Abstract
Delirium has been associated with prolonged pediatric intensive care unit (PICU) stay and mechanical ventilation times as well as high hospital costs and mortality rates. This work aimed to examine pediatric delirium awareness and delirium management in Turkey. A total of 19 physicians responsible for their respective PICUs completed the survey. Most of the units (57.9%) did not use any assessment tool. Varying measures were applied in different units to reduce the prevalence of delirium. The number of units that continuously measured noise was very low (15.8%). Eye mask and earpiece usage rates were also very low. In pharmacological treatment, haloperidol, dexmedetomidine, benzodiazepines, and atypical antipsychotics were the most preferred options. Some units have reached a sufficient level of pediatric delirium awareness and management. However, insufficiencies in delirium awareness and management remain in general.
Keywords: Awareness, delirium, management, pediatric, Turkey
Introduction
“Delirium” is defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V), as a syndrome characterized by acute onset cerebral dysfunction with fluctuations in basal mental state, disturbed awareness, disorganized thinking, or varying levels of consciousness. 1 These symptoms should not be explained by the preexisting neurocognitive disorder and or be assessed when someone is in a coma. However, it requires that the symptoms be attributed to an underlying medical condition, poisoning, drug abstinence, or drug side effects.
Management can be classified under two main categories: nonpharmacological and pharmacological methods. The management of delirium begins with identifying and modifying factors. Yet, no medications have been approved by the Food and Drug Administration for use in the prevention and treatment of delirium in children. However, drugs that can be used in certain situations provide a decline in delirium findings and support brain functions.
Recent studies have reported delirium prevalence rates of 13 to 28% in patients in pediatric intensive care units (PICUs). 2 3 In a limited number of studies, delirium has been associated with prolonged PICU stay and mechanical ventilation times as well as high hospital costs and mortality rates. 4 5 Unfortunately, a limited number of pediatric studies on such an important clinical condition have been published. In addition, studies have shown that general awareness about this subject is low in health care providers in the PICU. 6 7
In the literature, although there are studies examining awareness on adult delirium among anesthesiologists and residents, there are no multicentered pediatric clinical studies nor investigations into the general awareness on the pediatric delirium in Turkey. 8 Thus, the current study aimed to examine pediatric delirium awareness and delirium management in our country.
Materials and Methods
This survey-based study was conducted between June and July 2020. The survey participants were the physicians responsible for PICUs, who offer professional intensive care in Turkey. A 24-question survey was prepared to assess their knowledge of features of the units, delirium awareness (tools and diagnostic criteria for delirium, risk factors, presumed incidence of delirium, types of delirium, and strategies for prevention), and management of delirium. The questions were prepared with consensus after detailed literature review by the pediatric intensivists team. For this purpose, the characteristics of the participants' units were determined using 14 questions, while information on delirium awareness was extracted using 5 questions, and another 5 questions were dedicated to gathering data on delirium management. Through the Turkey Pediatric Emergency Medicine and Intensive Care Association, which we are a member of, we sent invitation letters to all participants by email (cayd@googlegroups.com). Participation was voluntary. There were 40 unit supervisors in the group and 19 (47.5%) of them returned positively. The participants were asked to join the survey, which was posted on the online polling website, Survey Monkey ( http://www.surveymonkey.com ). A total of 19 physicians responsible for their respective PICUs completed the survey. All responses were anonymous and not tracked to individual residents.
This study was conducted according to the Declaration of Helsinki and was approved by the Ethics Committee of the Izmir Democracy University.
Statistical Analysis
Data were collected anonymously and analyzed by using the graphical and analytical features of www.surveymonkey.com and IBM SPSS Statistics, version 21.0 (IBM Corp., Armonk, New York, United States). All answers were described as counts and percentages for categorical variables. Chi-square and Fisher's exact tests were used to compare the categorical data of the two groups, and the Z test (post hoc Bonferroni test) was used to compare the categorical data of more than two groups. Here, p <0.05 was considered significant.
Results
Pediatric Intensive Care Unit Features
A total of 19 physicians responsible for their respective PICUs completed the survey. The responses given regarding the unit features are summarized in Table 1 . The majority of the units were at the tertiary level (84.2%). The majority of the hospitals where the units located were training and research hospitals. Approximately 80% of the units had more than six beds. While most of the units provided specialist training, the number of units providing subspecialist training was low. Furthermore, at least one doctor was available continuously for almost all of the units. Certified nurse distributions were highly heterogeneous. The number of units that continuously measured noise was very low. Eye mask and earpiece usage rates were also very low. Only 4 units had single-patient rooms.
