Assessment and Management of Delirium in the Pediatric Intensive Care Unit: A Review

Abstract

Many critically ill patients suffer from delirium which is associated with significant morbidity and mortality. There is a paucity of data about the incidence, symptoms, or treatment of delirium in the pediatric intensive care unit (PICU). Risk factors for delirium are common in the PICU including central nervous system immaturity, developmental delay, mechanical ventilation, and use of anticholinergic agents, corticosteroids, vasopressors, opioids, or benzodiazepines. Hypoactive delirium is the most common subtype in pediatric patients; however, hyperactive delirium has also been reported. Various screening tools are validated in the pediatric population, with the Cornell Assessment of Pediatric Delirium (CAPD) applicable to the largest age range and able to detect signs and symptoms consistent with both hypo- and hyperactive delirium. Treatment of delirium should always include identification and reversal of the underlying etiology, reserving pharmacologic management for those patients without symptom resolution, or with significant impact to medical care. Atypical antipsychotics (olanzapine, quetiapine, and risperidone) should be used first-line in patients requiring pharmacologic treatment owing to their apparent efficacy and low incidence of reported adverse effects. The choice of atypical antipsychotic should be based on adverse effect profile, available dosage forms, and consideration of medication interactions. Intravenous haloperidol may be a potential treatment option in patients unable to tolerate oral medications and with significant symptoms. However, given the high incidence of serious adverse effects with intravenous haloperidol, routine use should be avoided. Dexmedetomidine should be used when sedation is needed and when clinically appropriate, given the positive impact on delirium. Additional well-designed trials assessing screening and treatment of PICU delirium are needed.

Adapting the Cornell assessment of pediatric delirium for Swedish context: translation, cultural validation and inter-rater reliability

“…Given the potential severity of delirium consequences, both during hospitalization [ 4 , 5 , 35 ], and post-discharge [ 6 – 9 ] it is imperative for children in a PICU to be assessed for delirium using a valid and reliable delirium assessment tool [ 17 , 18 ]. Given the fluctuating nature of delirium symptoms, conducting multiple assessments over the child’s hospitalization enhances the likelihood of detecting delirium [ 2 , 4 , 35 ]. Therefore, the importance of a user-friendly and efficient delirium assessment tool cannot be overstated.…”

Trends in sedation‐analgesia practices in pediatric liver transplant patients admitted postoperatively to the pediatric intensive care unit: An analysis of data from the pediatric health information system (PHIS) database

“…Dexmedetomidine provides sedation, anxiolysis, and analgesia. Dexmedetomidine is used as an adjunct sedative agent with opioids in intubated patients while on MV; it allows for a reduction in the dosing of opioids 25,26 . The advantages of dexmedetomidine include its minimal effect on respiration (maintains respiratory drive), its predictable hemodynamic effects, allowance for neurological assessment due to easy arousal, as well as the ability to mitigate postoperative agitation and delirium 2,27 .…”

Delirium pediátrico en pacientes hospitalizados

“…10,11 Su manifestación se ha relacionado con disminución del flujo sanguíneo cerebral y alteración en la permeabilidad de la barrera hematoencefálica, con desregulación de diversos neurotransmisores, entre los más importantes se ha documentado la función de la dopamina, acetilcolina y glutamato. 12,13,14 La hipótesis neuroinflamatoria plantea un incremento de radicales libres y citocinas proinflamatorias en el sistema nervioso central. 15,16 Además del diagnóstico clínico deben incluirse estudios de laboratorio y gabinete, según la sospecha clínica.…”