A Delirium Prevention and Management Initiative: Implementing a Best Practice Recommendation for the NICU.
Neonatal network : NN
Medically complex infants experiencing NICU stays can be difficult to manage, exhibiting refractory agitation, disengagement, or both-all signs of delirium, which can present in a hypoactive, hyperactive, or mixed form. Though documented in other settings, delirium is under-recognized in NICUs. Pediatric studies show that a high percentage of patients with delirium are under the age of 12 months. Delirium is associated with increased ventilation days, hospital days, and costs. It negatively affects neurodevelopment and social interaction. Studies show that pediatric nurses are unprepared to recognize delirium. Our nurse-led multidisciplinary group created a best practice recommendation (BPR) focused on detecting delirium and minimizing risk through thoughtful sedation management, promotion of sleep hygiene and mobility, and facilitation of meaningful caregiver presence. Occasionally, medications, including melatonin and risperidone, are helpful. In 2019, we introduced this BPR to reduce delirium risk in our NICU. Practice changes tied to this initiative correlate with a significant reduction in delirium scores and risk including exposure to deliriogenic medications. A multidisciplinary care bundle correlates with decreased delirium screening scores in NICU patients.
10.1891/NN-2023-0041
Recent advances in multidisciplinary critical care.
Blot Stijn,Afonso Elsa,Labeau Sonia
American journal of critical care : an official publication, American Association of Critical-Care Nurses
The intensive care unit is a work environment where superior dedication is crucial for optimizing patients' outcomes. As this demanding commitment is multidisciplinary in nature, it requires special qualities of health care workers and organizations. Thus research in the field covers a broad spectrum of activities necessary to deliver cutting-edge care. However, given the numerous research articles and education activities available, it is difficult for modern critical care clinicians to keep up with the latest progress and innovation in the field. This article broadly summarizes new developments in multidisciplinary intensive care. It provides elementary information about advanced insights in the field via brief descriptions of selected articles grouped by specific topics. Issues considered include care for heart patients, mechanical ventilation, delirium, nutrition, pressure ulcers, early mobility, infection prevention, transplantation and organ donation, care for caregivers, and family matters.
10.4037/ajcc2015321
Nursing experiences and knowledge of paediatric delirium: Analysing knowledge-practice gaps.
Nursing in critical care
BACKGROUND:Delirium commonly occurs in paediatric patients with acute critical illness and negatively affects clinical outcomes. Variations in delirium knowledge levels and its management have been noted among nurses. AIMS:This study investigated nurses' experiences and knowledge levels regarding paediatric delirium. Additionally, we aimed to assess the gap between knowledge levels and practical experiences with paediatric delirium. STUDY DESIGN:This cross-sectional descriptive study conveniently sampled paediatric nurses from a university hospital in South Korea between September 2022 and March 2023. Nursing experiences with paediatric delirium and delirium knowledge levels were measured using structured survey questionnaires. Delirium knowledge was scored 0 to 47, and higher scores indicated higher levels of delirium-related knowledge. Data were analysed using descriptive statistics and presented as mean, standard deviation, frequency and percentage. RESULTS:A total of 127 paediatric nurses participated in this study; 40.2% had experience with 1-5 delirium cases in the previous year, and 86.6% (n = 110) had never used assessment tools for paediatric delirium assessment. The mean total delirium knowledge score was 34.45 ± 5.4; the mean scores of knowledge regarding aetiology, signs and symptoms and nursing management of delirium were 8.93 ± 1.31, 13.24 ± 2.81 and 12.3 ± 2.7, respectively. Interventions associated with a lower level of delirium-related knowledge and a lower performance rate included avoiding restraint use and maintaining hydration and electrolyte levels. Interventions associated with a higher level of delirium-related knowledge but a lower rate of performance comprised providing orientation, offering emotional support, allowing participants to stay with family members and administering medications to manage delirium. CONCLUSIONS:Although nurses working in paediatric units exhibited high rate of delirium nursing care, there was the gap between their delirium-related knowledge and practice. Nurses need to be aware of the insufficient part of delirium care, and paediatric delirium education should be reinforced. RELEVANCE TO CLINICAL PRACTICE:Preventing, assessing and systematically managing paediatric delirium is crucial, and considering the study results, delirium education among nurses is needed.
10.1111/nicc.13068
Delirium is a Common and Early Finding in Patients in the Pediatric Cardiac Intensive Care Unit.