Table 1. Features of the participants' units.
| Questions and responses | n (%) |
|---|---|
| What is your PICU level? | |
| Secondary | 3 (15.8) |
| Tertiary | 16 (84.2) |
| What is the feature of the hospital where the PICU is located? | |
| University hospital | 5 (26.3) |
| Training and research hospital | 11 (57.9) |
| State hospital | 3 (15.8) |
| What is the number of beds in your PICU? | |
| ≤ 6 | 4 (21.1) |
| 6–10 | 7 (36.8) |
| ≥ 11 | 8 (42.1) |
| Does your PICU provide specialist training? | |
| Yes | 11 (57.9) |
| No | 8 (42.1) |
| Does your PICU provide subspecialist training? | |
| Yes | 8 (42.1) |
| No | 11 (57.9) |
| Is there at least one physician constantly in your PICU? | |
| Yes | 17 (89.5) |
| No | 2 (10.5) |
| What is the rate of certificated nurses in your PICU? | |
| All certificated | 1 (5.3) |
| ≥ 76% | 1 (5.3) |
| 51–75% | 5 (26.3) |
| 25–50% | 4 (21.1) |
| ≤ 24 | 6 (31.6) |
| None | 2 (10.5) |
| Does your PICU provide nurse certification training? | |
| Yes | 10 (52.6) |
| No | 9 (47.4) |
| What is the number of nurses per patient in your PICU? | |
| 1/1 | 1 (5.3) |
| 2/1 | 11 (57.9) |
| 3/1 | 6 (31.6) |
| 4/1 | 1 (5.3) |
| How is the bed layout in your PICU? | |
| Multiple occupancy rooms | 15 (78.9) |
| Single patient rooms | 4 (21.1) |
| How do day/night lighting systems work in your PICU? | |
| Always the same | 1 (5.3) |
| Dim at night | 12 (63.2) |
| Bed-based variable | 6 (31.6) |
| How is noise pollution detected in your PICU? | |
| Continuous measuring device (color visual) available | 3 (15.8) |
| Intermittent measurement is done | 8 (42.1) |
| No measurement | 8 (42.1) |
| What are the equipment used to maintain a good sleep–wake cycle in your PICU? | |
| Eye masks | 5 (26.3) |
| Earplugs/earmuff | 0 (0) |
| Bedside night light | 15 (78.9) |
| Music | 4 (21.1) |
| How often can you receive the relatives of patients in your PICU? | |
| Continuously in the appropriate patient | 5 (26.3) |
| According to the need, at certain intervals during the day | 13 (68.4) |
| Receiving only during the family visit time | 15 (78.9) |
| Never | 0 (0) |
Abbreviation: PICU, pediatric intensive care unit.
Delirium Awareness
The participants' delirium awareness was identified by using five questions ( Table 2 ). The majority of the participants thought that the delirium prevalence was below 10%. While most of the participants observed hyperactive type delirium, there were those who never saw cases of delirium. Although they possessed excellent knowledge of pain and iatrogenic withdrawal syndrome (IWS) in the differential diagnoses of delirium, their awareness of inadequate sedation was low. Moreover, while most of the participants preferred the use of assessment tools and clinical methods in the diagnosis of delirium, there were those who thought that laboratory and electroencephalogram/magnetic resonance could be used in diagnosis. Different answers were given to the measures that could be taken to reduce the prevalence of delirium. Notably, most of the participants did not have knowledge of some correct interventions (e.g., correcting anemia and metabolic disorders, especially electrolyte disorder). Furthermore, some participants thought that incorrect interventions (e.g., using benzodiazepine or increasing its dose, avoiding dexmedetomidine, etc.) were acceptable.
Table 2. Evaluation of delirium awareness.
