rater reliability testing resulted in an ICC of 0.857 (95% CI: 0.708-0.930), indicating good reliability. CONCLUSION This study successfully translated and culturally adapted the CAPD to align with Swedish contextual parameters. The resulting Swedish CAPD demonstrated good inter-rater reliability, establishing its viability as a tool for measuring delirium among pediatric patients in Swedish pediatric intensive care units. TRAIL REGISTRATION Not applicable.
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Affiliation(s)
- Sara Åkerman
- Department of Surgical Sciences, Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden.
- Uppsala Centre for Paediatric Anaesthesia and Intensive Care Research, Uppsala, Sweden.
| | - Anna Axelin
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Chani Traube
- Department of Pediatrics, Weill Cornell Medical Center, New York, NY, USA
| | - Robert Frithiof
- Department of Surgical Sciences, Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
- Uppsala Centre for Paediatric Anaesthesia and Intensive Care Research, Uppsala, Sweden
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Dornette S, Deptola S, Hemmann B, Venkatesan C, Cortezzo DE. Recognition and Management of Delirium in the Neonatal Intensive Care Unit: Case Series From a Single-Center Level IV Intensive Care Unit. J Child Neurol 2024; 39:171-177. [PMID: 38629166 DOI: 10.1177/08830738241246693] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
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.
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Affiliation(s)
- Stacey Dornette
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Stephen Deptola
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Brianna Hemmann
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Charu Venkatesan
- Division of Neurology, Cincinnati Children's Hospital, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - DonnaMaria E Cortezzo
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Pain and Palliative Medicine, Cincinnati Children's Hospital, Cincinnati, OH, USA
- Department of Anesthesia, Cincinnati, University of Cincinnati College of Medicine, OH, USA
- Division of Neonatology Pain & Palliative Care, Connecticut Children's Medical Center, Hartford, CT, USA
- Division of Pain & Palliative Care, Connecticut Children's Medical Center, Hartford, CT, USA
- Fetal Care Program, Connecticut Children's Medical Center, Hartford, CT, USA
- Department of Pediatrics, Hartford, University of Connecticut School of Medicine, CT, USA
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Fu CH, Li Y, Zhang YC, Yang XY, Liu J, Ju MJ, Xu TT. Nursing Care of a Child With Delirium Receiving Venoarterial Extracorporeal Membrane Oxygenation: A Case Report. Crit Care Nurse 2024; 44:13-20. [PMID: 38555967 DOI: 10.4037/ccn2024150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
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.
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Affiliation(s)
- Cong-Hui Fu
- Cong-hui Fu is a clinical nurse in the Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Li
- Yan Li is a clinical nurse in the Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine
| | - Yu-Cai Zhang
- Yu-cai Zhang is the Unit Director of the Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine
| | - Xiao-Ya Yang
- Xiao-ya Yang is a clinical nurse in the Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine
| | - Ji Liu
- Ji Liu is a clinical nurse in the Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine
| | - Min-Jie Ju
- Min-jie Ju is a clinical nurse in the Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine
| | - Ting-Ting Xu
- Ting-ting Xu is a superintendent nurse in the Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine
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Kim K, Jeong JH, Choi EK. Non-pharmacological interventions for delirium in the pediatric population: a systematic review with narrative synthesis. BMC Pediatr 2024; 24:108. [PMID: 38347509 PMCID: PMC10863154 DOI: 10.1186/s12887-024-04595-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 01/25/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Delirium is a serious complication experienced by hospitalized children. Therefore, preventive management strategies are recommended for these patients. However, comprehensive analyses of delirium interventions in children remain insufficient. Specifically, this systematic review aimed to summarize non-pharmacological interventions for pediatric delirium, addressing the urgent need for a comprehensive understanding of effective strategies. We also explored frequently measured outcome variables to contribute evidence for future research on delirium outcomes in children. METHODS This systematic review searched articles from PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and Excerpta Medica databases. The eligibility criteria were formed under the population, intervention, comparator, outcome, and study design framework. Studies were included if they involved (1) children aged under 18 years receiving hospital care, (2) non-pharmacological delirium interventions, (3) comparators involving no intervention or pharmacological delirium interventions, and (4) outcomes measuring the effectiveness of non-pharmacological delirium interventions. Only peer-reviewed articles published in English were included. RESULTS Overall, 16 studies were analyzed; of them, 9 assessed non-pharmacological interventions for emergence delirium and 7 assessed interventions for pediatric delirium. The intervention types were grouped as follows: educational (n = 5), multicomponent (n = 6), and technology-assisted (n = 5). Along with pediatric and emergence delirium, the most frequently measured outcome variables were pain, patient anxiety, parental anxiety, pediatric intensive care unit length of stay, agitation, analgesic consumption, and postoperative maladaptive behavior. CONCLUSIONS Non-pharmacological interventions for children are effective treatments without associated complications. However, determining the most effective non-pharmacological delirium intervention for hospitalized children based on current data remains challenging.
