Differentiating Delirium From Sedative/Hypnotic-Related Iatrogenic Withdrawal Syndrome: Lack of Specificity in Pediatric Critical Care Assessment Tools*

Abstract

Although important studies have demonstrated apparent high prevalence of iatrogenic withdrawal syndrome and delirium in the PICU population, the overlap in these scoring systems presents potential difficulty in distinguishing syndromes, both clinically and for research purposes.

Ranitidine-Induced Delirium in a 7-Year-Old Girl: A Case Report

“…15 Unfortunately, the literature on anticholinergic toxidrome and its relationship to delirium is limited to adult populations, and, thus, the magnitude of its occurrence in childhood is still unknown. 17 The fact that many risk factors described in the literature are lacking in this case gives further support to the hypothesis of a causal relationship between ranitidine and delirium. Important predisposing factors include the severity of the underlying disease, male sex, visual and hearing impairment, dehydration, malnutrition, low albumin, and past alcohol, substance, and/or cigarette abuse or multiple psychoactive drugs.…”

“…14 Several studies indicate anticholinergic drugs as risk factors for delirium and the role of anticholinergic burden in delirium pathophysiology. 5,[14][15][16][17] Anticholinergic toxidrome is described after exposure to anticholinergic drugs, including H2 blockers, 16,17 which antagonize peripheral and central muscarinic receptors, producing anticholinergic toxoids. One CNS manifestation of these drugs is delirium.…”

Parent’s experiences of their child’s withdrawal syndrome: a driver for reciprocal nurse-parent partnership in withdrawal assessment

“…Whilst diagnostic criteria do not exist for this population, this state has been termed Iatrogenic Withdrawal Syndrome (IWS) (Franck et al 2012;Best et al 2015) to reflect how the conditions for withdrawal in PICU are a consequence of clinically prescribed care. Prevalence of withdrawal ranges from 22% to 77% (Madden et al 2017), varying across settings due to differences in the drugs prescribed, peak doses administered and speed of drug weaning.…”

“…Validated assessment tools -the WAT-1 (Franck et al 2008) and SOS (Ista et al 2009) -focus on signs of withdrawal and demonstrate superior sensitivity over nurses' judgement (Franck et al 2008, Ista et al 2013. Assessing whether a child is displaying clinically significant withdrawal remains a challenge, due to confounders such as the concurrent tapering of more than one sedative or analgesic drug, the impact of the child's underlying condition on non-specific signs and symptoms of withdrawal, the nurses lack of familiarity with the child's typical behaviours (Craske et al 2017) and behavioural similarities with other differentials including delirium and adverse drug reactions (Madden et al 2017).…”

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

“…In a recent systematic review, we were not able to identify any pediatric studies that assessed the anticholinergic drug burden in the PICU ( 12 ). Because many of the medications assigned a value on the ADS and ACB scores are commonly used in the PICU, we sought to quantify the extent of exposure to anticholinergic medications in a single center because it is a potentially modifiable risk factor for morbidity, including ICU delirium.…”