Top

Published in:

Open Access 01-11-2009 | Review

Diagnostic considerations regarding pediatric delirium: a review and a proposal for an algorithm for pediatric intensive care units

Authors: Jan N. M. Schieveld, Judith A. van der Valk, Inge Smeets, Eline Berghmans, Renske Wassenberg, Piet L. M. N. Leroy, Gijs D. Vos, Jim van Os

Published in: Intensive Care Medicine | Issue 11/2009

Abstract

Context

If delirium is not diagnosed, it is unlikely that any effort will be made to reverse it. Given evidence for under-diagnosis, tools that aid recognition are required.

Objective

Relating three presentations of pediatric delirium (PD) to standard criteria and developing a diagnostic algorithm.

Results

Delirium-inducing factors, disturbance of consciousness and inattention are common in PICU patients: a pre-delirious state is present in most. An algorithm is introduced, containing (1) evaluation of the sedation-agitation level, (2) psychometric assessment of behavior and (3) opinion of the caregivers.

Discussion

It may be argued that the behavioral focus of the algorithm would benefit from the inclusion of neurocognitive measures.

Limitations

No sufficiently validated diagnostic instrument covering the entire algorithm is available yet.

Conclusion

This is the first proposal for a PD diagnostic algorithm. Given the high prevalence of pre-delirious states at the PICU, daily evaluation is mandatory. Future algorithmic refinement is urgently required.

American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders, 4th edn text, revision (DSM-IV-TR). American Psychiatric Association, Washington DC

American Psychiatric Association (1999) Practice guidelines for the treatment of patients with delirium. Am J Psychiatr 5:1–20

Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y (2007) Incidence, risk factors and consequences of ICU delirium. Intens Care Med 33:66–73CrossRef

Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, Chalfin DB, Masica MF, Bjerke HS, Coplin WM, Crippen DW, Fuchs BD, Kelleher RM, Marik PE, Nasraway Jr SA, Murray MJ, Peruzzi WT, Lumb PD (2002) Clinical practise guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 30(1):119–141CrossRefPubMed

Flaherty JH, Rudolph J, Shay K, Kamholz B, Boockvar KS, Shaughnessy M, Shapiro R, Stein J, Weir C, Edes T (2007) Delirium is a serious and under-recognized problem: why assessment of mental status should be the sixth vital sign. J Am Med Dir Assoc 8:273–275CrossRefPubMed

Cheung CZ, Alibhai SM, Robinson M, Tomlinson G, Chittock D, Drover J, Skrobik Y (2008) Recognition and labeling of delirium symptoms by intensivists: does it matter? Intens Care Med 34:437–446CrossRef

de Carvalho WB, Fonseca MC (2008) Pediatric delirium: a new diagnostic challenge of which to be aware. Crit Care Med 36:1986–1987CrossRefPubMed

Schieveld JNM (2008) On pediatric delirium in critical illness. A clinical multidisciplinary study in childneuropsychiatry at the PICU. Ph.D. thesis, Maastricht University, Maastricht. http://dissertaties.ub.unimaas.nl

Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, Speroff T, Gautam S, Bernard GR, Inouye SK (2001) Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 29:1370–1379CrossRefPubMed

10.

Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y (2001) Intensive care delirium screening checklist: evaluation of a new screening tool. Intens Care Med 27:859–864CrossRef

11.

Plaschke K, von Haken R, Scholz M, Engelhardt R, Brobeil A, Martin E, Weigand MA (2008) Comparison of the confusion assessment method for the intensive care unit (CAM-ICU) with the Intensive Care Delirium Screening Checklist (ICDSC) for delirium in critical care patients gives high agreement rate(s). Intens Care Med 34:431–436CrossRef

12.

Baldwin GA (2001) Handbook of pediatric emergencies. Lippincott, Williams & Wilkins

13.

Lewis M (2002) Child and adolescence psychiatry—a comprehensive textbook. Lippincott, William & Wilkins

14.

Shaw RJ, DeMaso DR (2006) Clinical Manual of Pediatric Psychosomatic Medicine—Mental Health Consultation With Physically Ill Children and Adolescents American Psychiatric Publishing, Inc

15.

Rutter M, Bishop D, Pine D, Scott S, Stevenson J, Taylor E, Thapar A (2008) Rutter’s child and adolescent psychiatry. Blackwell Publishing, OxfordCrossRef

16.