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Affiliation(s)
- Kyua Kim
- Department of Nursing, Yonsei University Graduate School & Pediatric Intensive Care Unit, Severance Hospital, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, South Korea
| | - Ju Hee Jeong
- Department of Nursing, Yonsei University Graduate School & Emergency Nursing, Severance Hospital, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, South Korea
| | - Eun Kyoung Choi
- College of Nursing &, Mo-Im Kim Nursing Research Institute, Yonsei University, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, South Korea.
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Tarrell A, Giles L, Smith B, Traube C, Watt K. Delirium in the NICU. J Perinatol 2024; 44:157-163. [PMID: 37684547 DOI: 10.1038/s41372-023-01767-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/18/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023]
Abstract
Delirium in the NICU is an underrecognized phenomenon in infants who are often complex and critically ill. The current understanding of NICU delirium is developing and can be informed by adult and pediatric literature. The NICU population faces many potential risk factors for delirium, including young age, developmental delay, mechanical ventilation, severe illness, and surgery. There are no diagnostic tools specific to infants. The mainstay of delirium treatment is to treat the underlying cause, address modifiable risk factors, and supportive care. This review will summarize current knowledge and areas where more research is needed.
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Affiliation(s)
- Ariel Tarrell
- University of Utah School of Medicine, Department of Pediatrics, Division of Neonatology, Salt Lake City, UT, USA.
| | - Lisa Giles
- University of Utah School of Medicine, Department of Pediatrics, Division of Pediatric Behavioral Health and Psychiatry, Salt Lake City, UT, USA
| | - Brian Smith
- Duke University Medical Center, Division of Neonatology, Durham, NC, USA
| | - Chani Traube
- Weill Cornell Medical College, Division of Pediatric Critical Care Medicine, New York, NY, USA
| | - Kevin Watt
- University of Utah School of Medicine, Department of Pediatrics, Divisions of Pediatric Critical Care Medicine and Clinical Pharmacology, Salt Lake City, UT, USA
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Lei L, Li Y, Xu H, Zhang Q, Wu J, Zhao S, Zhang X, Xu M, Zhang S. Incidence, associated factors, and outcomes of delirium in critically ill children in china: a prospective cohort study. BMC Psychiatry 2023; 23:925. [PMID: 38082396 PMCID: PMC10712132 DOI: 10.1186/s12888-023-05406-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/26/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Delirium occurs frequently in critically ill children and has been reported in many countries, but delirium is not well-characterized in China. The aim of this study was to represent the incidence of delirium in critically ill children in China, its associated factors, and the influence of delirium on in-hospital outcomes. METHODS This observational prospective cohort study was set up in a large academic medical center with a 57-bed PICU in southwestern China. Critically ill children who required PICU stays over 24 h and were admitted between November 2019 and February 2022 were included in this study. The Cornell Assessment of Pediatric Delirium was used twice daily for delirium evaluation by bedside nurses, and twenty-four clinical features were collected from medical and nursing records during hospitalization. RESULTS The incidence of delirium was 26.0% (n = 410/1576). Multivariate analysis revealed that seven independent risk factors including days of mechanical ventilation and physical restraints, admission diagnosis (neurologic disorder), sleep deprivation, use of benzodiazepines and dexmedetomidine, liver failure/liver dysfunction associated with delirium in critically ill children. One potentially protective factor was the watching television /listening to music/playing with toys. Children with delirium had longer lengths of stay in the PICU (median 11 vs. 10 days, p < 0.001) and hospital (median 18 vs. 15 days, p < 0.001) compared to those without delirium. Additionally, the in-hospital mortality rates were 4.63% and 0.77% in patients with and without delirium (p < 0.05). CONCLUSIONS Delirium is common in critically ill children in China and related to poor outcomes. Interventional studies are warranted to determine the best practices to reduce delirium exposure in at-risk children.
