Pediatric delirium: epidemiology and outcomes

Siegel, Elana J.; Traube, Chani

doi:10.1097/mop.0000000000000960

Cited by 51 publications

(51 citation statements)

References 54 publications

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“…Delirium incidence in our unit was 23%, with hypoactive delirium as the most common phenotype (75%). Delirium incidence was similar with the one reported by other medical PICUs ( 15 , 28 , 36 ). In the majority of the cases, delirium was treated with non-pharmacologic interventions.…”

Section: Discussionsupporting

confidence: 89%

“…In the last decade, advances in pediatric critical care significantly decreased mortality rates, however, this paralleled with an increase of children surviving with important functional morbidities ( 13 , 28 ). Delirium is a common complication of pediatric critical illness and favors the development of p-PICS ( 5 ), thus, strategies to reduce delirium risk factors, such as prolonged immobilization and benzodiazepine use ( 10 , 28 , 31 , 32 ), are now recommended by the Society of Critical Care Medicine ICU Liberation Campaign ( 10 ) to ensure optimal functional recovery in children after PICU stay.…”

Section: Discussionmentioning

confidence: 99%

“…Delirium treatment was performed using with non-pharmacologic interventions ( Supplementary Figure 1 ). Pharmacologic interventions were used only when the first interventions failed ( 15 , 24 , 28 ).…”

Section: Methodsmentioning

confidence: 99%

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The LiberAction Project: Implementation of a Pediatric Liberation Bundle to Screen Delirium, Reduce Benzodiazepine Sedation, and Provide Early Mobilization in a Human Resource-Limited Pediatric Intensive Care Unit

et al. 2021

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Background: Delirium, bed immobilization, and heavy sedation are among the major contributors of pediatric post-intensive care syndrome. Recently, the Society of Critical Care Medicine has proposed the implementation of daily interventions to minimize the incidence of these morbidities and optimize children functional outcomes and quality of life. Unfortunately, these interventions require important clinical and economical efforts which prevent their use in many pediatric intensive care units (PICU).Aim: First, to evaluate the feasibility and safety of a PICU bundle implementation prioritizing delirium screening and treatment, early mobilization (<72 h from PICU admission) and benzodiazepine-limited sedation in a human resource-limited PICU. Second, to evaluate the incidence of delirium and describe the early mobilization practices and sedative drugs used during the pre- and post-implementation periods. Third, to describe the barriers and adverse events encountered during early mobilization.Methods: This observational study was structured in a pre- (15th November 2019–30th June 2020) and post-implementation period (1st July 2020–31st December 2020). All patients admitted in PICU for more than 72 h during the pre and post-implementation period were included in the study. Patients were excluded if early mobilization was contraindicated. During the pre-implementation period, a rehabilitation program including delirium screening and treatment, early mobilization and benzodiazepine-sparing sedation guidelines was developed and all PICU staff trained. During the post-implementation period, delirium screening with the Connell Assessment of Pediatric Delirium scale was implemented at bedside. Early mobilization was performed using a structured tiered protocol and a new sedation protocol, limiting the use of benzodiazepine, was adopted.Results: Two hundred and twenty-five children were enrolled in the study, 137 in the pre-implementation period and 88 in the post-implementation period. Adherence to delirium screening, benzodiazepine-limited sedation and early mobilization was 90.9, 81.1, and 70.4%, respectively. Incidence of delirium was 23% in the post-implementation period. The median cumulative dose of benzodiazepines corrected for the total number of sedation days (mg/kg/sedation days) was significantly lower in the post-implementation period compared with the pre-implementation period: [0.83 (IQR: 0.53–1.31) vs. 0.74 (IQR: 0.55–1.16), p = 0.0001]. The median cumulative doses of fentanyl, remifentanil, and morphine corrected for the total number of sedation days were lower in the post-implementation period, but these differences were not significant. The median number of mobilizations per patient and the duration of each mobilization significantly increased in the post-implementation period [3.00 (IQR: 2.0–4.0) vs. 7.00 (IQR: 3.0–12.0); p = 0.004 and 4 min (IQR: 3.50–4.50) vs. 5.50 min (IQR: 5.25–6.5); p < 0.0001, respectively]. Barriers to early mobilization were: disease severity and bed rest orders (55%), lack of physicians' order (20%), lack of human resources (20%), and lack of adequate devices for patient mobilization (5%). No adverse events related to early mobilization were reported in both periods. Duration of mechanical ventilation and PICU length of stay was significantly lower in the post-implementation period as well as the occurrence of iatrogenic withdrawal syndrome.Conclusion: This study showed that the implementation of a PICU liberation bundle prioritizing delirium screening and treatment, benzodiazepine-limited sedation and early mobilization was feasible and safe even in a human resource-limited PICU. Further pediatric studies are needed to evaluate the clinical impact of delirium, benzodiazepine-limited sedation and early mobilization protocols on patients' long-term functional outcomes and on hospital finances.

