Delirium in the Pediatric Intensive Care Unit

Recognition, Prevention and Treatment

Shad Outsen, MDDirector, Pediatric Intermediate Care, Utah Valley HospitalPediatric Intensivist, Primary Children’s Hospital

Objectives

• Understand how delirium negatively impacts patients

• Use a validated score to diagnose delirium in the pediatric population

• Implement strategies to prevent and treat delirium

Delirium Defined

• A disturbance of attention or awareness

• Changes in cognition (not explained by other conditions)

• Develops within hours or days

• Often fluctuates during the day and is worse at night

• Probably the result of a medical condition or its treatment

Consciousness

Arousal Content

Sedation Assessment• RASS• SBS

Delirium Assessment• CAM-ICU• pCAM-ICU• psCAM-ICU• CAPD

Step 1 Step 2

In adult ICU patients…

Is independently predicted by:• Age

• Dementia

• Emergency surgery or trauma

• Severity of illness• Metabolic acidosis

• Benzodiazepines

• Coma

• Mechanical ventilation 60-80%

Independently predicts:

• Prolonged mechanical ventilation

• ↑ length of hospitalization

• ↑ 6-month mortality

• Long-term cognitive impairment

• ↑ medical costs

In pediatric ICU patients…

Independently predicted by:• Age ≤ 2 years• Developmental delay• Severity of illnesso Infectious and inflammatory disorders

• Coma status• Mechanical ventilation• Use of physical restraints• Medicationso Benzodiazepines

o Anticholinergics

o Vasopressors

o Antiepileptics

Independently predicts:• ↑ PICU LOS

• ↑ Hospital LOS

• ↑ duration of mechanical ventilation

• ↑ mortality• Posttraumatic stress symptoms

• Delusional memories or disturbing hallucinations 33%

Delirium in Pediatric ICU Patients

• Overall 17-25%oMedian duration 2 days

o78% develop delirium within first 3 PICU days• 20% in first 5 PICU days

• 38% after day 5

oMechanical ventilation 53%

• 3 typesoHypoactive 46%

oMixed 45%

oHyperactive 8%

Screening for DeliriumThe Cornell Assessment of Pediatric Delirium (CAPD)• Done at least one time per shifto At end of shifto Takes less than 2 minutes

• CAPD score ≥ 9 is a positive screen

• Sensitivity 94%, specificity 79%o Without developmental delay, 92%

and 87%o With delay, 96% and 51%

Anchors

Preventing Delirium

• Reduce medication exposureo Sedate as lightly as possible• Measure sedation levels

oAnalgesia first sedation

oAvoid benzodiazepines and anticholinergics

o Intermittent rather than continuous

o Spontaneous awake trials

• Protect sleepo Cluster cares!

oMinimizing overhead pages

o Turn off TV’s, soothing music

oDim hallway lights and darken room

o Earplugs and eye masks

oNoise reduction

oAvoid caffeine

oMelatonin or Ambien

Treating Delirium

• Investigate for underlying illness

• Investigate for iatrogenic causeso Iatrogenic Withdrawal Syndrome

• Investigate for abnormal environment

• Pharmacological treatmentoQuetiapine (Seroquel)

oRisperidone

oHaloperidol

Summary

• Delirium is an acute alteration in awareness, attention and cognition.• Pediatric delirium is associated with increased morbidity and mortality. • Pediatric delirium occurs in as many as 25% of critically ill children and in as many as

50% of mechanically ventilated children.• The CAPD score effectively screens for delirium at any age in pediatric patients with or

without developmental delay and should be performed one time per shift.• Preventing delirium includes reducing exposure to medications, particularly

benzodiazepines, and maintaining normal circadian rhythms.• When delirium is diagnosed, caregivers should investigate for underlying illness,

iatrogenic causes and environmental causes.• Certain antipsychotic medications have been used safely to treat pediatric delirium.

ReferencesTraube, C., Silver, G., Gerber, L. M., Kaur, S., Mauer, E. A., Kerson, A., et al. (2017). Delirium and Mortality in Critically Ill Children: Epidemiology and Outcomes of Pediatric Delirium. Critical Care Medicine, 45(5), 891–898.

Traube, C., Silver, G., Reeder, R. W., Doyle, H., Hegel, E., Wolfe, H. A., et al. (2017). Delirium in Critically Ill Children: An International Point Prevalence Study. Critical Care Medicine, 45(4), 584–590.

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Barr, J., Fraser, G. L., Puntillo, K., Ely, E. W., Gélinas, C., Dasta, J. F., et al. (2013). Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine, 41(1), 278–280.

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