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Affiliation(s)
- Lei Lei
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Yi Li
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Huilin Xu
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Qin Zhang
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Jiacai Wu
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Shoujv Zhao
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Xiaochao Zhang
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Min Xu
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Shuai Zhang
- Department of Pediatric Intensive Care Unit Nursing, West China Second University Hospital, Sichuan University, West China School of Nursing, Sichuan University, No. 20, Section 3, South Renmin Road, Chengdu, Sichuan, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China.
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Chaiyakulsil C, Thadahirunchot T. Implementation and effectiveness of a delirium care protocol in Thai critically ill children. Acute Crit Care 2023; 38:488-497. [PMID: 38052514 DOI: 10.4266/acc.2023.00045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 10/07/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Delirium in critically ill children can result in long-term morbidity. Our main objectives were to evaluate the effectiveness of a new protocol on the reduction, prevalence, and duration of delirium and to identify associated risk factors. METHODS The effectiveness of the protocol was evaluated by a chart review in all critically ill children aged 1 month to 15 years during the study period. A Cornell Assessment of Pediatric Delirium score ≥9 was considered positive for delirium. Data on delirium prevalence and duration from the pre-implementation and post-implementation phases were compared. Univariate and multivariate analyses were used to identify the risk factors of delirium. RESULTS A total of 120 children was analyzed (58 children in the pre-implementation group and 62 children in the post-implementation group). Fifty children (41.7%) screened positive for delirium. Age less than 2 years, delayed development, use of mechanical ventilation, and pediatric intensive care unit (PICU) stay >7 days were significantly associated with delirium. The proportion of children screened positive was not significantly different after the implementation (before, 39.7% vs. after, 43.5%; P=0.713). Subgroup analyses revealed a significant reduction in the duration of delirium in children with admission diagnosis of cardiovascular problems and after cardiothoracic surgery. CONCLUSIONS The newly implemented protocol was able to reduce the duration of delirium in children with admission diagnosis of cardiovascular problems and after cardiothoracic surgery. More studies should be conducted to reduce delirium to prevent long-term morbidity after PICU discharge.
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Affiliation(s)
- Chanapai Chaiyakulsil
- Division of Pediatric Critical Care, Department of Pediatrics, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
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Zilezinski M, Denninger NE, Tannen A, Kottner J. 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. BMJ Open 2023; 13:e073883. [PMID: 37899161 PMCID: PMC10619068 DOI: 10.1136/bmjopen-2023-073883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 10/10/2023] [Indexed: 10/31/2023] Open
Abstract
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.
