Delirium: an emerging frontier in the management of critically ill children.
ABSTRACT 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.
Pediatric Critical Care Medicine 10/2014; 15(8):771-3. DOI:10.1097/PCC.0000000000000208 · 2.33 Impact Factor
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ABSTRACT: Delirium is common in adult intensive care, with validated tools for measurement, known risk factors and adverse neurocognitive outcomes. We aimed to determine what is known about pediatric delirium in the pediatric intensive care unit (PICU). We conducted a systematic search for and review of studies of the accuracy of delirium diagnosis in children in the PICU. Secondary aims were to determine the prevalence, risk factors and outcomes associated with pediatric delirium. We created screening and data collection tools based on published recommendations. After screening 145 titles and abstracts, followed by 35 full-text publications and reference lists of included publications, 9 reports of 5 studies were included. Each of the five included studies was on a single index test: (1) the Pediatric Anesthesia Emergence Delirium Scale (PAED; for ages 1 to 17 years), (2) the Pediatric Confusion Assessment Method for the Intensive Care Unit (p-CAM-ICU; for ages ≥5 years), (3) the Cornell Assessment of Pediatric Delirium (CAP-D; a modification of the PAED designed to detect hypoactive delirium), (4) the revised Cornell Assessment of Pediatric Delirium (CAP-D(R)) and (5) clinical suspicion. We found that all five studies had a high risk of bias on at least one domain in the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). Sample size, sensitivity, specificity, and effectiveness (correct classification divided by total tests done) were: PAED 144, 91%, 98%, <91% (>16% of scores required imputation for missing data); p-CAM 68, 78%, 98%, 96%; CAP-D 50, 91%, 100%, 89%; CAP-D (R) 111, and of assessments 94%, 79%, <82% (it is not clear if any assessments were not included); and clinical suspicion 877, N/A (only positive predictive value calculable, 66%). Prevalence of delirium was 17%, 13%, 28%, 21%, and 5% respectively. Only the clinical suspicion study researchers statistically determined any risk factors for delirium (pediatric risk of mortality, pediatric index of mortality, ventilation, age) or outcomes of delirium (length of stay and mortality). High-quality research to determine the accuracy of delirium screening tools in the PICU are required before prevalence, risk factors and outcomes can be determined and before a routine screening tool can be recommended. Direct comparisons of the p-CAM-ICU and CAP-D(R) should be performed.Critical care (London, England) 09/2014; 18(5):489. DOI:10.1186/s13054-014-0489-x
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ABSTRACT: Medically ill adolescents are at increased risk for psychological distress and/or functional impairment. However, there are few research studies examining the optimal psychiatric treatments for this population. Psychiatric medication recommendations are largely based on studies of youth with a primary psychiatric disorder, adult studies, hypothesized mechanisms of action, and/or clinical experience. This paper provides evidence-informed recommendations for the psychopharmacological treatment of acutely medically ill adolescents suffering from significant psychological distress and/or functional impairment. Representing the most common problems among medically ill adolescents that are treated with psychiatric medications, recommendations are provided for anxiety and depression; iatrogenic medical trauma, inadequate sleep and insomnia; and, delirium.Current Psychiatry Reports 10/2013; 15(10):395. DOI:10.1007/s11920-013-0395-y · 3.05 Impact Factor