Delirium in a Tertiary Pediatric Cardiac Intensive Care Unit: Risk Factors and Outcomes

Abstract

Objective Delirium is an increasingly recognized hospital complication associated with poorer outcomes in critically ill children. We aimed to evaluate risk factors for screening positive for delirium in children admitted to a pediatric cardiac intensive care unit (CICU) and to examine the association between duration of positive screening and in-hospital outcomes. Study design Retrospective cohort study in a single-center quaternary pediatric hospital CICU evaluating children admitted from March 2014-October 2016 and screened for delirium using the Cornell Assessment of Pediatric Delirium. Statistical analysis used multivariable logistic and linear regression. Results Among 942 patients with screening data (98% of all admissions), 67% of patients screened positive for delirium. On univariate analysis, screening positive was associated with younger age, single ventricle anatomy, duration of mechanical ventilation, continuous renal replacement therapy, extracorporeal life support, and surgical complexity, as well as higher average total daily doses of benzodiazepines, opioids, and dexmedetomidine. On multivariable analysis, screening positive for delirium was independently associated with age <2 years, duration of mechanical ventilation, and greater than the median daily doses of benzodiazepine and opioid. In addition to these factors, duration of screening positive was also independently associated with higher STAT category (3-5) or medical admission, organ failure, acute kidney injury (AKI), and higher dexmedetomidine exposure. Duration of positive delirium screening was associated with both increased CICU and hospital length of stay (each additional day of positive screening was associated with a 3% longer CICU stay [95% CI = 1%-6%] and 2% longer hospital stay [95% CI = 0%-4%]). Conclusions Screening positive for delirium is common in the pediatric CICU and is independently associated with prolonged intensive care unit (ICU) and hospital stay. Longer duration of mechanical ventilation and higher sedative doses are independent risk factors for screening positive for delirium. Efforts aimed at reducing these exposures may decrease the burden of delirium in this population.

Factors Associated With Delirium in Children: A Systematic Review and Meta-Analysis*

“…Two studies found that older age was associated with PD, that is, in children 2-5 years old (29) and in children greater than or equal to 12 years old (38). However, overall we did not find an association between age under 2 years and greater odds of PD in the pooled analysis (OR 2.01 [95% CI 0.69-5.88]) (24,25,30,32,36,37,41,43).…”

“…1 ). Thus, 24 articles (22–45) were included in our detailed analyses. The characteristics of the 24 pediatric cohort studies are summarized in Supplemental Digital Content 3 (http://links.lww.com/PCC/C331).…”

“…The children were from eight different countries; 63% were from the United States, and the rest were from other countries (e.g., Germany, The Netherlands, Brazil, Argentina, Turkey, China). The settings varied with 17 studies evaluating general PICU patients (23–29, 31–33, 35–37, 39, 41, 42, 44, 45), four studies evaluating pediatric cardiac ICU patients (22, 30, 34, 43), two studies evaluating patients after major surgery (26, 27), and three studies evaluating pediatric oncology patients (35, 38, 40). All 19 studies were of moderate to good methodological quality.…”

“…In pooled analysis, physical restraints was associated with greater odds of PD (OR 4.67 [95% CI 1.82-11.96]) (Supplemental Digital Content 6, http://links.lww. com/PCC/C331) (24,30,31,34,37,39,43,44). We did not identify any differences in the overall effect between the PICU versus PCICU settings (Q = 2.96, p = 0.086).…”

Delirium: The Next Vital Sign in the PICU?*

“…(1) Despite knowledge that ICU care bundles similar to PICU Liber8 bundle can hasten liberation from mechanical ventilation and the ICU while improving patient outcomes (5-7), implementation in PICUs remain variable. National guidelines recommend implementing such bundles ( 8), yet, significant barriers derail successful implementation and/or sustainability, even for those who want it (9). The key strength of the work by Jones et al (2) is their low cost, simple, effective, and feasible tool, which could be adapted for all…”