Implementation and effectiveness of a delirium care protocol in Thai critically ill children

Chanapai Chaiyakulsil; Thananya Thadahirunchot

doi:10.4266/acc.2023.00045

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Original Article Pediatrics Implementation and effectiveness of a delirium care protocol in Thai critically ill children: Acute and Critical Care 2023;38(4):488-497.
DOI: https://doi.org/10.4266/acc.2023.00045
Published online: November 28, 2023

Chanapai Chaiyakulsil¹

, Thananya Thadahirunchot²

¹Division of Pediatric Critical Care, Department of Pediatrics, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, Thailand

²Pediatric Intensive Care Unit, Thammasat University Hospital, Pathumthani, Thailand

Corresponding author: Chanapai Chaiyakulsil Division of Pediatric Critical Care, Department of Pediatrics, Thammasat University Hospital, Faculty of Medicine, Thammasat University, 95 Phahol Yothin Rd, Klong-Neung, Klong-Luang, Pathumthani 12120, Thailand Tel: +66-2926-9514, E-mail: chanapai.chai@hotmail.com

• Received: January 3, 2023 • Revised: August 11, 2023 • Accepted: October 7, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
KEY MESSAGES
NOTES
Acknowledgments
REFERENCES

Abstract

Background
Delirium in critically ill children can result in long-term morbidity. Our main objectives were to evaluate the effectiveness of a new protocol on the reduction, prevalence, and duration of delirium and to identify associated risk factors.
Methods
The effectiveness of the protocol was evaluated by a chart review in all critically ill children aged 1 month to 15 years during the study period. A Cornell Assessment of Pediatric Delirium score ≥9 was considered positive for delirium. Data on delirium prevalence and duration from the pre-implementation and post-implementation phases were compared. Univariate and multivariate analyses were used to identify the risk factors of delirium.
Results
A total of 120 children was analyzed (58 children in the pre-implementation group and 62 children in the post-implementation group). Fifty children (41.7%) screened positive for delirium. Age less than 2 years, delayed development, use of mechanical ventilation, and pediatric intensive care unit (PICU) stay >7 days were significantly associated with delirium. The proportion of children screened positive was not significantly different after the implementation (before, 39.7% vs. after, 43.5%; P=0.713). Subgroup analyses revealed a significant reduction in the duration of delirium in children with admission diagnosis of cardiovascular problems and after cardiothoracic surgery.
Conclusions
The newly implemented protocol was able to reduce the duration of delirium in children with admission diagnosis of cardiovascular problems and after cardiothoracic surgery. More studies should be conducted to reduce delirium to prevent long-term morbidity after PICU discharge.
Key Words: children; delirium; intensive care; morbidity

INTRODUCTION

Delirium is an acute cerebral dysfunction that can be caused by systemic illness or a medical treatment, especially in a critical care setting. It is sometimes referred to as intensive care unit psychosis or toxic psychosis [1,2]. According to the International Statistical Classification of Diseases and Related Health Problems 10th revision (ICD-10) in 2015, delirium is also defined as disturbances in consciousness, attention, perception, thinking, memory, emotion, and sleep-wake schedule [3]. The prevalence rate of delirium in critically ill children ranges from 10% to 56%, with higher rates among children younger than 2 years [1-2,4-10].

Delirium can be classified into three subtypes: hyperactive, hypoactive, or mixed [1-2,11]. Children experiencing delirium have more frequent severe perceptual disturbances, mood lability, agitation, and visual hallucinations [11]. Critically ill children with delirium are associated with longer pediatric intensive care unit (PICU) and hospital stays, neurocognitive dysfunction, post-traumatic stress disorder, and higher rates of mortality [1,10]. Moreover, with a longer duration of delirium, more frequent severe cognitive and memory problems develop among children surviving critical illness [12,13]. Thus, delirium in critically ill children is a major health issue that can result in long-term morbidity.

Studies by Patel et al. in 2017 [14] and Jesus et al. [15] in 2020 suggested systematic approaches for the management of delirium in children who are critically ill. The first step of these approaches is to recognize and manage the underlying conditions and iatrogenic factors leading to delirium. Then, perform a stepwise approach using environmental modification, nonpharmacologic intervention, and then pharmacologic intervention [14,15]. A mnemonic known as “BRAIN MAPS” is used as a part of the assessment, evaluation, and treatment in the delirium clinical pathway and is recommended by the Society of Critical Care Medicine. BRAIN MAPS involves bringing oxygen (B), reducing or removing deliriogenic drugs such as benzodiazepines or anticholinergics (R), atmosphere modification (A), infection/inflammation control and reducing immobilization (I), treatment of new organ dysfunction and metabolic disturbances (NM), awakening schedule (A), pain (P), and sedation control (S) [16-18]. There is limited evidence of the effectiveness of such approaches in reducing delirium in critically ill children. Furthermore, there is no local guideline in Thailand on the management of delirium in critically ill children. Thus, the main objective of this study was to evaluate the effectiveness of the newly devised delirium care map protocol in the reduction of delirium in critically ill children in terms of both prevalence and duration, PICU stay, and ventilator days. The secondary objective was to identify the risk factors associated with delirium in critically ill children.