| Questions and responses a | n (%) |
|---|---|
| What is the prevalence of delirium in PICUs? (%) | |
| ≤ 5 | 5 (26.3) |
| 5–10 | 7 (36.8) |
| 10–20 | 3 (15.8) |
| 20–30 | 3 (15.8) |
| 30–50 | 1 (5.3) |
| What type of delirium have you seen so far in your PICU? | |
| Hyperactive | 14 (73.7) |
| Hypoactive | 8 (42.1) |
| Mixed type | 5 (26.3) |
| None | 3 (15.8 |
| What are the conditions that can be confused with delirium? | |
| Pain | 18 (94.7) |
| Iatrogenic withdrawal syndrome | 19 (100) |
| Under sedation | 12 (63.2) |
| All | 0 (0) |
| None | 0 (0) |
| What methods can be used in the diagnosis of delirium? | |
| Clinically | 16 (84.2) |
| Laboratory | 2 (10.5) |
| Assessment tools | 18 (94.7) |
| EEG and MR | 2 (10.5) |
| From treatment to diagnosis | 9 (47.4) |
| In your opinion, which of the following measures can be applied to prevent the development of delirium in PICUs? | |
| Modifying factors that contribute to the development of delirium | 19 (100) |
| Maintaining a normal sleep–wake cycle | 19 (100) |
| Staying with the child's loved one | 16 (84.2) |
| Using eye patch | 8 (42.1) |
| Using an earpiece | 8 (42.1) |
| Reducing noise pollution by the use of noise measuring devices | 15 (78.9) |
| Using dim light at night | 18 (94.7) |
| Optimizing sedation goals | 17 (89.5) |
| Reducing immobilization | 17 (89.5) |
| Encouraging early physical therapy | 11 (57.9) |
| Limiting the use of antibiotics | 1 (5.3) |
| Implementation of an analgosedation approach | 16 (84.2) |
| Setting an oxygen saturation target of 95% and above | 3 (15.8) |
| Correcting anemia, transfusing if necessary | 5 (26.3) |
| Improve metabolic disturbances (especially electrolytes) | 8 (42.1) |
| Starting benzodiazepine infusion or increasing the current dose | 3 (15.8) |
| Avoiding dexmedetomidine infusion | 1 (5.3) |
| Avoiding anticholinergic use | 1 (5.3) |
Abbreviations: EEG, electroencephalogram; MR, magnetic resonance; PICU, pediatric intensive care unit.
More than one item can be selected apart from the first question.
The relationship between delirium awareness parameters and unit features was compared in detail by the post hoc Bonferroni test. When the relationship between PICU characteristics and delirium differential diagnosis information was examined, results indicated that the differential diagnosis information was significantly higher in the units that had at least one physician constantly in the PICU ( p = 0.028). When the diagnostic methods were compared with the unit features, results showed that—in the tertiary units and those with a nurse/patient ratio of 2/1 (2 patients for every 1 nurse)—knowledge of which clinical and assessment tools should be used in the diagnosis of delirium was significantly high ( p = 0.003). Furthermore, knowledge that laboratory methods cannot be used directly in the diagnosis of delirium was significantly higher in the tertiary units ( p = 0.018).
The information about what can be done to reduce the prevalence of delirium, and the unit features were compared one by one. Knowledge of avoiding the use of benzodiazepines to reduce the prevalence of delirium was highly available in tertiary units (93.7%) ( p = 0.051). Awareness of avoiding anticholinergic use was found to be very low (5.2%). However, this low awareness was not associated with the units' characteristics. The misinformation on avoiding the use of dexmedetomidine was known to almost all units (94.7%), and such high level of awareness was not related to the units' characteristics. Most of the units did not know that the treatment of anemia, metabolic disorders (especially electrolyte disorder), and hypoxia could reduce the prevalence of delirium. Unfortunately, such a low level of awareness was not related to the units' characteristics.
Delirium Management
Information on the delirium management in the participants' respective units was identified ( Table 3 ). In most of the units (63.2%), delirium evaluation was performed by pediatricians. Only 5 (26.3%) units performed delirium screening at least once a day, and most of the units (57.9%) did not use any assessment tool. The units that employed assessment tools mostly used The Pediatric Anesthesia Emergence Delirium (PAED), although some units used other tools. Nonpharmacological interventions were the most preferred treatment method with haloperidol, dexmedetomidine, benzodiazepines, and atypical antipsychotics as the most preferred options in the units.
Table 3. Evaluation of delirium management.
