Changes in Sedation Practices in Association with Delirium Screening in Infants After Cardiopulmonary Bypass

Abstract

Sedation in the cardiac intensive care unit (CICU) is necessary to keep critically ill infants safe and comfortable. However, long-term use of sedatives may be associated with adverse neurodevelopmental outcomes. We aimed to examine sedation practices in the CICU after the implementation of the Cornell Assessment of Pediatric Delirium (CAPD). We hypothesize the use of the CAPD would be associated with a decrease in sedative weans at CICU discharge. This is a single institution, retrospective cohort study. The study inclusion criteria were term infants, birthweight > 2.5 kg, cardiopulmonary bypass (CPB), and mechanical ventilation (MV) on postoperative day zero. During the study period, 50 and 35 patients respectively, met criteria pre-and post-implementation of CAPD screening. Our results showed a statistically significant increase in the incidence of sedative habituation wean at CICU discharge after CAPD implementation (24% vs. 45.7%, p = 0.036). There was a statistically significant increase in exposure to opiate (56% vs. 88.6%, p = 0.001) and dexmedetomidine infusions (52% vs 80%, p = 0.008), increased likelihood of clonidine use at CICU discharge (OR 9.25,, and increase in the duration of intravenous sedative infusions (8.1 days vs. 5.1 days, p = 0.04) No statistical difference was found in exposure to fentanyl (42% vs. 58.8%, p = 0.13) or midazolam infusions (22% vs. 25.7%, p = 0.691); and there was no change in benzodiazepine or opiate use at CICU discharge or dosage. The prevalence of delirium in the CAPD cohort was 92%. CAPD implementation in the CICU was associated with changes in sedation practices, specifically an increase in the use of dexmedetomidine, which possibly explains the increased clonidine weans at CICU discharge. This is the first report of the association between CAPD monitoring and changes in sedative practices. Multi-center prospective studies are recommended to evaluate sedative practices, delirium, and its effects on neurodevelopment.

The Year in Review: Anesthesia for Congenital Heart Disease 2021

“…Modifiable risk factors associated with a positive delirium screen were higher pain score at time of screen, total opioid exposure, pain medication or sedative administered in the previous 4 hours, no progressive physical therapy or ambulation schedule, and parents absent from the bedside. 52 Chomat et al 53 reported a delirium prevalence of 92% in infants after cardiac surgery, supporting prior research stating infants are at the highest risk for delirium after CPB.…”

Depth of anesthesia, temperature, and postoperative delirium in children and adolescents undergoing cardiac surgery

“…In our study, the median CAP-D score was highest in the group of patients aged up to 0.5 years, and second-highest in the group > 0.5 to 1 year. Age < 2 years has been described as a risk factor for delirium after cardiopulmonary bypass [ 58 ].…”

Intraoperative transfusion is a risk factor for cerebral injury after cardiac surgery in children: a prospective observational study

“…Так, послеоперационный делирий (ПОД) встречается в 40-57 % случаев [1][2][3]. При этом ПОД в большой степени пролонгирует длительность пребывания пациента в отделении реанимации за счет повышенной потребности в искусственной вентиляции легких, седативных препаратах и других манипуляциях [1,4]. Но перечисленными эффектами не ограничивается нега тивное воздействие ПОД, так как доказано его долгосрочное влияние и способность к снижению когнитивных способнос тей ребенка на многие месяцы после операции [5].…”