Delirium in Critically Ill Children: An International Point Prevalence Study. (Carroll)

Traube C, Silver G, Reeder RW, et al. Delirium in Critically Ill Children: An International Point Prevalence Study. Crit Care Med. 2017 Apr; 45(4) :584-590.

OBJECTIVES: To determine prevalence of delirium in critically ill children and explore associated risk factors.

DESIGN: Multi-institutional point prevalence study.

SETTING: Twenty-five pediatric critical care units in the United States, the Netherlands, New Zealand, Australia, and Saudi Arabia.

PATIENTS: All children admitted to the pediatric critical care units on designated study days (n = 994).

INTERVENTION: Children were screened for delirium using the Cornell Assessment of Pediatric Delirium by the bedside nurse. Demographic and treatment-related variables were collected.

MEASUREMENTS AND MAIN RESULTS: Primary study outcome measure was prevalence of delirium. In 159 children, a final determination of mental status could not be ascertained. Of the 835 remaining subjects, 25% screened positive for delirium, 13% were classified as comatose, and 62% were delirium-free and coma-free. Delirium prevalence rates varied significantly with reason for ICU admission, with highest delirium rates found in children admitted with an infectious or inflammatory disorder. For children who were in the PICU for 6 or more days, delirium prevalence rate was 38%. In a multivariate model, risk factors independently associated with development of delirium included age less than 2 years, mechanical ventilation, benzodiazepines, narcotics, use of physical restraints, and exposure to vasopressors and antiepileptics.

CONCLUSIONS: Delirium is a prevalent complication of critical illness in children, with identifiable risk factors. Further multi-institutional, longitudinal studies are required to investigate effect of delirium on long-term outcomes and possible preventive and treatment measures. Universal delirium screening is practical and can be implemented in pediatric critical care units.

Improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospital… (Betters)

Barnes-Daly MA, Phillips G, Ely EW. Improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospitals: Implementing PAD Guidelines Via the ABCDEF Bundle in 6,064 Patients. Crit Care Med. 2017 Feb; 45(2):171-178.

OBJECTIVES: To track compliance by an interprofessional team with the Awakening and Breathing Coordination, Choice of drugs, Delirium monitoring and management, Early mobility, and Family engagement (ABCDEF) bundle in implementing the Pain, Agitation, and Delirium guidelines. The aim was to study the association between ABCDEF bundle compliance and outcomes including hospital survival and delirium-free and coma-free days in community hospitals.

DESIGN: A prospective cohort quality improvement initiative involving ICU patients.

SETTING: Seven community hospitals within California’s Sutter Health System.

PATIENTS: Ventilated and nonventilated general medical and surgical ICU patients enrolled between January 1, 2014, and December 31, 2014.

MEASUREMENTS AND MAIN RESULTS: Total and partial bundle compliance were measured daily. Random effects regression was used to determine the association between ABCDEF bundle compliance accounting for total compliance (all or none) or for partial compliance (“dose” or number of bundle elements used) and outcomes of hospital survival and delirium-free and coma-free days, after adjusting for age, severity of illness, and presence of mechanical ventilation. Of 6,064 patients, a total of 586 (9.7%) died before hospital discharge. For every 10% increase in total bundle compliance, patients had a 7% higher odds of hospital survival (odds ratio, 1.07; 95% CI, 1.04-1.11; p < 0.001). Likewise, for every 10% increase in partial bundle compliance, patients had a 15% higher hospital survival (odds ratio, 1.15; 95% CI, 1.09-1.22; p < 0.001). These results were even more striking (12% and 23% higher odds of survival per 10% increase in bundle compliance, respectively, p < 0.001) in a sensitivity analysis removing ICU patients identified as receiving palliative care. Patients experienced more days alive and free of delirium and coma with both total bundle compliance (incident rate ratio, 1.02; 95% CI, 1.01-1.04; p = 0.004) and partial bundle compliance (incident rate ratio, 1.15; 95% CI, 1.09-1.22; p < 0.001).

CONCLUSIONS: The evidence-based ABCDEF bundle was successfully implemented in seven community hospital ICUs using an interprofessional team model to operationalize the Pain, Agitation, and Delirium guidelines. Higher bundle compliance was independently associated with improved survival and more days free of delirium and coma after adjusting for age, severity of illness, and presence of mechanical ventilation.