| Questions and responses | n (%) |
|---|---|
| Who conducts delirium assessments in your PICU? | |
| Pediatrician | 12 (63.2) |
| Nurse | 4 (21.1) |
| Child psychiatry | 2 (10.5) |
| None | 1 (5.3) |
| How often are delirium evaluations performed in your PICU? | |
| At least once per shift | 3 (15.8) |
| Once each day | 2 (10.5) |
| Rarely patient based | 13 (68.4) |
| Never | 1 (5.3) |
| What assessment tools do you use for delirium evaluation in your PICU? a | |
| The Delirium Rating Scale | 1 (5.3) |
| The Pediatric Anesthesia Emergence Delirium | 6 (31.6) |
| The Cornell Assessment of Pediatric Delirium | 2 (10.5) |
| The Pediatric Confusion Assessment Method | 3 (15.8) |
| The Preschool Confusion Assessment Method for the ICU | 0 (0) |
| Sophia Observation withdrawal Symptoms-Pediatric Delirium Scale | 1 (5.3) |
| Not being used | 11 (57.9) |
| What methods do you use in the treatment of delirium in your PICU? a | |
| Nonpharmacological interventions | 16 (84.2) |
| Haloperidol | 13 (68.4) |
| Atypical antipsychotics | 6 (31.6) |
| Melatonin | 3 (15.8) |
| Clonidine | 0 (0) |
| Dexmedetomidine | 10 (52.6) |
| Benzodiazepines | 9 (47.4) |
| Anticholinergics | 1 (5.3) |
| Which of the following measures do you implement to prevent the development of delirium in your PICU? a | |
| Modifying factors that contribute to the development of delirium | 19 (100) |
| Maintaining a normal sleep–wake cycle | 12 (63.2) |
| Staying with the child's loved one | 11 (57.9) |
| Using an eye patch | 5 (26.3) |
| Using an earpiece | 1 (5.3) |
| Reducing noise pollution by the use of noise measuring devices | 4 (21.1) |
| Using dim light at night | 16 (84.2) |
| Optimizing sedation goals | 16 (84.2) |
| Reducing immobilization | 10 (52.6) |
| Encouraging early physical therapy | 13 (68.4) |
| Limiting the use of antibiotics | 2 (10.5) |
| Implementation of an analgosedation approach | 13 (68.4) |
| Setting an oxygen saturation target of 95% and above | 3 (15.8) |
| Correcting anemia, transfusing if necessary | 4 (21.1) |
| Improving metabolic disturbances (especially electrolytes) | 6 (31.6) |
| Starting benzodiazepine infusion or increasing the current dose | 2 (10.5) |
| Avoiding dexmedetomidine infusion | 1 (5.3) |
| Avoiding anticholinergic drug use | 1 (5.3) |
| None | 0 (0) |
Abbreviation: PICU, pediatric intensive care unit.
Multiple options can be selected.
Furthermore, varying measures were applied in different units to reduce the prevalence of delirium. Results indicated that 8 units did not allow the prolonged stay of a child's loved one. Eye patch and/or earpiece use was generally very low, and only a few units continuously measured and reduced noise pollution. The treatment of anemia, metabolic disorders (especially electrolyte disorder), and hypoxia were the measures implemented in very few units. Very few units avoided the use of anticholinergic drugs.
When the relationship between unit features and frequency of delirium screening was examined, results showed that routine screening was not performed as the number of beds increased ( p = 0.007). In addition, the post hoc Bonferroni test results indicated that the routine screening at the units with 6 or less beds was significantly higher than the other units. The use of assessment tools was found to be significantly lower at secondary PICUs ( p = 0.045), and pharmacological and nonpharmacological treatments were applied in the tertiary more than in the secondary PICUs ( p = 0.044). In addition, an increase in the nurse/patient ratio resulted in a significant increase in the frequency of treatment ( p = 0.03).
The measures applied to reduce the prevalence of delirium and the unit features were compared in detail using the post hoc Bonferroni test. The results indicated that there was no significant relation between the units' characteristics and the use of benzodiazepine, dexmedetomidine, and anticholinergic drugs. The units with 6 to 10 beds and can provide nurse certification training were able to maintain better sleep–wake cycles compared with other units ( p = 0.028 and p = 0.036, respectively). In addition, we found that such cycles can be well maintained in units that could retain parents ( p = 0.045). The use of eye patch was significantly lower in units with 11 or more beds and those that did not detect noise ( p = 0.037 and p = 0.049, respectively). The rates of early physical therapy initiation and knowledge of treating anemia were significantly lower in units that did not measure routine noise ( p = 0.019 and p = 0.049, respectively). In the units providing nurse certification training, we found that the rate of children staying with their parents was significantly higher than in others ( p = 0.036).
Discussion
Delirium has a high prevalence rate in PICUs, affecting an estimated 30% of the patients admitted. The diagnosis of delirium in children has been associated with longer hospitalization, higher costs, increased morbidity, and increased mortality. 5 Although there are a limited number of studies in the literature examining delirium awareness in PICUs, no comprehensive study has demonstrated the actual situation in Turkey. Thus, we believe that this article will make a great contribution to the literature by revealing the experiences and awareness of professional PICUs on the subject within the context of Turkey's health care system.
