IntroductionPediatric delirium is a significant problem when encounterd in an intensive care unit (ICU). The pathophysiology of pediatric delirium is complex and the etiology is typically multifactorial. Even though various risk factors associated with pediatric delirium in a pediatric ICU have been identified, there is still a paucity of literature associated with the condition, especially in extremely critically ill children, sedated and mechanically ventilated.Aim of the studyTo identify factors associated with delirium in mechanically ventilated children in an ICU.Material and MethodsThis is a single-center study conducted at a tertiary care pediatric ICU. Patients admitted to the pediatric ICU requiring sedation and mechanical ventilation for >48 hours were included. Cornell Assessment of Pediatric Delirium scale was used to screen patients with delirium. Baseline demographic and clinical factors as well as daily and cumulative doses of medications were compared between patients with and without delirium. Firth’s penalized maximum likelihood logistic regression was used on a priori set of variables to examine the association of potential factors with delirium. Two regression models were created to assess the effect of daily medication doses (Model 1) as well as cumulative medication doses (Model 2) of opioids and benzodiazepines.Results95 patient visits met the inclusion criteria. 19 patients (20%) were diagnosed with delirium. Older patients (>12 years) had higher odds of developing delirium. Every 1mg/kg/day increase in daily doses of opioids was associated with an increased risk of delirium (OR=1.977, p=0.017). Likewise, 1 mg/kg increase in the cumulative opioid dose was associated with a higher odds of developing delirium (OR=1.035, p=0.022). Duration of mechanical ventilation was associated with the development of delirium in Model 1 (p=0.007).ConclusionsAge, daily and cumulative opioid dosage and the duration of mechanical ventilation are associated with the development of delirium in mechanically ventilated children.

Accuracy of delirium diagnosis in mechanically ventilated children is often limited by their varying developmental abilities. The purpose of this study was to examine the performance of the Cornell Assessment of Pediatric Delirium (CAPD) scale in these patients. This is a single-center prospective observational study of patients requiring sedation and mechanical ventilation for 2 days or more. CAPD scale was implemented in our unit for delirium screening. Each CAPD assessment was accompanied by a physician assessment using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria. Sensitivity analysis was performed to determine the best cut-off score in our target population. We also evaluated ways to improve the accuracy of this scale in patients with and without developmental delay. A total of 837 paired assessments were performed. Prevalence of delirium was 19%. Overall, CAPD score ≥ 9 had sensitivity of 81.8% and specificity of 44.8%. Among typically developed patients, the sensitivity and specificity were 76.7 and 65.4%, respectively, whereas specificity was only 16.5% for developmentally delayed patients. The best cut-off value for CAPD was 9 for typically developed children and 17 for those with developmental delay (sensitivity 74.4%, specificity 63.2%). Some CAPD questions do not apply to patients with sensory and neurocognitive deficits; upon excluding those questions, the best cut-off values were 5 for typically developed and 6 for developmentally delayed children. In mechanically ventilated patients with developmental delay, CAPD ≥ 9 led to a high false-positive rate. This emphasizes the need for either a different cut-off score or development of a delirium scale specific to this patient population.

Delirium screening and identification in the pediatric intensive care unit (PICU) can be a diagnostic challenge. Primarily, the burden of screening falls on the bedside nurses, who are juggling countless tasks throughout their shift. The nursing staff at the researcher's institution were concerned that the existing screen, Cornell Assessment for Pediatric Delirium (CAPD), detracted from workflow. The PEdiatric Delirium Scale (PEDS) was developed to accurately identify delirium in children of all developmental abilities and improve nursing workflow. This is a single-center, double-blinded, preliminary exploratory validation study that assesses the feasibility and accessibility of PEDS. This study was performed in a busy 24-bed quaternary PICU serving a diverse, noncardiac patient population. Enrolled patients underwent screening for delirium using the CAPD and PEDS. These results were compared to the gold standard psychiatric evaluation to determine the validity of the novel screen. Finally, the surveyed nurses reviewed their experience with CAPD and PEDS. The primary outcome was to explore the validation of PEDS in the PICU. Using the Youden index, an overall sensitivity of 79% for the detection of delirium (95% confidence interval [CI]: 0.61–0.91) and a specificity of 68% (95% CI: 0.64–0.73) were achieved with an optimal cut-point of 4, on a scale of 0 to 10. PEDS demonstrated a higher predictive value compared to CAPD. Elicited nursing feedback favored PEDS over CAPD, with 86% of respondents citing a shorter time to perform the screen. PEDS is a streamlined tool that can be used to detect pediatric delirium regardless of developmental abilities. Nursing surveys revealed improved workflow when comparing PEDS to CAPD.

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