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Affiliation(s)
- Max Zilezinski
- Institute of Clinical Nursing Science, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Natascha-Elisabeth Denninger
- Department of Primary Care and Health Services Research, Nursing Science and Interprofessional Care, Medical Faculty Heidelberg, Heidelberg University, Heidelberg, Germany
- Institute for Health and Nursing Science, International Graduate Academy, Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Antje Tannen
- Institute of Clinical Nursing Science, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Kottner
- Institute of Clinical Nursing Science, Charité Universitätsmedizin Berlin, Berlin, Germany
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Flagg LK, Mauney JA. Updates and Clinical Implications of Pediatric Delirium. Crit Care Nurs Clin North Am 2023; 35:315-325. [PMID: 37532385 DOI: 10.1016/j.cnc.2023.04.006] [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: 08/04/2023]
Abstract
Delirium is a fluctuating level of awareness based on a physiologic disease process. Within pediatrics, delirium affects approximately 30% of patients admitted to critical care units and is associated with increased mortality, morbidity, length of stay, and care costs. Multiple pediatric critical care societies recommend the implementation of screening practices using validated delirium tools. Delirium remains underrecognized because of suboptimal screening and protocol implementation in pediatric critical care units nationally and internationally. The mainstay of delirium prevention and management is nonpharmacologic, focusing on normalizing a patient's environment, sleep/wake cycles, nutritional status, and activity levels.
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Affiliation(s)
- Lauren K Flagg
- Yale University School of Nursing, Orange, CT, USA; Yale New Haven Hospital, Pediatric Critical Care, New Haven, CT, USA.
| | - Jennifer A Mauney
- University of Florida College of Nursing, 1225 Center Drive, PO Box 100197, Gainesville, FL 32610, USA
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Sperotto F, Ramelet AS, Daverio M, Mondardini MC, von Borell F, Brenner S, Tibboel D, Ista E, Pokorna P, Amigoni A. Assessment and management of iatrogenic withdrawal syndrome and delirium in pediatric intensive care units across Europe: An ESPNIC survey. Pharmacotherapy 2023; 43:804-815. [PMID: 37203273 DOI: 10.1002/phar.2831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Analgesia and sedation are essential for the care of children in the pediatric intensive care unit (PICU); however, when prolonged, they may be associated with iatrogenic withdrawal syndrome (IWS) and delirium. We sought to evaluate current practices on IWS and delirium assessment and management (including non-pharmacologic strategies as early mobilization) and to investigate associations between the presence of an analgosedation protocol and IWS and delirium monitoring, analgosedation weaning, and early mobilization. METHODS We conducted a multicenter cross-sectional survey-based study collecting data from one experienced physician or nurse per PICU in Europe from January to April 2021. We then investigated differences among PICUs that did or did not follow an analgosedation protocol. RESULTS Among 357 PICUs, 215 (60%) responded across 27 countries. IWS was systematically monitored with a validated scale in 62% of PICUs, mostly using the Withdrawal Assessment Tool-1 (53%). The main first-line treatment for IWS was a rescue bolus with interruption of weaning (41%). Delirium was systematically monitored in 58% of PICUs, mostly with the Cornell Assessment of Pediatric Delirium scale (48%) and the Sophia Observation Scale for Pediatric Delirium (34%). The main reported first-line treatment for delirium was dexmedetomidine (45%) or antipsychotic drugs (40%). Seventy-one percent of PICUs reported to follow an analgosedation protocol. Multivariate analyses adjusted for PICU characteristics showed that PICUs using a protocol were significantly more likely to systematically monitor IWS (odds ratio [OR] 1.92, 95% confidence interval [CI] 1.01-3.67) and delirium (OR 2.00, 95% CI 1.07-3.72), use a protocol for analgosedation weaning (OR 6.38, 95% CI 3.20-12.71) and promote mobilization (OR 3.38, 95% CI 1.63-7.03). CONCLUSIONS Monitoring and management of IWS and delirium are highly variable among European PICUs. The use of an analgosedation protocol was associated with an increased likelihood of monitoring IWS and delirium, performing a structured analgosedation weaning and promoting mobilization. Education on this topic and interprofessional collaborations are highly needed to help reduce the burden of analgosedation-associated adverse outcomes.