Alvarez Rita V,Palmer Claire,Czaja Angela S,Peyton Chris,Silver Gabrielle,Traube Chani,Mourani Peter M,Kaufman Jon
The Journal of pediatrics
OBJECTIVE:To determine incidence, associated risk factors, and characteristics of delirium in a pediatric cardiac intensive care unit (CICU). Delirium is a frequent and serious complication in adults after cardiac surgery, but there is limited understanding of its impact in children with critical cardiac disease. STUDY DESIGN:Single-center prospective observational study of CICU patients ≤21 years old. All were screened for delirium using the Cornell Assessment for Pediatric Delirium each 12-hour shift. RESULTS:Ninety-nine patients were included. Incidence of delirium was 57%. Median time to development of delirium was 1 day (95% CI 0, 1 days). Children with delirium were younger (geometric mean age 4 vs 46 months; P < .001), had longer periods of mechanical ventilation (mean 35.9 vs 8.8 hours; P = .002) and had longer cardiopulmonary bypass times (geometric mean 126 vs 81 minutes; P = .001). Delirious patients had longer length of CICU stay than those without delirium (median 3 (IQR 2, 12.5) vs 1 (IQR1, 2) days; P < .0001). A multivariable generalized linear mixed model showed a significant association between delirium and younger age (OR 0.35 for each additional month, 95% CI 0.19, 0.64), need for mechanical ventilation (OR 4.1, 95% CI 1.7, 9.89), and receipt of benzodiazepines (OR 3.78, 95% CI 1.46, 9.79). CONCLUSIONS:Delirium is common in patients in the pediatric CICU and is associated with longer length of stay. There may be opportunities for prevention of delirium by targeting modifiable risk factors, such as use of benzodiazepines.
10.1016/j.jpeds.2017.11.064
Infants with Delirium: A Primer on Prevention, Recognition, and Management.
Porter Sallie,Holly Cheryl,Echevarria Mercedes
Pediatric nursing
Delirium is a serious neuropsychiatric condition that emerges acutely in all age groups, including infants, children, and adolescents. Delirium serves as an urgent signal of distress that a young child’s brain is in trouble. Prevention, recognition, and management of infants with delirium is often especially challenging due to their pre-verbal status and still immature cognitive development. This article presents an overview of delirium in infants, offers details regarding the presentation of delirium in infants, discusses the challenges to screening and identification of infants with delirium, and provides evidence-based suggestions for pediatric nurses to optimize nursing care for infants at risk for or exhibiting delirium.
Recognition and Management of Delirium in the Neonatal Intensive Care Unit: Case Series From a Single-Center Level IV Intensive Care Unit.
Journal of child neurology
Delirium often goes unrecognized in neonates and children because of lack of experience in evaluating behavior and cognition, insufficient awareness of the prevalence, and nondistinctive symptoms in this population. Although there are increasing reports of the presence of delirium in neonates, there are little data to guide the pharmacologic treatment in this population. In this retrospective single-center case series, we present our experience using quetiapine to treat delirium in 9 medically complex neonates. Based on an extensive literature review, expert opinion, and institutional experience, we propose an approach for monitoring and treating delirium in neonates and infants.
10.1177/08830738241246693
Severe irritability in a critically ill preterm infant: a case of delirium at the neonatal intensive care unit.
Dementia & neuropsychologia
Delirium is a common disorder in intensive care units, being associated with greater morbidity and mortality. However, in neonatal intensive care units, delirium is rarely diagnosed, due to the low familiarity of the neonatologist with the subject and the difficulties in the applicability of diagnostic questionnaires. This case report aimed to assess the presence of this disorder in this group of patients and identify the difficulties encountered in the diagnosis and treatment. We report the case of a premature newborn with necrotizing enterocolitis during hospitalization and underwent three surgical approaches. The newborn exhibited intense irritability, having received high doses of fentanyl, dexmedetomidine, clonidine, ketamine, phenytoin, and methadone, without the control of the symptoms. A diagnosis of delirium was then made and treatment with quetiapine was started, with a complete reversal of the symptoms. This is the first case reported in Brazil and the first describing the withdrawal of the quetiapine.
10.1590/1980-5764-DN-2022-0046
Detection and Management of Delirium in the Neonatal Unit: A Case Series.