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Section: Discussionsupporting

confidence: 89%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

The LiberAction Project: Implementation of a Pediatric Liberation Bundle to Screen Delirium, Reduce Benzodiazepine Sedation, and Provide Early Mobilization in a Human Resource-Limited Pediatric Intensive Care Unit

et al. 2021

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“…As with pain and sedation, regular assessment by using validated tools is the key for adequate management. Delirium remains underdiagnosed and misinterpreted in children and therefore undertreated, especially as children in hypoactive delirium are often seen as just especially calm and “easy” to comfort ( 58 ). All children admitted to a PICU should be subject to routine screening for withdrawal and early detection of symptoms and diagnosis of both hypo- and hyperactive as well as mixed forms of delirium in children…”

Section: Resultsmentioning

confidence: 99%

Modified ABCDEF-Bundles for Critically Ill Pediatric Patients - What Could They Look Like?

et al. 2022

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Background and SignificanceAdvances in pediatric intensive care have led to markedly improved survival rates in critically ill children. Approximately 70% of those children survive with varying forms of complex chronic diseases or impairment/disabilities. Length of stay, length of mechanical ventilation and number of interventions per patient are increasing with rising complexity of underlying diseases, leading to increasing pain, agitation, withdrawal symptoms, delirium, immobility, and sleep disruption. The ICU-Liberation Collaborative of the Society of Critical Care Medicine has developed a number of preventative measures for prevention, early detection, or treatment of physical and psychiatric/psychological sequelae of oftentimes traumatic intensive care medicine. These so called ABCDEF-Bundles consist of elements for (A) assessment, prevention and management of pain, (B) spontaneous awakening and breathing trials (SAT/SBT), (C) choice of analgesia and sedation, (D) assessment, prevention and management of delirium, (E) early mobility and exercise and (F) family engagement and empowerment. For adult patients in critical care medicine, research shows significant effects of bundle-implementation on survival, mechanical ventilation, coma, delirium and post-ICU discharge disposition. Research regarding PICS in children and possible preventative or therapeutic intervention is insufficient as yet. This narrative review provides available information for modification and further research on the ABCDEF-Bundles for use in critically ill children.Material and MethodsA narrative review of existing literature was used.ResultsOne obvious distinction to adult patients is the wide range of different developmental stages of children and the even closer relationship between patient and family. Evidence for pediatric ABCDEF-Bundles is insufficient and input can only be collected from literature regarding different subsections and topics.ConclusionIn addition to efforts to improve analgesia, sedation and weaning protocols with the aim of prevention, early detection and effective treatment of withdrawal symptoms or delirium, efforts are focused on adjusting ABCDEF bundle for the entire pediatric age group and on strengthening families' decision-making power, understanding parents as a resource for their child and involving them early in the care of their children.

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“…Recent studies have demonstrated a consistent and robust association between exposure to benzodiazepines and delirium development in pediatric critical illness [ 1 , 2 , 3 , 4 , 5 ]. As pediatric delirium is related to poor outcomes (including increased duration of mechanical ventilation, increased ICU and hospital length of stay, and even excess mortality), there is a compelling need to explore alternatives to benzodiazepine-based sedation in mechanically ventilated children [ 6 , 7 , 8 ].…”

Section: Introductionmentioning

confidence: 99%

“Difficult to Sedate”: Successful Implementation of a Benzodiazepine-Sparing Analgosedation-Protocol in Mechanically Ventilated Children

et al. 2021

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We sought to evaluate the success rate of a benzodiazepine-sparing analgosedation protocol (ASP) in mechanically ventilated children and determine the effect of compliance with ASP on in-hospital outcome measures. In this single center study from a quaternary pediatric intensive care unit, our objective was to evaluate the ASP protocol, which included opiate and dexmedetomidine infusions and was used as first-line sedation for all intubated patients. In this study we included 424 patients. Sixty-nine percent (n = 293) were successfully sedated with the ASP. Thirty-one percent (n = 131) deviated from the ASP and received benzodiazepine infusions. Children sedated with the ASP had decrease in opiate withdrawal (OR 0.16, 0.08–0.32), decreased duration of mechanical ventilation (adjusted mean duration 1.81 vs. 3.39 days, p = 0.018), and decreased PICU length of stay (adjusted mean 3.15 vs. 4.7 days, p = 0.011), when compared to the cohort of children who received continuous benzodiazepine infusions. Using ASP, we report that 69% of mechanically ventilated children were successfully managed with no requirement for continuous benzodiazepine infusions. The 69% who were successfully managed with ASP included infants, severely ill patients, and children with chromosomal disorders and developmental disabilities. Use of ASP was associated with decreased need for methadone use, decreased duration of mechanical ventilation, and decreased ICU and hospital length of stay.

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Pediatric delirium: epidemiology and outcomes

Cited by 51 publications

References 54 publications

The LiberAction Project: Implementation of a Pediatric Liberation Bundle to Screen Delirium, Reduce Benzodiazepine Sedation, and Provide Early Mobilization in a Human Resource-Limited Pediatric Intensive Care Unit

The LiberAction Project: Implementation of a Pediatric Liberation Bundle to Screen Delirium, Reduce Benzodiazepine Sedation, and Provide Early Mobilization in a Human Resource-Limited Pediatric Intensive Care Unit

Modified ABCDEF-Bundles for Critically Ill Pediatric Patients - What Could They Look Like?

“Difficult to Sedate”: Successful Implementation of a Benzodiazepine-Sparing Analgosedation-Protocol in Mechanically Ventilated Children

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