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Affiliation(s)
- Francesca Sperotto
- Cardiovascular Critical Care Unit, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine University of Lausanne, Lausanne, Switzerland
| | - Marco Daverio
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Maria Cristina Mondardini
- Pediatric Anesthesia and Intensive Care Unit, Department of Woman's and Child's Health, IRCCS University Hospital of Bologna Policlinico S.Orsola, Bologna, Italy
| | - Florian von Borell
- Department of Pediatrics, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Sebastian Brenner
- Department of Pediatrics, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Dick Tibboel
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Erwin Ista
- Department of Neonatal & Pediatric Intensive Care, Division Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Paula Pokorna
- Department of Neonatal & Pediatric Intensive Care, Division Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
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Köditz H, Drouche A, Dennhardt N, Schmidt M, Schultz M, Schultz B. Depth of anesthesia, temperature, and postoperative delirium in children and adolescents undergoing cardiac surgery. BMC Anesthesiol 2023; 23:148. [PMID: 37131120 PMCID: PMC10152600 DOI: 10.1186/s12871-023-02102-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 04/20/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND After pediatric cardiosurgical interventions, postoperative delirium can occur, which can be associated with undesirable consequences during and after the hospital stay. It is therefore important to avoid any factors causing delirium as far as possible. Electroencephalogram (EEG) monitoring can be used during anesthesia to individually adjust dosages of hypnotically acting drugs. It is necessary to gain knowledge about the relationship between intraoperative EEG and postoperative delirium in children. METHODS In a dataset comprising 89 children (53 male, 36 female; median age: 0.99 (interquartile range: 0.51, 4.89) years) undergoing cardiac surgery involving use of a heart-lung machine, relationships between depth of anesthesia as measured by EEG (EEG index: Narcotrend Index (NI)), sevoflurane dosage, and body temperature were analyzed. A Cornell Assessment of Pediatric Delirium (CAP-D) score ≥ 9 indicated delirium. RESULTS The EEG could be used in patients of all age groups for patient monitoring during anesthesia. In the context of induced hypothermia, EEG monitoring supported individually adjusted sevoflurane dosing. The NI was significantly correlated with the body temperature; decreasing temperature was accompanied by a decreasing NI. A CAP-D score ≥ 9 was documented in 61 patients (68.5%); 28 patients (31.5%) had a CAP-D < 9. Delirious patients with an intubation time ≤ 24 h showed a moderate negative correlation between minimum NI (NImin) and CAP-D (rho = -0.41, 95% CI: -0.70 - -0.01, p = 0.046), i.e., CAP-D decreased with increasing NImin. In the analysis of all patients' data, NImin and CAP-D showed a weak negative correlation (rho = -0.21, 95% CI: -0.40 - 0.01, p = 0.064). On average, the youngest patients had the highest CAP-D scores (p = 0.002). Patients with burst suppression / suppression EEG had a longer median intubation time in the intensive care unit than patients without such EEG (p = 0.023). There was no relationship between minimum temperature and CAP-D score. CONCLUSIONS The EEG can be used to individually adjust sevoflurane dosing during hypothermia. Of the patients extubated within 24 h and classified as delirious, patients with deeper levels of anesthesia had more severe delirium symptoms than patients with lighter levels of anesthesia.
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Affiliation(s)
- H Köditz
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - A Drouche
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - N Dennhardt
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - M Schmidt
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - M Schultz
- Medical University of Vienna, Vienna, Austria
| | - Barbara Schultz
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany.
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12
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Padilla Lamadrid M, Durantez-Fernández C, Barba-Pérez MÁ. Inclusion of protocols for the prevention and management of delirium in PICUs: Emerging challenges in the care of pediatric critical patients. Med Intensiva 2022; 46:641-644. [PMID: 36257883 PMCID: PMC9574942 DOI: 10.1016/j.medine.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/30/2022] [Indexed: 11/03/2022]
Affiliation(s)
| | - C Durantez-Fernández
- Departamento de Enfermería, Fisioterapia y Terapia Ocupacional, Facultad de Ciencias de la Salud, Universidad de Castilla-La Mancha, Talavera de la Reina, Toledo, Spain.