Groves Alan,Traube Chani,Silver Gabrielle
Pediatrics
Delirium is increasingly recognized as a common syndrome in critically ill children, but in our experience, it is rarely considered in the NICU. Delirium is independently associated with prolonged length of stay and adverse long-term outcomes in children. We report the cases of 3 infants cared for in our NICU at corrected gestational ages of 4, 11, and 17 weeks who presented with classic symptoms of delirium. All 3 children had complex medical problems and were receiving multiple analgesic and sedative medications. All 3 children exhibited agitation that was unresponsive to increasing doses of medications, and they all appeared to improve after treatment with quetiapine, allowing weaning of other medications. It is possible that with increased vigilance, delirium will be increasingly recognized in newborns, thus allowing tailored intervention. Further research is needed to investigate the prevalence and associated risk factors for developing delirium in the NICU and to explore possible treatment options.
10.1542/peds.2015-3369
Delirium in the NICU: A Point Prevalence Study.
Siegel Elana J,Groves Alan M,Silver Gabrielle,Hojsak Joanne,Lim C Anthoney,Traube Chani
Hospital pediatrics
OBJECTIVES:Delirium is a well-described complication of critical illness, with occurrence rates of >25% in the PICU, and associated morbidity. Infants in the NICU are likely at risk. There have been no previous screening studies to quantify delirium rates in the neonatal population. We hypothesized that delirium was prevalent in term neonates in the NICU. In this pilot study, our objective was to estimate prevalence using a validated pediatric delirium screening tool, which has not yet been tested in NICUs. METHODS:In this point prevalence study, all term or term-corrected infants admitted to the NICU on designated study days were screened for delirium using the Cornell Assessment of Pediatric Delirium. RESULTS:A total of 149 infants were eligible for screening over 8 study days. A total of 147 (98.6%) were successfully screened with the Cornell Assessment of Pediatric Delirium. Overall, 22.4% ( = 33) screened positive for delirium. Delirium was more commonly detected in children on invasive mechanical ventilation (67% vs 17%, < .01) and those with underlying neurologic disorders (64% vs 13%, < .01). A multivariate logistic regression revealed that neurologic disability and mechanical ventilation were both independently associated with a positive delirium screen (aOR: 12.3, CI: 4.5-33.6 and aOR: 9.3, CI: 2.5-34.6, respectively). CONCLUSIONS:Our results indicate that delirium likely occurs frequently in term-equivalent infants in the NICU. Further research is necessary to establish feasibility, validity, and interrater reliability of delirium screening in this population.
10.1542/hpeds.2020-005736
Delirium in the NICU: Risk or Reality?
Liviskie Caren,McPherson Christopher
Neonatal network : NN
Delirium is a frequent complication of critical illness in adult and pediatric populations and is associated with significant morbidity and mortality. Little is known about the incidence, risk, symptoms, or treatment of delirium in the NICU. Only 4 cases of NICU delirium have been reported, but many pediatric studies include infants. The Cornell Assessment of Pediatric Delirium tool has been validated in neonatal and infant populations for identification of delirium. Initial treatment should focus on identification and reversal of the cause, with pharmacologic management reserved for patients with symptoms that do not resolve or that significantly impact medical care. Routine use of intravenous haloperidol should be avoided because of the high incidence of serious adverse effects, but it may be considered in patients with significant symptoms who are unable to take oral medications. Atypical antipsychotics (olanzapine, quetiapine, and risperidone) appear to be efficacious with a low incidence of adverse effects. Risperidone has weight-based dosing and a liquid dosage form available, making it a good option for use in the NICU. Additional data from large cohorts of NICU patients routinely screened for delirium, and treated as indicated, are needed.
10.1891/0730-0832/11-T-727
Non-pharmacological interventions to prevent and manage delirium in critically ill children in neonatal and paediatric intensive care units (NICU/PICU): a scoping review protocol.
BMJ open
INTRODUCTION:Delirium is one of the most common forms of acute cerebral dysfunction in critically ill children leading to increased morbidity and mortality. Prevention, identification and management of delirium is an important part of paediatric and neonatological intensive care. This scoping review aims to identify and map evidence on non-pharmacological interventions for paediatric delirium prevention and management in paediatric and neonatal intensive care settings. METHODS AND ANALYSIS:This scoping review will be conducted according to the Joanna Briggs Institute methodology for scoping reviews and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Searches will be performed in the databases Medline (via PubMed), CINAHL, Cochrane Library, Ovid (Journals), EMBASE and Web of Science (01/2000-current). Two reviewers will independently review retrieved studies, and relevant information will be extracted using data extraction forms. The results will be presented in tabular format and accompanied by a narrative summary. INCLUSION CRITERIA:The review will include references that describe or evaluate non-pharmacological interventions to prevent or manage paediatric delirium. Conference abstracts, editorials, opinion papers and grey literature will be excluded. ETHICS AND DISSEMINATION:Due to the nature of research involving humans or unpublished secondary data, approval of an ethics committee are not required. The dissemination of findings is planned via professional networks and publication in an open-access scientific journal.
