Abstract
Delirium is an acute neuropsychiatric syndrome reflecting serious cerebral dysfunction.
The characteristic core symptoms of delirium include the inability to direct, focus,
sustain, and shift attention; abnormalities of the sleep-wake cycle; impaired consciousness
and awareness; disturbance of thought processes; and behavioral dyscontrol. Delirium
is particularly prevalent in critically ill and post-operative patients in the intensive
care unit, and may result from hypoxia or infection. It is most likely in the most
severely ill, and length of stay is prolonged, and morbidity and mortality and higher
with delirium.
A variety of clinical instruments have been developed to facilitate the diagnosis
of delirium. The Delirium Rating Scale, and its 1998 revision (DRS and DRS-R98) are
for psychiatrists to use and are based on DSM criteria. The Pediatric Confusion Assessment
Method, adapted for pediatric patients in the ICU (pCAM-ICU), is designed for non-psychiatrists
and nurses in the intensive care unit. The Pediatric Anesthesia Emergence Delirium
scale (PAED) is the basis for the Cornell Assessment of Pediatric Delirium (CAP-D),
and both are for nurses and doctors in the pediatric ICU to use to identify delirium
in their patients.
Delirium is typically multifactorial and its pathogenesis reflects neurotransmitter
changes associated with metabolic and inflammatory processes. Benzodiazepines and
anticholinergic drugs, including opioids and antihistamines, are widely used in the
pediatric ICU and may precipitate or exacerbate delirium. Benzodiazepines especially
are best used sparingly, in the lowest dose possible, if at all.
The treatment of delirium is predicated on detecting and addressing its underlying
cause, which usually results in its rapid resolution. Environmental interventions
may ameliorate the risk for delirium, and drugs which may precipitate or worsen delirium
should be avoided. Antipsychotics can provide benefit in managing agitation, perceptual
disturbances, sleep-wake cycle abnormalities, and behavioral dyscontrol. Atypical
antipsychotics, including olanzapine, risperidone, and quetiapine, have largely replaced
haloperidol in newer approaches to management because of lower risk for adverse side
effects.
The risk for delirium may be mitigated by vigilance, and awareness of its presentation,
pathogenesis, and management. Its prevention will be of significant benefit in reducing
morbidity, improving outcome, and providing comfort to these very ill and fragile
children.
Keywords
Delirium - management - antipsychotic - pediatric - intensive care
