State of the science in pediatric ICU delirium: An integrative review

Abstract

Delirium is a complication of critical illness associated with poor outcomes. Although widely studied in adults, comparatively little is understood about delirium in pediatric intensive care units (ICUs). The purpose of this integrative review is to determine the extent and nature of current evidence, identify gaps in the literature, and outline future areas for investigation of pediatric ICU delirium. Eligible articles included research reports of delirium in pediatric ICU samples published in English since 2009. After an extensive literature search and consideration for inclusion/exclusion criteria, 22 articles were chosen for review. Delirium was highly prevalent in the ICU. Delirium episodes developed early in hospitalization, lasted several days, and consisted of hypoactive or mixed motor subtypes. Frequently identified independent risk factors included young age, developmental delay, mechanical ventilation, and benzodiazepine exposure. Pediatric delirium was independently associated with increased length of stay, costs, and mortality. The long‐term cognitive, psychological, and functional morbidities associated with pediatric delirium remain largely unknown. Few researchers have implemented interventions to prevent or manage delirium. There was little evidence for the efficacy or safety of pharmacological management. Multicomponent delirium bundles may significantly decrease delirium incidence. Key quality issues among studies included variation in delirium screening, low levels of evidence (i.e., observational studies), and limited ability to determine intervention efficacy in quasi‐experimental designs. Although the quantity and quality of pediatric delirium research has rapidly increased, further studies are needed to understand the long‐term effects of pediatric delirium and determine the efficacy and safety of interventions for prevention and management.

Sleep disruption and delirium in critically ill children: Study protocol feasibility

“…Clinical variables collected from the electronic medical record (EMR) included presence of preexisting developmental delay, past medical history, admission diagnosis, severity of illness (Pediatric Risk for Mortality [PRISM] III; score range 0 to $$\gt $$40; Pollack et al, 1996), anticholinergic medication exposure (Boustani et al, 2008; Carnahan et al, 2006), benzodiazepine exposure in midazolam equivalents (mg/kg; Curley et al, 2015), mechanical ventilation status, and scores on the Faces, Legs, Activity, Cry, Consolability Behavioral Tool (Merkel et al, 1997; Voepel‐Lewis et al, 2010) and SBS. These variables are previously identified independent risk factors for delirium or confounders of delirium assessment (Kalvas & Harrison, 2020b; Leroy & Schieveld, 2017).…”

“…Pollack et al, 1996), anticholinergic medication exposure (Boustani et al, 2008;Carnahan et al, 2006), benzodiazepine exposure in midazolam equivalents (mg/kg; Curley et al, 2015), mechanical ventilation status, and scores on the Faces, Legs, Activity, Cry, Consolability Behavioral Tool (Merkel et al, 1997;Voepel-Lewis et al, 2010) and SBS. These variables are previously identified independent risk factors for delirium or confounders of delirium assessment (Kalvas & Harrison, 2020b;Leroy & Schieveld, 2017).…”

“…Children with PCCI have a history of multiple prior PICU stays, and therefore may interact differently with the PICU environment. Children with general anesthesia exposure frequently experience postoperative delirium, which may be a distinct clinical syndrome with unique contributing factors and presentation (Kalvas & Harrison, 2020b). However, in future, large‐sale studies, children with PCCI or anesthesia exposure could be included, and these factors considered as covariates to control for potential contribution to sleep disruption or delirium risk.…”

“…Pediatric chronic critical illness (PCCI) was defined as admission to the Complex Care Service and/or meeting PCCI criteria outlined by Shapiro et al (2017). Children with general anesthesia exposure were also excluded, as postoperative delirium may be a separate clinical syndrome (Kalvas & Harrison, 2020b).…”

Implementation of a Delirium Bundle for Pediatric Intensive Care Patients

“…There are few reports of low quality on pharmacological management of pediatric delirium with typical and atypical antipsychotic drugs which led to improvement in delirium symptoms, but side effects such as extrapyramidal symptoms, heavy sedation, and prolonged corrected QT (QTc) interval were common (12)(13)(14). It remains unclear if antipsychotic use reduces overall delirium prevalence or effectively treats hypoactive or mixed delirium (15). The risks associated with antipsychotic management may not outweigh the risks in all patients, however, in hyperactive delirium the benefits may outweigh the risks.…”