Colville G, Kerry S, Pierce C (2008) Children’s factual and delusional memories of intensive care. Am J Respir Crit Care Med 177:976–982CrossRefPubMed

17.

Schieveld JN, Leroy PL, van Os J, Nicolai J, Vos GD, Leentjens AF (2007) Pediatric delirium in critical illness: phenomenology, clinical correlates and treatment response in 40 cases in the pediatric intensive care unit. Intens Care Med 33:1033–1040CrossRef

18.

Larsen GY, Donaldson AE, Parker HB, Grant MJ (2007) Preventable harm occurring to critically ill children. Pediatr Crit Care Med 8:331–336CrossRefPubMed

19.

Pandharipande P, Cotton BA, Shintani A, Thompson J, Costabile S, Truman Pun B, Dittus R, Ely EW (2007) Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care unit patients. Intens Care Med 33:1726–1731CrossRef

20.

van Munster BC (2009) Pathophysiological studies in delirium, a focus on genetics. Ph.D thesis, University of Amsterdam

21.

Ely EW, Truman B, Manzi DJ, Sigl JC, Shintani A, Bernard GR (2004) Consciousness monitoring in ventilated patients: bispectral EEG monitors arousal not delirium. Intens Care Med 30:1537–1543

22.

Fukumoto Y, Okumura A, Hayakawa F, Suzuki M, Kato T, Watanabe K, Morishima T (2007) Serum levels of cytokines and EEG findings in children with influenza associated with mild neurological complications. Brain Dev 29:425–430CrossRefPubMed

23.

Ouimet S, Riker RR, Bergeron N, Cossette M, Kavanagh BP, Skrobik YK (2007) Subsyndromal delirium in the ICU: evidence for a disease spectrum. Intens Care Med 33:1007–1013CrossRef

24.

McCusker J, Cole MG, Dendukuri N, Belzile E (2003) Does delirium increase hospital stay? J Am Geriatr Soc 51:1539–1546CrossRefPubMed

25.

Cole MG, McCusker J, Ciampi A, Belzile E (2008) The 6- and 12-month outcomes of older medical inpatients who recover from subsyndromal delirium. J Am Geriatr Soc 56:2093–2099CrossRefPubMed

26.

World Health Organisation (2004) ICD-10: International classification of diseases and related health problems: 10th revision. World Health Organisation, Geneva

27.

Dantzer R, Konsman JP, Bluthe RM, Kelley KW (2000) Neural and humoral pathways of communication from the immune system to the brain: parallel or convergent? Auton Neurosci 85:60–65CrossRefPubMed

28.

Kelley KW, Bluthe RM, Dantzer R, Zhou JH, Shen WH, Johnson RW, Broussard SR (2003) Cytokine-induced sickness behavior. Brain Behav Immun 17:112–118CrossRef

29.

Teeling JL, Felton LM, Deacon RMJ, Cunningham C, Rawlins JNP, Perry VH (2007) Sub-pyrogenic systemic inflammation impacts on brain and behavior, independent of cytokines. Brain Behav Immun 21:836–850CrossRefPubMed

30.

Maclullich AMJ, Ferguson KJ, Miller T, de Rooij SEJA, Cunningham C (2008) Unravelling the pathophysiology of delirium: a focus on the role of aberrant stress responses. J Psychosom Res 65:229–238CrossRefPubMed

31.

Trzepacz PT, Meagher DJ (2005) Delirium. In: Levinson JL (ed) Textbook of psychosomatic medicine. The American Psychiatric Publishing, Washington DC, pp 92–130

32.

Kanner L (1935) Child psychiatry. Chas. C. Thomas, Springfield

33.

Turkel SB, Tavare CJ (2003) Delirium in children and adolescents. J Neuropsych Clin Neurosci 15:431–435

34.

Trzepacz PT, Baker RW, Greenhouse J (1988) A symptom rating scale for delirium. Psychiatr Res 23:89–97CrossRef

35.

Trzepacz PT, Mittal D, Torres R, Kanary K, Norton J, Jimerson N (2001) Validation of the Delirium Rating Scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium. J Neuropsychiatr Clin Neurosci 13:229–242

36.

Sikich N, Lerman J (2004) Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale. Anesthesiology 100:1138–1145CrossRefPubMed

37.

