Implementation of a Delirium Bundle for Pediatric Intensive Care Patients

Abstract

Background and ObjectiveDelirium represents the most common form of acute cerebral dysfunction in critical illness. The prevention, recognition, and treatment of delirium must become the focus of modern pediatric intensive care, as delirium can lead to increased morbidity and mortality. The aim of this study is to evaluate the impact of a delirium bundle consisting of mainly non-pharmacological measures.Material and MethodsThis is a pre-/post-implementation study in an interdisciplinary pediatric intensive care unit of a tertiary care university hospital. In the pre-implementation period, pediatric intensive care delirium was monitored using the Sophia Observation withdrawal Symptoms and Pediatric Delirium scale. After introduction of a delirium bundle consisting of non-pharmacological prevention and treatment measures a period of 4 months was interposed to train the PICU staff and ensure that the delirium bundle was implemented consistently before evaluating the effects in the post-implementation period. Data collection included prevalence of delirium and withdrawal, length of PICU stay, duration of mechanical ventilation, and cumulative dose of sedatives and analgesics.ResultsA total of 792 critically ill children aged 0–18 years were included in this study. An overall delirium prevalence of 30% was recorded in the pre-implementation group and 26% in the post-implementation group (p = 0.13). A significant reduction in the prevalence of pediatric delirium from was achieved in the subgroup of patients under 5 years of age (27.9 vs. 35.8%, p = 0.04) and in patients after surgery for congenital heart disease (28.2 vs. 39.5%, p = 0.04). Young age, length of PICU stay, and iatrogenic withdrawal syndrome were found to be risk factors for developing delirium.ConclusionsBased on a validated delirium monitoring, our study gives new information regarding the prevalence of pediatric delirium and the characteristics of intensive care patients at risk for this significant complication. Especially young patients and patients after surgery for congenital heart disease seem to benefit from the implementation of non-pharmacological delirium bundles. Based on our findings, it is important to promote change in pediatric intensive care—toward a comprehensive approach to prevent delirium in critically ill children as best as possible.

Modified ABCDEF-Bundles for Critically Ill Pediatric Patients - What Could They Look Like?

“…After close consideration in each case, benefits may outweigh the risks and should not be discounted completely. Nevertheless, these results emphasize the importance of non-pharmacological treatment of delirium and the necessity of a change of culture in pediatric intensive care toward prevention of delirium in critically ill children ( 67 ).…”

“…Early use of non-pharmacological measures such as helping the children to reorient themselves after sedation, providing glasses and hearing aids and toys from home can prevent development of delirium or go a long way in treating symptoms that have already manifested ( 64 ). One most promising aspect in prevention of delirium presents standardized analgesia and sedation, which aims at a reduction in dosage (especially concerning benzodiazepines and anticholinergic substances) and a shortening in length of sedation ( 65 ).…”

“…The most important factors include treatment within a calm and comforting environment, including the presence of pictures or toys from home and the continuous care by a parent or other close caregiver. Orientation (or reorientation) in space and time should be encouraged by use of hearing aids and glasses, clocks and calendars and upright positioning in bed where tolerated ( 66 , 67 ).…”

Inclusión de protocolos para la prevención y manejo del delirium en las UCIP: desafíos emergentes en el cuidado del paciente crítico pediátrico

“…Estos factores de riesgo incluyen elementos farmacológicos y no farmacológicos, por lo que precisan la actuación de diferentes profesionales para el abordaje holístico del paciente. Por esta razón, la evidencia destaca la necesidad de incluir no solo medidas en referencia a la prevención y evaluación del delirium, sino también aquellas destinadas a detectar la causa del mismo, para lo que se consideran de utilidad acrónimos como los recogidos por diferentes grupos de trabajo: I WATCH DEATH o BRAIN MAPS, que señalan algunas de las principales causas de aparición de este trastorno 9 , 10 . En este punto, cabe destacar el solapamiento sintomatológico que existe entre el delirium y el síndrome de abstinencia o retirada farmacológica.…”

“…Estos estudios han logrado resultados esperanzadores, como una disminución de la prevalencia del delirium, especialmente en la población de niños menores de 5 años, y una mayor adherencia al cribado del delirium por parte de los profesionales 9 , 12 . Aunque hay variables, como la duración de la estancia en la UCI, donde los resultados no fueron determinantes 10 .…”