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Jan N M Schieveld, Erwin Ista, Hennie Knoester & Marja L Molag DEPRESSION IN CHILDREN AND ADOLESCENTS PSYCHIATRY & PEDIATRICS Pediatric Delirium: A Practical Approach Adapted by Julie Chilton Chapter I.5 Companion PowerPoint Presentation
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The “IACAPAP Textbook of Child and Adolescent Mental Health” is available at the IACAPAP website http://iacapap.org/iacapap-textbook-of-child-and-adolescent-mental-healthPlease note that this book and its companion PowerPoint are:· Free and no registration is required to read or download it· This is an open-access publication under the Creative Commons Attribution Non- commercial License. According to this, use, distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited and the use is non-commercial.
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The Basics Epidemiology Clinical Characteristics Etiology Diagnosis Treatment Sequelae Pediatric DeliriumOutline
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Pediatric DeliriumThe Basics: “also known as” acute confusional state toxic psychosis ICU psychosis organic psychosyndrome encephalopathy
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Pediatric DeliriumThe Basics: Historical Context First described in 1935 Underrecognized and underdescribed until 1991 Awareness increasing in last few years More publications lately More research needed Paul Eugen Bleuler
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Pediatric DeliriumThe Basics: Definition Latin de-lira (out of the track) Neurocognitive disorder due to a somatic illness or its treatment One of several brain reactions to illness: Sickness behavior Fever Epilepsy Catatonia Delirium Refractory agitation Coma
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Pediatric DeliriumThe Basics: DSM-5 Criteria Disturbance of attention*/awareness Changes in cognition Develops quickly and fluctuates Typically worse in evening Likely result of medical condition or treatment Excludes coma *attention is the first to be lost and the last back
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Pediatric DeliriumThe Basics: ICD-10 Criteria Etiologically nonspecific organic cerebral syndrome with disturbances of: Consciousness and attention Perception Thinking Memory Psychomotor behavior Emotion Sleep-wake schedule Variable duration and severity
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Pediatric DeliriumEpidemiology: Delirium High prevalence 10-30% of general hospital patients Up to 80% in intensive care In adults, associated with increased: Length of stay Morbidity Mortality In elderly, associated with: Faster cognitive decline Loss of independence Increased mortality x 1 year Most important predictor of proximity of death in elderly and oncology patients of any age
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Pediatric DeliriumEpidemiology: Pediatric Delirium 20-30% of critically ill children A worldwide problem in PICU’s* Risk factors include: Younger age Severity of underlying illness Number of medications Diagnostic tools used General ward vs intensive care unit Developmental delay Previous episode Zbigniew J Lipowski PICU: Pediatric intensive care unit
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Pediatric DeliriumClinical Characteristics Can be benign or non-benign 2 types of benign delirium: Emergence delirium/agitation Immediate postoperative period After anesthesia withdrawal Short-lived~ 30-45 minutes Resolves completely Common/general practice delirium With infections, fevers Confusion Waxing/waning course Worse at night Resolves within 2-3 days If persistent, or already present in the morning, it requires emergency medical evaluation
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Pediatric DeliriumClinical Characteristics: Non-Benign Hyperactive Agitation Irritability Increased motor activity Hypoactive: Apathetic Uninterested Mixed
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Pediatric DeliriumCase Vignette: Hyperactive Delirium 6 year old boy with asthma attack Intubated and sedated in ICU After extubation on day 3: Confused and anxious Hallucinations of flying objects and monsters Verbally aggressive Diagnosed with delirium and treated with lorazepam and IV haloperidol Improved after 24 hours
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Pediatric DeliriumCase Vignette: Hypoactive Delirium 3 year old girl mechanically ventilated for 6 days after tracheal surgery Sedated with midazolam, ketamine, dexmedetomidine, levomepromazine, dexamethasone, and morphine Everything tapered for extubation and morphine switched to methadone Day after extubation became: Agitated and disoriented Unable to focus attention Then apathetic and unresponsive 21 points on the CAP-D
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Pediatric DeliriumEtiology: I WATCH DEATH* *MG Wise in Textbook of Neuropsychiatry (1987)
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Pediatric DeliriumDiagnosis: Important Questions Eye contact with parents? Purposeful actions? Aware of surroundings? Restless? Inconsolable? Underactive? Increased response latency? “This is NOW not my child anymore!” (comment by parents, family)
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Pediatric DeliriumDiagnosis: 3 Questions to Ask after a Positive Score Developing somatic complications? Medication change? Physical discomfort?
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Pediatric DeliriumTreatment: Non-pharmacological Interventions Minimize risk factors: Repeated orientation Early mobilization Noise reduction Non-pharmacologic sleep management Day-night rhythm Single room
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Pediatric DeliriumPharmacologic Treatment: Hyperactive Delirium Preventive administration not recommended Consider for: Anxiety, agitation, hallucinations, sleep Monitor drug-drug interactions Weigh risks and benefits Same medications used in adults and children Benzodiazepine withdrawal benzodiazepines and clonidine Opiate withdrawal clonidine and methadone Recommendations based on consensus not evidence IV and PO haloperidol (EKG if risk factors) PO risperidone adverse effects: dystonia, oculogyric crisis, akathisia, hyperpyrexia Start low and go slow Scales 3 times a day Wean gradually
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Pediatric DeliriumPharmacologic Treatment: Hyperactive Delirium EXAMPLE Using repeated loading doses (starting low & going slow) try to find a therapeutic response after 1 or 2 hours, or in the first 24 hours, and the duration of it. Then calculate, based on these data, a maintenance dosage for the next 24 hours (divided in 3 doses). The maintenance dosages suggested are only indicative.
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Pediatric DeliriumPharmacologic Treatment Preventive administration not recommended
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Pediatric DeliriumPharmacological Treatment: Hypoactive Delirium No studies No consensus
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Pediatric DeliriumSequelae of Delirium in Children and Parents No studies on delirium Increased length of hospital stay Large increase in hospital costs Increased mortality PTSD symptoms Delusional memories Cognitive problems after intensive care unit stays Hypoxia Hypoperfusion Infection Trauma Neurotoxicity in animal studies Benzodiazepines Opioids Anesthetics
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Pediatric Delirium Thank You!