Recent studies have found that delirium is quite frequent, with prevalence rates between 12 and 65% in pediatric medical, surgical, and cardiac PICUs, depending on the specific population being studied. 2 9 Despite its high prevalence, routine delirium screening have been rarely performed. A survey performed in Canada reported that only 16% of respondents routinely screened for delirium. 10 However, in such studies, there has been no answer provided to the question of why a disease with such a high-prevalence rate is screened less frequently. Given that the majority of the participants in our study estimated the delirium prevalence to be below 10%, we think that they may not have routinely screened for delirium on a daily basis.
Pediatric delirium can be presented in three subtypes: hyperactive, mixed, or hypoactive. 11 Hyperactive delirium—which is characterized by restlessness, agitation, aggression, and emotional lability—is easy to recognize. Hypoactive delirium manifests as decreased responsiveness, slowed or sparse speech, and hypoactive or slowed motor activity, as well as lethargy and apathy. It is often missed without routine screening. Mixed delirium can present with both clinical signs of hyperactive and hypoactive delirium. Epidemiological studies have shown that, contrary to popular belief, only a small proportion of delirium in children is of the hyperactive subtype. A comprehensive study that examined a large number of patients found that hypoactive delirium is most common (46%), closely followed by mixed delirium (45%), and hyperactive delirium (8%). 9 In our study, we considered that the low rate of hypoactive delirium detected by the participants may be attributed to either their low awareness of the subject or their failure to perform routine delirium screening.
The gold standard for diagnosing delirium in children is diagnosis by a child and adolescent psychiatrist, using the DSM-V criteria. 12 However, it is very difficult to conduct a child psychiatrist assessment at any time of the day in each center. Thus, bedside assessment tools have been developed for use by nonpsychiatrists to routinely screen for delirium in all children who are seriously ill. All of the screening tools have a high sensitivity and specificity for detecting delirium in children. Thus, these tools have enabled real-time delirium detection and facilitated appropriate treatment in PICUs. 13 One example is the Pediatric Confusion Assessment Method (pCAM-ICU), which is an interactive screening tool designed for children aged 5 years and older. However, as delirium fluctuates throughout the day, this tool is limited in that it will not detect delirium if they occur earlier in the nursing shift. Another major limitation is that it cannot be used for children under 5 years of age. The Preschool Confusion Assessment Method for the ICU (psCAM-ICU) is a screening tool designed for children aged 6 months to 5 years old. Delirium assessment with this tool is a two-step process; arousal is assessed by using a sedation scale and then delirium is assessed by using this tool if the patient is at least arousable to voice. Meanwhile, the PAED, designed for immediate postoperative use by anesthesiologists, selects for the hyperactive subtype of delirium. 14 The PAED is a valid tool that can be easily used at the bedside to detect the emergence of hyperactive delirium. However, it cannot be used to detect hypoactive delirium, which is frequently observed in children. The Cornell Assessment of Pediatric Delirium (CAPD) is a strictly observational screening tool used in children of all ages. It is adapted from the PAED to better identify hypoactive and hyperactive delirium by using a behavioral scale. Traube et al reported that CAPD is a valid, rapid, and observational nursing screening tool that is urgently needed for the detection of delirium in PICU settings. 15 Furthermore, the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) proposed the evaluation of all children who are critically ill for delirium using the CAPD at least once per shift. 16
In our study, after comparing the diagnostic methods based on the units' features, we found that, in the tertiary units and those with a nurse/patient ratio of 2/1, the participants' knowledge of which clinical and assessment tools should be used in the diagnosis of delirium was significantly high. The knowledge that laboratory methods cannot be used directly in the diagnosis of delirium was also found to be significantly higher in the tertiary than in other units. When the relationship between unit features and the frequency of delirium screening was examined, the results indicated that routine screening was not performed as the number of beds increased. In addition, in the post hoc Bonferroni test, we observed that the routine screening at the units with 6 or less beds was significantly higher than in other units. While the majority of the participants did not use tools, the majority of users employed the PAED. Considering the limitations of PAED and the ESPNIC recommendation, we think that the use of CAPD may be more appropriate in the PICUs in our country.
Low awareness of situations that can be confused with delirium can lead to errors in delirium detection. In fact, the ESPNIC states that it may be difficult to distinguish among pain, distress, inadequate sedation, withdrawal syndrome, and delirium. 16 In our study, although the participants had excellent knowledge of pain and IWS in the differential diagnoses of delirium, inadequate sedation awareness was low among the participants. Furthermore, the differential diagnosis information was found to be significantly higher in the units with at least one physician constantly in the PICU ( p = 0.028).
