Practice Variability in Screening and Treating Pediatric Critical Illness Delirium: Survey

Abstract

The best practice in pediatric delirium (PD) screening and treatment is still unknown. Current recommendations come from small studies and adult data. We surveyed the Pediatric Critical Care Medicine fellowship directors on PD screening and treatment practices in their centers. We report high variability in the screening and treatment practices for PD in large academic medical centers in the United States. The Cornell Assessment of Pediatric Delirium tool is the most commonly used tool for screening, and quetiapine is the most commonly used pharmacologic agent. A national guideline on PD screening, prevention, and treatment is needed to standardize practice and provide guidance.

Differences in Delirium Evaluation and Pharmacologic Management in Children With Developmental Delay: A Retrospective Case-Control Study

“…In comparing first recorded CAPD scores between the 2 groups, median time from ICU admission to first CAPD was 26.3 h for the overall cohort and without significant difference between the 2 groups (P = .92). Patients with DD had significantly higher initial CAPD scores (Figure 1A): DD median 17 [14][15][16][17][18][19], NT median 13 [6][7][8][9][10][11][12][13][14][15][16][17], P = .02. Patients with DD had only slightly higher CAPD scores at initiation of pharmacologic treatment for delirium (Figure 1B), with median score of 18 [17][18][19][20][21] than their NT counterparts (median 16.5 [12][13][14][15][16][17][18][19], (P = .047).…”

“…Patients with DD had significantly higher initial CAPD scores (Figure 1A): DD median 17 [14][15][16][17][18][19], NT median 13 [6][7][8][9][10][11][12][13][14][15][16][17], P = .02. Patients with DD had only slightly higher CAPD scores at initiation of pharmacologic treatment for delirium (Figure 1B), with median score of 18 [17][18][19][20][21] than their NT counterparts (median 16.5 [12][13][14][15][16][17][18][19], (P = .047). Time from first CAPD score to initiation of therapy did not differ significantly between the groups, with a median of 5.8 days [1.3-10.8 days] in the DD group and 4.3 days [2.3-11.0 days] in the NT group (P = .97).…”

“…Quetiapine use in pediatric delirium patients quickly rose, and our study is consistent with a recent report of quetiapine being the favored choice for treatment of delirium in critically ill pediatric patients. 13 However, despite increased use and assumed increased comfort with quetiapine's safety profile and efficacy, it has only been shown to decrease opioid and benzodiazepine requirements in pediatric patients with congenital heart disease. 14 It has not been shown to improve delirium screening scores when compared to untreated, matched patients.…”

“…The nonideal documentation in our study is likely, not unique and reflects educational opportunities: It reinforces previous studies noting inadequate knowledge among providers about delirium screening and prevention and recommending increased standardization and education. 13,28 Second, in our ICU, day–night dexmedetomidine cycling is often used as a first-line pharmacologic treatment for delirium prior to antipsychotic use. As such, some patients who received nonantipsychotic pharmacologic intervention for delirium were likely excluded from the analysis.…”

Melatonin Use in Pediatric Intensive Care Units: A Single-Center Experience

“…This suggests that challenges to using melatonin in the PICU could be overcome through more focused education, including improved awareness regarding the close relationship between sleep disruption and delirium. There are currently no national guidelines for the treatment of delirium in the PICU and the current recommendations are based on adult data and small pediatric studies [ 44 ]. The prevalence of pediatric delirium being 20–44% in PICUs nationally and 24% at our PICU (data not shown) requires providers to have a more standardized approach that is based on both evidence-based practice and expert consensus.…”