Anticholinergic Medication Burden in Pediatric Prolonged Critical Illness: A Potentially Modifiable Risk Factor for Delirium

Abstract

Objectives:It is important to describe and understand the prevalence and risk factors for the syndrome of delirium in critical illness. Since anticholinergic medication may contribute to the development of delirium in the PICU, we have sought to quantify anticholinergic medication exposure in patients with prolonged admission. We have used Anticholinergic Drug Scale scores to quantify the magnitude or extent of this burden.Design:Retrospective cohort study, January 2011 to December 2015.Setting:Single academic medical center PICU.Patients:Children under 18 years old with a PICU admission of 15 days or longer, requiring mechanical ventilation.Interventions:None.Measurements and Main Results:Daily Anticholinergic Drug Scale scores for the first 15 days of admission, in each of 88 subjects (total of 1,320 PICU days), were collected and assessed in relation to demographic data, severity of illness, and medication use. Median (interquartile range) of daily Anticholinergic Drug Scale score was 5 (interquartile range, 3–7). Anticholinergic Drug Scale score was not associated with age, sex, medical history, presenting Severity of Illness score, PICU length of stay, ventilator hours, or hospital mortality. Medications most frequently associated with high Anticholinergic Drug Scale score were low potency anticholinergic drugs such as morphine, midazolam, vancomycin, steroids, and furosemide, with the exception of ranitidine (Anticholinergic Drug Scale score 2). Patients receiving high doses of midazolam infusion had significantly higher Anticholinergic Drug Scale scores compared with those receiving lower or no midazolam dosing.Conclusions:A high number of medications with anticholinergic effects are administered to PICU patients receiving prolonged mechanical ventilation. These exposures are much higher than those reported in adult intensive care patients. Since anticholinergic drug exposure is associated with delirium, further study of this exposure in PICU patients is needed.

Causes and effects of lack of sleep in hospitalized children

“…25 Triggering factors include noise, lighting restriction during the day, absence of windows, opioids, propofol, steroids, and anticholinergic use. 21,26 Fragmentation, a reduced total sleep time, the absence of slow, deep sleep and REM sleep, as well as a displacement toward daytime hours, are alterations that may also act as triggers. Their presence worsens patient course, prolongs their stay, and increases the risk for complications and mortality.…”

“…In critically-ill patients, benzodiazepines are an independent risk factor for delirium. 26,33 The temporal relationship suggests causality and somehow supposes a contraindication to its use, although they are most commonly used as first-line drugs. 20,28,34 In adults, new agents, such as suvorexant (randomized, controlled study), would have a beneficial effect on the prevention of delirium.…”

Causas y efectos en la falta de sueño en niños hospitalizados

“…El nivel de luz al aire libre es de, aproximadamente, 10 000 unidades lux (lux = un factores precipitantes el ruido, la iluminación restringida de día, la ausencia de ventanas, los opioides, el propofol y los esteroides, así como anticolinérgicos. 21,26 La fragmentación, el tiempo total del sueño disminuido, la ausencia del sueño lento profundo y del sueño REM, así como el desplazamiento hacia los horarios diurnos, constituyen alteraciones que pueden funcionar como desencadenantes. Su presencia agrava la evolución, prolonga la estadía y aumenta el riesgo de complicaciones y la mortalidad.…”

“…En los pacientes críticos, las benzodiazepinas son un factor independiente de riesgo para el desarrollo del delirium. 26,33 La relación temporal sugiere causalidad y, de alguna manera, supone una contraindicación a su uso, pese a ser las más utilizadas como drogas de primera línea. 20,28,34 En los adultos, nuevos agentes, como el suvorexant (estudio controlado aleatorizado), tendrían un efecto beneficioso en la prevención del delirium en los adultos.…”

Exposure to Anticholinergic Medications in Pediatric Severe Sepsis and Feasibility of Delirium Screening

“…17 In our previous work in the mechanically ventilated PICU population, we found that PICU patients undergoing prolonged mechanical ventilation received many medications with anticholinergic effects, with a median ADS score of 5 in that cohort. 18 Due to the possible mechanism of cholinergic blockade in SAE, the likely role of anticholinergic medications in PICU delirium, the purpose of this study was to measure the anticholinergic medication burden in these PICU patients with severe sepsis or septic shock. In addition, because of the sedation practices in the PICU, we sought to quantify the feasibility of delirium screening in this population.…”