Thus far, little information is available on the management of delirium for children. Management can be classified under two main categories: nonpharmacological and pharmacological methods. The management of delirium begins with identifying and modifying factors that contribute to the development of delirium. This factors include hypoxia, medications (e.g., anticholinergic drugs and benzodiazepines), metabolic disturbances, pain, and anxiety. Pediatric delirium mostly improves by properly managing the underlying medical illnesses, optimizing the PICU environment, and minimizing iatrogenic triggers. 3 17 It is recommended to use limited delirium-related drugs, such sedatives, anticholinergics, and steroids, as far away from patients as possible. 18 19 Environmental factors could also play a big role in the prevention and management of pediatric delirium. 20 In intensive care, it is recommended to reduce unpleasant smell, noise, and bright light. 21 Maintaining a normal sleep–wake cycle is important in ensuring immunity and thermoregulation and in preventing the occurrence of a catabolic state. 7 22 A delirious child will benefit from the continued presence of a parent or loved one. 4 If possible, physical exercise and activities are recommended during the day.
In our study, we found that many nonpharmacological interventions were known and applied by many units ( Table 4 ). However, some measures, such as eye patch and/or earpiece use; the treatment of anemia, metabolic disorders (especially electrolyte disorder), and hypoxia; reduction of noise pollution by using noise measuring devices; and avoiding the use of anticholinergic drugs were not very much known to the participants nor were they applied frequently. Meanwhile, compared with other units, those with 6 to 10 beds and can provide nurse certification training maintained higher rates of normal sleep–wake cycles. In addition, such cycles were maintained in units that could retain parents. The use of eye patch was significantly lower in units with 11 or more beds and those that did not detect noise. The rate of early physical therapy initiation and knowledge of correcting anemia were significantly lower in units that did not measure routine noise. In the units providing nurse certification training, we found that the rate of children staying with their parents was significantly higher ( p = 0.036). Overall, such data indicate that that the general delirium diagnosis and treatment awareness among practitioners in our country is low.
Table 4. What can be done to reduce the frequency of delirium?
| Which of the following measures to prevent the development of delirium? a | Awareness | Performed |
|---|---|---|
| Modifying factors that contribute to the development of delirium | 19 (100) | 19 (100) |
| Maintaining a normal sleep–wake cycle | 19 (100) | 12 (63.2) |
| Staying with the child's loved one | 16 (84.2) | 11 (57.9) |
| Using eye patch | 8 (42.1) | 5 (26.3) |
| Using earpiece | 8 (42.1) | 1 (5.3) |
| Reducing noise pollution by the use of noise measuring devices | 15 (78.9) | 4 (21.1) |
| Using dim light at night | 18 (94.7) | 16 (84.2) |
| Optimizing sedation goals | 17 (89.5) | 16 (84.2) |
| Reducing immobilization | 17 (89.5) | 10 (52.6) |
| Encouraging early physical therapy | 11 (57.9) | 13 (68.4) |
| Limiting the use of antibiotics | 1 (5.3) | 2 (10.5) |
| Implementing an analgosedation approach | 16 (84.2) | 13 (68.4) |
| Setting an oxygen saturation target of 95% and above | 3 (15.8) | 3 (15.8) |
| Correcting anemia, transfusing if necessary | 5 (26.3) | 4 (21.1) |
| Improving metabolic disturbances (especially electrolytes) | 8 (42.1) | 6 (31.6) |
| Starting benzodiazepine infusion or increasing the current dose | 3 (15.8) | 2 (10.5) |
| Avoiding dexmedetomidine infusion | 1 (5.3) | 1 (5.3) |
| Avoiding anticholinergic drug use | 1 (5.3) | 1 (5.3) |
Multiple options can be selected.
Yet, no medications have been approved by the Food and Drug Administration for use in the prevention and treatment of delirium in children. However, drugs that can be used in certain situations provide a decline in delirium findings and support brain functions. In the literature, experiences with beneficial use of haloperidol, atypical antipsychotics (such as risperidone, olanzapine, quetiapine, and ziprasidone), melatonin, dexmedetomidine, and clonidine have been shared. 21 23 24 25 26 27 28 29 30
In our study, more pharmacological and nonpharmacological treatments were applied in the tertiary than in the secondary level PICUs ( p = 0.044). In addition, as the number of nurses per patient increased, there was a significant increase in the frequency of treatment ( p = 0.03). Nonpharmacological interventions and the use of haloperidol and dexmedetomidine were the common treatment methods used by the units. However, almost half of the units used benzodiazepines. Thus, awareness of this inappropriate treatment method must be increased. In addition, frequent use of pharmacological and nonpharmacological treatments in tertiary PICUs indicate the high levels of awareness in these units in terms of the treatment of delirium.
