Overview
Definition:
Pediatric delirium is an acute, fluctuating disturbance of consciousness characterized by inattention, altered cognition, and perceptual disturbances
In the Pediatric Intensive Care Unit (PICU), it is a common yet often unrecognized complication impacting critically ill children.
Epidemiology:
The prevalence of delirium in PICU settings ranges widely, from 10% to over 60% in various studies, depending on the population and diagnostic tools used
Risk factors include younger age, sedation, mechanical ventilation, use of benzodiazepines and opioids, underlying neurological conditions, and prolonged PICU stay.
Clinical Significance:
Pediatric delirium is associated with prolonged mechanical ventilation, increased ICU length of stay, higher rates of reintubation, impaired long-term neurocognitive outcomes, and increased mortality
Early recognition and intervention are crucial for improving patient outcomes and reducing healthcare costs.
Screening And Diagnosis
Screening Tools:
Validated pediatric delirium screening tools are essential
Examples include the Cornell Assessment to Identify Delirium (CASE) for younger children and the Pediatric Confusion Assessment Method for the ICU (pCAM-ICU) for older children and adolescents
These tools assess attention, arousal, and cognition.
Assessment Approach:
A systematic approach is vital
Start with assessing level of consciousness (using scales like the Full Outline of Unresponsiveness or Pediatric Glasgow Coma Scale)
Then, screen for inattention and cognitive changes
Observe for fluctuations in mental status throughout the shift.
Clinical Features:
Symptoms can be hyperactive (agitation, hallucinations), hypoactive (lethargy, somnolence), or mixed
Children may exhibit irritability, confusion, disorientation, visual or auditory hallucinations, or a decreased ability to interact with their environment
The presentation can be subtle and may mimic sedation.
Diagnostic Criteria:
Diagnosis relies on established criteria like the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
Key elements include an acute onset and fluctuating course, inattention, and either an altered level of consciousness or a change in cognition not better explained by another neurocognitive disorder.
Risk Factors And Prevention
Modifiable Risk Factors:
Key modifiable factors include minimizing sedative and analgesic exposure, implementing early mobilization and physical therapy, ensuring adequate sleep hygiene (dim lights at night, minimize noise), encouraging family presence and interaction, and managing pain effectively.
Non Modifiable Risk Factors:
While age and underlying critical illness are non-modifiable, awareness of these factors aids in heightened vigilance for delirium
Pre-existing developmental delays or neurological impairments also increase susceptibility.
Preventive Strategies:
Implement a multidisciplinary delirium prevention protocol
This includes regular neurological assessments, pain management optimization, sedation reduction protocols (e.g., daily interruption of sedation), early mobilization, promoting sleep, and minimizing environmental stressors
Family involvement is paramount.
Pharmacological Considerations:
Avoid benzodiazepines and other sedatives where possible
If sedation is necessary, use agents with shorter half-lives (e.g., propofol, dexmedetomidine)
Opioid use should be carefully titrated and monitored
Antipsychotics are generally not recommended for routine prevention but may be considered in select cases of severe agitation refractory to other measures.
Management Of Delirium
Underlying Cause Identification:
The first step in management is to identify and treat any underlying precipitants of delirium, such as infection, metabolic derangements (hypoglycemia, electrolyte imbalances), hypoxia, medication effects, or withdrawal syndromes.
Pharmacological Treatment:
While avoiding causative agents is primary, pharmacological treatment is reserved for severe symptoms that pose a risk to the patient or staff
Antipsychotics like haloperidol or atypical antipsychotics (e.g., risperidone, olanzapine) may be used cautiously, starting with low doses and titrating slowly
Close monitoring for side effects is essential.
Non Pharmacological Management:
Focus on optimizing the environment: ensure adequate lighting, minimize noise, provide consistent caregiver presence, reorient the child frequently, and facilitate family engagement
Address sensory deficits like vision and hearing impairments
Ensure comfort and manage pain proactively.
Supportive Care:
Continuous monitoring of vital signs, neurological status, and fluid balance is critical
Nutritional support should be maintained
Family education and support are integral to management, helping them understand the condition and participate in care.
Long Term Outcomes And Key Points
Neurocognitive Sequelae:
Pediatric delirium is linked to long-term deficits in attention, memory, executive function, and overall cognitive development
These outcomes can impact academic performance and quality of life.
Impact On Icu Stay:
Delirium is an independent predictor of prolonged PICU stay, increased healthcare utilization, and higher rates of readmission
Effective prevention and management can mitigate these effects.
Exam Focus:
DNB/NEET SS aspirants must understand the prevalence, risk factors, screening tools (pCAM-ICU, CASE), and preventive strategies (sedation vacation, sleep hygiene, family presence)
Management of agitated delirium and its link to poor neurocognitive outcomes are high-yield.
Clinical Pearls:
Remember that delirium can present as hypoactive symptoms (lethargy) which are easily mistaken for sedation or illness severity
Regular, systematic assessment with validated tools is crucial for early detection
Always consider medication side effects and withdrawal as potential causes.