MATERIALS AND METHODS

This study was approved by the Ethics Committee of Thammasat University Hospital, Thammasat University, Thailand (No. MTU-EC-PE-0-246/65). Informed consent was waived due to the retrospective review of the implemented protocol.

Study Design and Participants

A chart review of all children aged 1 month to 15 years who were admitted to the PICU from March to October 2022 was conducted. Our PICU is a mixed medical-surgical tertiary, single-patient room intensive care unit that receives approximately 25–30 patients per month. The nurse-to-patient ratio is 1:1 or 1:2 based on the severity of the patient’s condition.

Intervention

From March 2022, the Cornell Assessment of Pediatric Delirium (CAPD) has been used as a screening tool for delirium in our critical care unit. The CAPD was conducted in all patients admitted to the PICU every 8 hours at the start of the nursing shift. Before this, no screening tool for delirium was used in the unit. All pediatric critical care nurses were trained by attending pediatric intensivists and senior critical care nurses who were familiar with the screening tool. Good interrater reliability of 0.85 was obtained before initiation of the routine assessment. The CAPD is a valid screening tool with excellent sensitivity and specificity for critically ill children of all ages and can be conducted in patients with developmental delays. CAPD consists of eight questions aiming to assess consciousness, cognition, orientation, psychomotor activity, and affect/distress. The score was given on a Likert scale of 0–4 (0=always, 1=often, 2=sometimes, 3=rarely, and 4=never) based on the assessment. The CAPD is faster, needing less than 2 minutes to complete [1]. A CAPD score ≥9 is considered positive for delirium. Deeply sedated patients (Richmond Agitation-Sedation scale [RASS] <–4 or State Behavioral Scale [SBS] <–2) were not assessed until awake. RASS is a 10-point scale for the evaluation of agitation and sedation ranging from +4 (combative) to –5 (unarousable) [19]. The SBS is also used for evaluation of sedation and agitation in mechanically ventilated children in our unit. This is a 6-point scale ranging from +2 (agitated) to –3 (unresponsive) [20]. These scales are currently used as a standard practice for evaluation of sedation and agitation in our PICU (RASS in non-mechanically ventilated children, SBS in mechanically ventilated children).

The delirium care map protocol based on the mnemonic “BRAIN MAPS” was outlined as a quality improvement project of the hospital by pediatric intensivists and pediatric critical care nurses in June 2022 to decrease the proportion and duration of patients with delirium (Figure 1). The components of the protocol mostly focus on the non-pharmacologic management of delirium, adjustment of the PICU environment, and treatment of the underlying conditions. Pharmacologic treatment of delirium was reserved only for patients who were combative or at risk of self-harm. A 1-month training period was required before implementation to ensure consistency and compliance with the protocol. Thus, the patients who were admitted from March 1, 2022, to June 30, 2022, were considered as a pre-implementation group, and the patients admitted from July 1, 2022, to October 31, 2022, served as the post-implementation group. To ensure the effectiveness of the protocol, screening and protocol compliance were randomly assessed. All demographic data, as well as admission diagnosis, underlying comorbidities, delirium duration, PICU duration, sedation, the neuromuscular blocking agent used, and ventilator days, were recorded.

Statistical Analyses

Delirium duration was calculated as the number of shifts with CAPD ≥9 points multiplied by 8 hours (shift duration). For instance, if a child screened positive for delirium 10 times during the PICU stay, the duration was recorded as 80 hours. Delayed development was defined using the red flags described by the American Academy of Pediatrics [21]. All demographic data, PICU length of stay, and ventilator days were analyzed using descriptive statistics. The prevalence of delirium was reported as a percentage. Data on delirium from the pre-implementation and post-implementation phases were compared with the expectation of reductions in delirium rates and duration. The Mann-Whitney U-test was used to compare quantitative data among intervention groups. Univariate analyses were used to identify the risk factors of delirium. Statistically significant factors from the univariate analyses were used for the adjustment during multivariate analyses. A P-value <0.05 was considered statistically significant. All statistical analyses were performed using IBM SPSS ver. 24 (IBM Corp.).

RESULTS

Demographic Data

The demographic data are presented in Table 1. A total of 120 children was admitted to the PICU during the study period. All children were included in the analysis. Fifty-eight children were allocated to the pre-implementation group and the remaining 62 children were allocated to the post-implementation group (Figure 2). The median age for the overall cohort was 3.1 years (interquartile range [IQR], 0.9–6.8), and 43 children (35.8%) were younger than 2 years. Approximately 56.7% of the participants were male.

