The objective of this study was to investigate, under circumstances of routine care, the impact of paediatric delirium (PD) on length of stay in the paediatric intensive care unit (PICU) as well as on direct financial costs. A five-year prospective observational study (2002)(2003)(2004)(2005)(2006)(2007) was carried out in a tertiary eight-bed PICU in the Netherlands. Critically ill children aged 1 to 18 years who were acutely, non-electively and consecutively admitted to the PICU and detected as having PD in routine care were compared to critically ill children aged 1 to 18 years without signs of PD. PD, population characteristics and severity of illness at admission were used as predictors for length of PICU stay. Differences in length of stay yielded short-term, direct medical costs associated with PD. Fortynine children with and 98 children without PD were included. PD prolonged length of PICU stay with 2.39 days, independent of severity of illness, age, gender, mechanical ventilation and medical indication for admission (B = 0.38, P \ 0.001). PD increased direct medical costs with 1.5%. The results suggest a negative prognostic influence of PD on duration of PICU stay in routine care, resulting in an increase of direct medical costs.
Given the fact that PIM and PRISM II are widely used mortality scoring instruments, prospective associations with PD suggest additional value for ruling in, or out, patients at risk of PD.
ContextIf delirium is not diagnosed, it is unlikely that any effort will be made to reverse it. Given evidence for under-diagnosis, tools that aid recognition are required.ObjectiveRelating three presentations of pediatric delirium (PD) to standard criteria and developing a diagnostic algorithm.ResultsDelirium-inducing factors, disturbance of consciousness and inattention are common in PICU patients: a pre-delirious state is present in most. An algorithm is introduced, containing (1) evaluation of the sedation-agitation level, (2) psychometric assessment of behavior and (3) opinion of the caregivers.DiscussionIt may be argued that the behavioral focus of the algorithm would benefit from the inclusion of neurocognitive measures.LimitationsNo sufficiently validated diagnostic instrument covering the entire algorithm is available yet.ConclusionThis is the first proposal for a PD diagnostic algorithm. Given the high prevalence of pre-delirious states at the PICU, daily evaluation is mandatory. Future algorithmic refinement is urgently required.
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