10.1136/bmjopen-2023-073883
Cornell Assessment of Pediatric Delirium: a valid, rapid, observational tool for screening delirium in the PICU*.
Traube Chani,Silver Gabrielle,Kearney Julia,Patel Anita,Atkinson Thomas M,Yoon Margaret J,Halpert Sari,Augenstein Julie,Sickles Laura E,Li Chunshan,Greenwald Bruce
Critical care medicine
OBJECTIVE:To determine validity and reliability of the Cornell Assessment of Pediatric Delirium, a rapid observational screening tool. DESIGN:Double-blinded assessments were performed with the Cornell Assessment of Pediatric Delirium completed by nursing staff in the PICU. These ratings were compared with an assessment by consultation liaison child psychiatrist using the Diagnostic and Statistical Manual IV criteria as the "gold standard" for diagnosis of delirium. An initial series of duplicate Cornell Assessment of Pediatric Delirium assessments were performed in blinded fashion to assess interrater reliability. Nurses recorded the time required to complete the Cornell Assessment of Pediatric Delirium screen. SETTING:Twenty-bed general PICU in a major urban academic medical center over a 10-week period, March-May 2012. PATIENTS:One hundred eleven patients stratified over ages ranging from 0 to 21 years and across developmental levels. INTERVENTION:Two hundred forty-eight paired assessments completed. MEASUREMENTS AND MAIN RESULTS:The Cornell Assessment of Pediatric Delirium had an overall sensitivity of 94.1% (95% CI, 83.8-98.8%) and specificity of 79.2% (95% CI, 73.5-84.9%). Overall Cronbach's α of 0.90 was observed, with a range of 0.87-0.90 for each of the eight items, indicating good internal consistency. A scoring cut point of 9 demonstrated good interrater reliability of the Cornell Assessment of Pediatric Delirium when comparing results of the screen between nurses (overall κ = 0.94; item range κ = 0.68-0.78). In patients without significant developmental delay, sensitivity was 92.0% (95% CI, 85.7-98.3%) and specificity was 86.5% (95% CI, 75.4-97.6%). In developmentally delayed children, the Cornell Assessment of Pediatric Delirium showed decreased specificity of 51.2% (95% CI, 24.7-77.8%) but sensitivity remained high at 96.2% (95% CI, 86.5-100%). The Cornell Assessment of Pediatric Delirium takes less than 2 minutes to complete. CONCLUSIONS:With an overall prevalence rate of 20.6% in our study population, delirium is a common problem in pediatric critical care. The Cornell Assessment of Pediatric Delirium is a valid, rapid, observational nursing screen that is urgently needed for the detection of delirium in PICU settings.
10.1097/CCM.0b013e3182a66b76
Delirium in the NICU.
Journal of perinatology : official journal of the California Perinatal Association
Delirium in the NICU is an underrecognized phenomenon in infants who are often complex and critically ill. The current understanding of NICU delirium is developing and can be informed by adult and pediatric literature. The NICU population faces many potential risk factors for delirium, including young age, developmental delay, mechanical ventilation, severe illness, and surgery. There are no diagnostic tools specific to infants. The mainstay of delirium treatment is to treat the underlying cause, address modifiable risk factors, and supportive care. This review will summarize current knowledge and areas where more research is needed.
10.1038/s41372-023-01767-5
Delirium in the Neonate.
Clinics in perinatology
Delirium is likely present in the neonatal intensive care unit and has been largely unrecognized. There are several risk factors for delirium including illness severity, neurosedative exposure, and environmental disruptions that put infants at risk for delirium. Regular use of scoring systems should be considered to improve delirium detection. When identified, initial steps in management should include resolving underlying causes and implementation of standard nonpharmacologic measures. Mounting pediatric evidence suggests that the atypical antipsychotics, as well as the α-2 agonists, may be additionally beneficial in treating delirium as well as improving the ability to wean off other neurosedative medications.
10.1016/j.clp.2021.11.001