In conclusion, some units have reached a sufficient level of pediatric delirium awareness and management. However, overall insufficiencies in both aspects remain. We believe that the success rate of delirium management can increase with the implementation of a well-designed protocol by the units. We planned to create a delirium diagnosis and treatment protocol to be applied in our clinic.
Funding Statement
Funding None.
Conflict of Interest None declared.
Authors' Contributions
C.K., A.B.A., and D.L. supported in literature search. C.K., M.A., and E.P.K. carried out data collection. C.K. and A.B.A. performed study design and review of manuscript. C.K. and M.T. involved in analysis of data. C.K. dedicated in manuscript preparation.
References
- 1.Dechnik A, Traube C. Delirium in hospitalised children. Lancet Child Adolesc Health. 2020;4(04):312–321. doi: 10.1016/S2352-4642(19)30377-3. [DOI] [PubMed] [Google Scholar]
- 2.Traube C, Silver G, Reeder R W. Delirium in critically ill children: an international point prevalence study. Crit Care Med. 2017;45(04):584–590. doi: 10.1097/CCM.0000000000002250. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Patel A K, Bell M J, Traube C. Delirium in pediatric critical care. Pediatr Clin North Am. 2017;64(05):1117–1132. doi: 10.1016/j.pcl.2017.06.009. [DOI] [PubMed] [Google Scholar]
- 4.Bettencourt A, Mullen J E. Delirium in children: identification, prevention, and management. Crit Care Nurse. 2017;37(03):e9–e18. doi: 10.4037/ccn2017692. [DOI] [PubMed] [Google Scholar]
- 5.Smith H A, Berutti T, Brink E. Pediatric critical care perceptions on analgesia, sedation, and delirium. Semin Respir Crit Care Med. 2013;34(02):244–261. doi: 10.1055/s-0033-1342987. [DOI] [PubMed] [Google Scholar]
- 6.McGetrick M E, Lach C, Mullen J E, Munoz-Pareja J C. Assessing nursing and pediatric resident understanding of delirium in the pediatric intensive care unit. Crit Care Nurs Clin North Am. 2019;31(04):481–488. doi: 10.1016/j.cnc.2019.07.003. [DOI] [PubMed] [Google Scholar]
- 7.Kudchadkar S R, Yaster M, Punjabi N M. Sedation, sleep promotion, and delirium screening practices in the care of mechanically ventilated children: a wake-up call for the pediatric critical care community. Crit Care Med. 2014;42(07):1592–1600. doi: 10.1097/CCM.0000000000000326. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Gokmen N, Iyilikci L, Kucukguclu S.Approaches of Turkish anesthesiologists to delirium observed in intensive care unit patients Crit Care 20071141817626610 [Google Scholar]
- 9.Traube C, Silver G, Gerber L M. Delirium and mortality in critically ill children: epidemiology and outcomes of pediatric delirium. Crit Care Med. 2017;45(05):891–898. doi: 10.1097/CCM.0000000000002324. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Sedation Withdrawal and Analgesia Team, and the Canadian Critical Care Trials Group . Garcia Guerra G, Joffe A R, Cave D. Survey of sedation and analgesia practice among canadian pediatric critical care physicians. Pediatr Crit Care Med. 2016;17(09):823–830. doi: 10.1097/PCC.0000000000000864. [DOI] [PubMed] [Google Scholar]
- 11.Meagher D J, O'Hanlon D, O'Mahony E, Casey P R, Trzepacz P T. Relationship between symptoms and motoric subtype of delirium. J Neuropsychiatry Clin Neurosci. 2000;12(01):51–56. doi: 10.1176/jnp.12.1.51. [DOI] [PubMed] [Google Scholar]
- 12.American Psychiatric Association ; Diagnostic and Statistical Manual of Mental Disorders . 5th edition. Washington: American Psychiatric Association; 2013. [Google Scholar]
- 13.Traube C, Greenwald B M. “The times they are a-changin”: universal delirium screening in pediatric critical care. Pediatr Crit Care Med. 2017;18(06):594–595. doi: 10.1097/PCC.0000000000001142. [DOI] [PubMed] [Google Scholar]
- 14.Sikich N, Lerman J. Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale. Anesthesiology. 2004;100(05):1138–1145. doi: 10.1097/00000542-200405000-00015. [DOI] [PubMed] [Google Scholar]