| | - M Á Barba-Pérez
- Hospital Clínico Universitario de Valladolid (HCUV), Valladolid, Spain; Grupo de Investigación en Cuidados de Enfermería (GICE), Departamento de Enfermería, Universidad de Valladolid, Valladolid, Spain
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13
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Padilla Lamadrid M, Durantez-Fernández C, Barba-Pérez MÁ. [Inclusion of protocols for the prevention and management of delirium in PICUs: emerging challenges in the care of pediatric critical patients]. Med Intensiva 2022; 46:641-644. [PMID: 35813520 PMCID: PMC9250416 DOI: 10.1016/j.medin.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/30/2022] [Indexed: 11/28/2022]
Affiliation(s)
| | - C Durantez-Fernández
- Departamento de Enfermería, Fisioterapia y Terapia Ocupacional, Facultad de Ciencias de la Salud, Universidad de Castilla-La Mancha, Talavera de la Reina, Toledo, España
| | - M Á Barba-Pérez
- Hospital Clínico Universitario de Valladolid (HCUV), Valladolid, España
- Grupo de Investigación en Cuidados de Enfermería (GICE), Departamento de Enfermería, Universidad de Valladolid, Valladolid, España
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14
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Stenkjaer RL, Herling SF, Egerod I, Weis J, van Dijk M, Kudchadkar SR, Ramelet AS, Ista E. Development of a non-pharmacologic delirium management bundle in paediatric intensive care units. Nurs Crit Care 2022; 27:867-876. [PMID: 35726841 PMCID: PMC10084175 DOI: 10.1111/nicc.12809] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Non-pharmacologic interventions might be effective to reduce the incidence of delirium in pediatric intensive care units (PICU). AIM To explore expert opinions and generate informed consensus decisions regarding the content of a non-pharmacologic delirium bundle to manage delirium in PICU patients. STUDY DESIGN A two-round online Delphi study was conducted from February to April 2021. PICU experts (nurses, physicians, researchers, physical therapists, play specialists, and occupational therapists) located in Europe, North America, South America, Asia, and Australia participated. RESULTS We developed a questionnaire based on the outcomes of a comprehensive literature search in the domains: 1) cognition support; 2) sleep support; and 3) physical activity support. Under these domains, we listed 11 strategies to promote support with 61 interventions. Participants rated the feasibility of each intervention on a 9-point Likert scale (ranging from 1 strongly disagree to 9 strongly agree). A disagreement index and panel median were calculated to determine the level of agreement among experts. In the second round, participants reassessed the revised statements and ranked the interventions in each domain in order of importance for age groups: 0-2, 3-5, and 6-18 years of age. During the first Delphi round, 53 of 74 (72%) questionnaires were completed, and in the second round 45 of 74 (61%) were completed. Five of the highest ranked interventions across the age groups were: 1) developing a daily routine, 2) adjusting light exposure according to the time of day, 3) scheduling time for sleep, 4) providing eyeglasses and hearing aids if appropriate, 5) encouraging parental presence. CONCLUSIONS Based on expert consensus, we developed an age-specific non-pharmacologic delirium bundle of interventions to manage delirium in PICU patients. RELEVANCE TO CLINICAL PRACTICE An age-specific Non-Pharmacological Delirium bundle is now ready to be tested in the PICU and will hopefully reduce pediatric delirium.
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Affiliation(s)
- Rikke Louise Stenkjaer
- Department of Neonatology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Ingrid Egerod
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Janne Weis
- Department of Neonatology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Monique van Dijk
- Department of Pediatric Surgery, Pediatric Intensive care, Erasmus MC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sapna Ravi Kudchadkar
- Anesthesiology & Critical Care Medicine, Pediatrics, and Physical Medicine & Rehabilitation, Associate Vice Chair for Research, ACCM, Johns Hopkins University School of Medicine, Charlotte Bloomberg Children's Center, Baltimore, Maryland, USA
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare (IUFRS), University of Lausanne, Lausanne, Switzerland.,Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Erwin Ista
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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15
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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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