Delirium: An Emerging Frontier in the Management of Critically Ill Children

Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
Anesthesiology Clinics 12/2011; 29(4):729-50. DOI: 10.1016/j.anclin.2011.09.011
Source: PubMed


Delirium is a syndrome of acute brain dysfunction that commonly occurs in critically ill adults and most certainly is prevalent in critically ill children all over the world. The dearth of information about the incidence, prevalence, and severity of pediatric delirium stems from the simple fact that there have not been well-validated instruments for routine delirium diagnosis at the bedside. This article reviewed the emerging solutions to this problem, including description of a new pediatric tool called the pCAM-ICU. In adults, delirium is responsible for significant increases in both morbidity and mortality in critically ill patients. The advent of new tools for use in critically ill children will allow the epidemiology of this form of acute brain dysfunction to be studied adequately, will allow clinical management algorithms to be developed and implemented following testing, and will present the necessary incorporation of delirium as an outcome measure for future clinical trials in pediatric critical care medicine.

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    • "Delirium is highly prevalent in intensive care units (ICUs) (Morandi et al., 2008; Ouimet et al., 2007), and up to 80% of intubated patients may develop its symptoms (Ely et al., 2001a). Risk factors for delirium include host, severe disease, and iatrogenic factors (Smith et al., 2009). The condition is associated with increased mortality, prolonged hospitalisation, and long-term cognitive impairment (Ely et al., 2004; Pisani et al., 2009; van Rompaey et al., 2009). "
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    ABSTRACT: Delirium may lead to adverse outcomes in patients with serious conditions, but is often under-diagnosed due to inadequate screening. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is an established method for assessing delirium in the ICU. The validity and reliability of the Japanese version of the CAM-ICU has not, however, been verified, and we undertook this study to verify these parameters. CAM-ICU validity and reliability were assessed in two Japanese ICUs. Using the evaluation of the DMS-IV-TR in the psychiatrists group as the standard criteria for delirium diagnosis, we compared the evaluation of the Japanese version of the CAM-ICU between the research nurses group and the staff nurses group. According to DSM-IV-TR criteria, the prevalence of delirium was 22.0%, and according to CAM-ICU delirium was found in 22.0% with Research Nurses and 19.5% with Staff Nurses. CAM-ICU sensitivity ratings were 83% and 78%, while their specificity ratings were 95% and 97%, respectively. The Kappa inter-rater reliability was good (κ=0.85), and Cronbach's alpha coefficient was 0.69 (95% CI: 0.57-0.79). Mean rating time for the CAM-ICU was 2.5-2.8minutes for Research Nurses and Staff Nurses, respectively. The Japanese version of the CAM-ICU has comparable validity and reliability as a delirium assessment tool in surgical patients in two Japanese ICUs. With training, CAM-ICU can be incorporated into daily clinical practice. Copyright © 2014 Elsevier Ltd. All rights reserved.
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    ABSTRACT: Although our understanding of children's psychological outcomes following intensive care lags significantly behind advances in medicine, there is a growing awareness that intensive care admission impacts children beyond the boundaries of physical well-being. Intensive care presents a variety of disease-related, treatment-related, and environment-related stressors that may place children at risk of post-traumatic stress (PTS), particularly as children may have limited resources to understand and cope with aspects of the admission, its consequences, or treatment events. This article summarises the current literature on children's PTS responses following intensive care admission with emphasis on: (1) children's experience of intensive care; (2) the prevalence of PTS in children following intensive care admission; (c) factors associated with vulnerability to PTS; and (d) the role of memory and appraisal in the development of children's PTS. Existing research does have methodological limitations, and future studies utilising larger sample sizes and developmentally appropriate diagnostic measures are warranted. Furthermore, longitudinal studies investigating the aetiology and course of PTS following paediatric intensive care unit admission, particularly with further investigation of memory and cognitive factors, may lead to advances in screening, prevention, and early intervention strategies for children.
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