- 15.Traube C, Silver G, Kearney J. Cornell assessment of pediatric delirium: a valid, rapid, observational tool for screening delirium in the PICU. Crit Care Med. 2014;42(03):656–663. doi: 10.1097/CCM.0b013e3182a66b76. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Harris J, Ramelet A-S, van Dijk M. Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals. Intensive Care Med. 2016;42(06):972–986. doi: 10.1007/s00134-016-4344-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Van Tuijl S G, Van Cauteren Y J, Pikhard T, Engel M, Schieveld J N. Management of pediatric delirium in critical illness: a practical update. Minerva Anestesiol. 2015;81(03):333–341. [PubMed] [Google Scholar]
- 18.American College of Critical Care Medicine . Barr J, Fraser G L, Puntillo K. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(01):263–306. doi: 10.1097/CCM.0b013e3182783b72. [DOI] [PubMed] [Google Scholar]
- 19.Silver G, Traube C, Gerber L M. Pediatric delirium and associated risk factors: a single-center prospective observational study. Pediatr Crit Care Med. 2015;16(04):303–309. doi: 10.1097/PCC.0000000000000356. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Inouye S K, Bogardus S T, Jr, Charpentier P A. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340(09):669–676. doi: 10.1056/NEJM199903043400901. [DOI] [PubMed] [Google Scholar]
- 21.Hatherill S, Flisher A J, Nassen R. The diagnosis and treatment of delirium in children. J Child Adolesc Ment Health. 2009;21(02):157–165. doi: 10.2989/JCAMH.2009.21.2.7.1015. [DOI] [PubMed] [Google Scholar]
- 22.Kudchadkar S R, Aljohani O A, Punjabi N M. Sleep of critically ill children in the pediatric intensive care unit: a systematic review. Sleep Med Rev. 2014;18(02):103–110. doi: 10.1016/j.smrv.2013.02.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Turkel S B, Hanft A. The pharmacologic management of delirium in children and adolescents. Paediatr Drugs. 2014;16(04):267–274. doi: 10.1007/s40272-014-0078-0. [DOI] [PubMed] [Google Scholar]
- 24.Turkel S B, Jacobson J, Munzig E, Tavaré C J. Atypical antipsychotic medications to control symptoms of delirium in children and adolescents. J Child Adolesc Psychopharmacol. 2012;22(02):126–130. doi: 10.1089/cap.2011.0084. [DOI] [PubMed] [Google Scholar]
- 25.Wang H R, Woo Y S, Bahk W M. Atypical antipsychotics in the treatment of delirium. Psychiatry Clin Neurosci. 2013;67(05):323–331. doi: 10.1111/pcn.12066. [DOI] [PubMed] [Google Scholar]
- 26.Marseglia L, D'Angelo G, Manti S. Analgesic, anxiolytic and anaesthetic effects of melatonin: new potential uses in pediatrics. Int J Mol Sci. 2015;16(01):1209–1220. doi: 10.3390/ijms16011209. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Carrasco G, Baeza N, Cabré L. Dexmedetomidine for the treatment of hyperactive delirium refractory to haloperidol in nonintubated ICU patients: a nonrandomized controlled trial. Crit Care Med. 2016;44(07):1295–1306. doi: 10.1097/CCM.0000000000001622. [DOI] [PubMed] [Google Scholar]
- 28.SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group . Riker R R, Shehabi Y, Bokesch P M. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009;301(05):489–499. doi: 10.1001/jama.2009.56. [DOI] [PubMed] [Google Scholar]
- 29.Jiang L, Ding S, Yan H. A retrospective comparison of dexmedetomidine versus midazolam for pediatric patients with congenital heart disease requiring postoperative sedation. Pediatr Cardiol. 2015;36(05):993–999. doi: 10.1007/s00246-015-1110-z. [DOI] [PubMed] [Google Scholar]
- 30.Malviya S, Voepel-Lewis T, Ramamurthi R J, Burke C, Tait A R. Clonidine for the prevention of emergence agitation in young children: efficacy and recovery profile. Paediatr Anaesth. 2006;16(05):554–559. doi: 10.1111/j.1460-9592.2006.01818.x. [DOI] [PubMed] [Google Scholar]