Ely EW, Truman B, Shintani A, Thomason JW, Wheeler AP, Gordon S, Francis J, Speroff T, Gautam S, Margolin R, Sessler CN, Dittus RS, Bernard GR (2003) Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). Jama 289:2983–2991CrossRefPubMed

38.

Stoddard FJ, Wilens TE (1995) Delirium. In: Jellinek MS, Herzog DB (eds) Psychiatric aspects of general hospital pediatrics. Yearbook Medical Publishers, Chicago, pp 254–259

39.

Schieveld JN, Leentjens AF (2005) Delirium in severely ill young children in the pediatric intensive care unit (PICU). J Am Acad Child Adolesc Psychiatr 44:392–394 discussion 395CrossRef

40.

Stoddard FJ, Wilens TE (1995) Delirium. In: Jellinek MS, Herzog DB (eds) Psychiatric aspects of general hospital pediatrics. Chicago

41.

Isik B, Arslan M, Tunga AD, Kurtipek O (2006) Dexmedetomidine decreases emergence agitation in pediatric patients after sevoflurane anesthesia without surgery. Paediatr Anaesth 16:748–753CrossRefPubMed

42.

Abu-Shahwan I, Chowdary K (2007) Ketamine is effective in decreasing the incidence of emergence agitation in children undergoing dental repair under sevoflurane general anesthesia. Paediatr Anaesth 17:846–850CrossRefPubMed

43.

Aouad MT, Yazbeck-Karam VG, Nasr VG, El-Khatib MF, Kanazi GE, Bleik JH (2007) A single dose of propofol at the end of surgery for the prevention of emergence agitation in children undergoing strabismus surgery during sevoflurane anesthesia. Anesthesiology 107:733–738CrossRefPubMed

44.

Abu-Shahwan I (2008) Effect of propofol on emergence behavior in children after sevoflurane general anesthesia. Paediatr Anaesth 18:55–59PubMed

45.

Ozdemir Kol I, Egilmez H, Kaygusuz K, Gursoy S, Mimaroglu C (2008) Open-label, prospective, randomized comparison of propofol and sevoflurane for laryngeal mask anesthesia for magnetic resonance imaging in pediatric patients. Clin Ther 30:175–181CrossRef

46.

Hasani A, Ozgen S, Baftiu N (2009) Emergence agitation in children after propofol versus halothane anesthesia. Med Sci Monit 15:CR302–CR306PubMed

47.

Pisani MA, Araujo KL, Van Ness PH, Zhang Y, Ely EW, Inouye SK (2006) A research algorithm to improve detection of delirium in the intensive care unit. Crit Care 10:R121CrossRefPubMed

48.

McNicoll L, Pisani MA, Zhang Y, Ely EW, Siegel MD, Inouye SK (2003) Delirium in the intensive care unit: occurrence and clinical course in older patients. J Am Geriatr Soc 51:591–598CrossRefPubMed

Title: Diagnostic considerations regarding pediatric delirium: a review and a proposal for an algorithm for pediatric intensive care units
Authors: Jan N. M. Schieveld
Judith A. van der Valk
Inge Smeets
Eline Berghmans
Renske Wassenberg
Piet L. M. N. Leroy
Gijs D. Vos
Jim van Os
Publication date: 01-11-2009
Publisher: Springer-Verlag
Published in: Intensive Care Medicine / Issue 11/2009
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-009-1652-8

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Diagnostic considerations regarding pediatric delirium: a review and a proposal for an algorithm for pediatric intensive care units

Abstract

Context

Objective

Results

Discussion

Limitations

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Context

Objective

Results

Discussion

Limitations

Conclusion

Please log in to get access to this content

Other articles of this Issue 11/2009

Plasma tryptophan and tyrosine levels are independent risk factors for delirium in critically ill patients

Unilateral pulmonary edema and shock: a diagnostic challenge

Tidal volume during acute lung injury: let the patient choose?

Impact of acute hypercapnia and augmented positive end-expiratory pressure on right ventricle function in severe acute respiratory distress syndrome

Is volume and leak monitoring feasible during nasopharyngeal continuous positive airway pressure in neonates?

Neutrophil and monocyte CD64 indexes, lipopolysaccharide-binding protein, procalcitonin and C-reactive protein in sepsis of critically ill neonates and children