Patterns of Postoperative Delirium in Children. (Emrath)

Meyburg J, et al. Patterns of Postoperative Delirium in Children. Pediatr Crit Care Med. 2016 Oct 21. [Epub ahead of print]

OBJECTIVE: Intensive care delirium is a substantial problem in adults. Intensive care delirium is increasingly recognized in pediatrics in parallel with the development of specific scoring systems for children. However, little is known about the fluctuating course of intensive care delirium in children after surgery and possible implications on diagnostic and therapeutic strategies.

DESIGN: Patients that needed treatment in the PICU following elective surgery were screened for intensive care delirium with the Cornell Assessment of Pediatric Delirium. When the patients were awake (Richmond Agitation and Sedation Score > -3), two trained investigators conducted the Cornell Assessment of Pediatric Delirium twice daily for five consecutive days.

PATIENTS: Ninety-three patients aged 0 to 17 years.

INTERVENTIONS: Eight hundred forty-five assessments completed.

MEASUREMENTS AND MAIN RESULTS: Of the 845 scores, 230 were consistent with delirium (27.2%). Sixty-one patients (65.5%) were diagnosed with intensive care delirium. Half of these patients (n = 30; 32.2%) had a short-lasting delirium that resolved within 24 hours, and half (n = 31; 33.3%) had delirium of longer duration. Delirium could be clearly distinguished from sedation by analysis of individual test items of the Cornell Assessment of Pediatric Delirium. Time spent delirious had a measurable effect on outcome variables, including hospital length of stay.

CONCLUSION: Most postoperative PICU patients develop intensive care delirium. Some have a short-lasting course, which underlines the need for early screening. Our findings support the view of delirium as a continuum of acute neurocognitive disorder. Further research is needed to investigate prophylactic and treatment approaches for intensive care delirium.

Validity of Different Delirium Assessment Tools for Critically Ill Children: Covariates Matter. (Patel)

Luetz A, et al. Validity of Different Delirium Assessment Tools for Critically Ill Children: Covariates Matter. Crit Care Med. 2016 Nov; 44(11):2060-2069.

OBJECTIVES: To evaluate test validity of the Pediatric Confusion Assessment Method for the ICU, the Pediatric Anesthesia Emergence Delirium scale, and the newly developed severity scale for the Pediatric Confusion Assessment Method for the ICU; to prospectively assess covariates and their influence on test validity of the scores.

DESIGN: Prospective observational cohort study.

SETTING: PICU of a tertiary care medical center.

PATIENTS: Critically ill patients 5 years old or older ventilated or nonventilated with an ICU length of stay of at least 24 hours.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Patients were scored with the Pediatric Confusion Assessment Method for the ICU and the Pediatric Anesthesia Emergence Delirium scale once daily for a maximum of 21 days. Validity was determined by comparing scoring results with the evaluations of the delirium experts who used the criteria of the Diagnostic and Statistical Manual, 4th Edition, Text Revision, for delirium diagnosis. Sixty-four patients were enrolled and 214 assessments were conducted and included in data analysis. The first assessments within each patient revealed sensitivities of 69.2% for the Pediatric Anesthesia Emergence Delirium scale, 76.9% for the Pediatric Confusion Assessment Method for the ICU, and 84.9% for the severity scale for the Pediatric Confusion Assessment Method for the ICU. Specificities were 98% for all scores. Considering repeated measurements, sensitivities decreased to 35.9% for the Pediatric Anesthesia Emergence Delirium scale and to 52.3% for the Pediatric Confusion Assessment Method for the ICU. The sensitivity of the severity scale for the Pediatric Confusion Assessment Method for the ICU dropped to 71.8%, which was significantly higher compared to the Pediatric Anesthesia Emergence Delirium scale (p = 0.0008). Receiver operator characteristic regression unveiled that sedation and mechanical ventilation had a significant negative effect on the validity of the Pediatric Anesthesia Emergence Delirium scale and the severity scale for the Pediatric Confusion Assessment Method for the ICU. Age and gender had a significant impact on the receiver operator characteristic curve of the severity scale for the Pediatric Confusion Assessment Method for the ICU.

CONCLUSIONS: The severity scale for the Pediatric Confusion Assessment Method for the ICU showed the best test validity when used in critically ill children of 5 years old or older. Nevertheless, validity of delirium screening itself depends on patient specific factors. These factors should be taken into consideration when choosing a delirium screening instrument.