Cardiovascular comorbidity served as the main underlying condition in the cohort (41.7%), followed by neurologic comorbidity (7.5%) and gastrointestinal comorbidity (5.8%). A total of 37 children (30.8%) had developmental delays and 56 children (46.7%) were admitted to the PICU for postoperative care. Among the children admitted for postoperative care, the major type of surgery was cardiothoracic surgery (32/56, 57%). The most common admission diagnoses were cardiovascular (38.2%) and gastrointestinal (13.3%) problems. The median Pediatric Risk for Mortality (PRISMI) III score [22] was 2.0 (IQR, 0.0–5.0). Inotropic medications were used in 47 children (39.2%) with a median vasoactive inotropic score (VIS) [23] of 14.0 (IQR, 7.0–24.0). Extracorporeal membrane oxygenator support (ECMO) was compulsory in four children (3.3%), one (1.7%) during the pre-implementation phase, and three (4.8%) in the post-implementation phase. A total of 48 children (40.0%) was mechanically ventilated with a median duration of 2.5 days (IQR, 1.0–8.8 days). Continuous infusion of sedatives and neuromuscular blocker (NMB) were used in 42 (35.0%) and nine (7.5%) children, respectively. Five children (4.2%) exhibited signs of withdrawal. The median PICU stay was 3.0 days (IQR, 1.0–8.0 days), and 35 children (29.2%) required PICU admission for greater than 7 days. Three children (2.5%) died during the study period. The overall demographic data including age, gender, underlying condition, admission diagnoses, developmental status, PRISM III score, VIS, inotropic support, ECMO support, respiratory support, sedation use, NMB use, and withdrawal were not significantly different between intervention groups.

Outcomes of Delirium Care Protocol

The compliance rate of the screening was 95%. The bundle compliance was randomly examined and found to be 70%. The most difficult components with which to comply were a sleeping routine and reduction of night-time noises. Parental visits were limited to 30 minutes each day to comply with the hospital policy. A total of 50 children (41.7%) had positive delirium screening. The median CAPD score for the overall cohort was 7.0 (3.0–12.0). The proportion of children with positive CAPD screening was not significantly different among groups (39.7% during the pre-intervention phase vs. 43.5% during the post-intervention phase; P=0.713). The median delirium duration during the post-intervention phase seemed to be shorter than the pre-intervention phase, but the difference was not significant (32.0 hours [IQR, 18.0–8.0] vs. 56.0 hours [IQR, 32.0–72.0], P=0.274). No children received atypical antipsychotics during the study period. The median CAPD score, mechanical ventilator support days, PICU stays, and mortality rates were not statistically different between the groups (Table 1).

In a subgroup analysis of children with the admission diagnosis of cardiovascular problems, there was a significant reduction in the duration of delirium after implementation of the protocol, from 64.0 hours (IQR, 54–80 hours) to 32.0 hours (IQR, 22–68 hours) (P=0.001). A similar result was found in children after cardiothoracic surgery (60.0 hours [IQR, 50–70) vs. 28.0 hours [IQR, 24–58), P=0.02).

Factors Associated with Positive Delirium Screening

Table 2 outlines the factors associated with delirium among participants. The proportion of children younger than 2 years was significantly higher in the positive delirium screening group (48.0% vs. 27.1%, P=0.022). There was also a significantly larger proportion of children with delayed development in the delirium group (52.0% vs. 15.7%, P<0.001). Children with positive screening for delirium had significantly higher median PRISM III scores, median CAPD scores, longer mechanical ventilation support days, and longer PICU stays. All children who required ECMO and NMB had positive delirium screening. Withdrawal was only found in children with delirium. The proportions of children with admission diagnosis of cardiovascular problems, who required mechanical ventilation, continuous infusion of sedation, PICU stay >7 days, and mechanical ventilation >7 days were significantly larger in the delirium group. Median age, sex, underlying comorbidity, postoperative status, and mortality were not significantly different among groups.

The univariate and multivariate analyses of associating factors are presented in Tables 3 and 4. Age younger than 2 years, delayed development, admission diagnosis of cardiovascular problem, inotropic support, mechanical ventilator, mechanical ventilation >7 days, use of sedation and NMB, and PICU stay >7 days were associated with positive delirium screening (P<0.05) according to univariate analyses. After adjustment for significant factors, age younger than 2 years, delayed development, and PICU stay >7 days were associated with positive delirium screening with adjusted odds ratio (aOR) of 3.41 (95% confidence interval [CI], 1.19–9.73), 5.03 (95% CI, 1.73–14.59), and 11.58 (95% CI, 2.90–46.23), respectively.

DISCUSSION

The prevalence rate of delirium in this cohort was substantially high at 41.7%. This was comparable to previous studies, with the prevalence of delirium ranging from 10% to 57% [1,2,4-10]. We also demonstrated that age less than 2 years, delayed development, use of mechanical ventilation, and a PICU stay >7 days were significantly associated with delirium in critically ill children. These findings were consistent with the previously reported studies by Silver et al. [5] and Traube et al. [1].

A large study in critically ill adults revealed that the multimodal ABCDEF bundle was associated with a lower likelihood of delirium with an aOR of 0.60 (95% CI, 0.49–0.72) [24]. There were limited data on the effectiveness of the multimodal protocol for the management of delirium in critically ill children [25-27]. The implementation of our new delirium protocol was unable to significantly reduce the prevalence and duration of delirium in the overall study cohort. Nevertheless, in the subgroup analysis of children with the admission diagnosis of cardiovascular problems, there was a significant decline in the duration of delirium from 64.0 hours (IQR, 54–80 hours) to 32 hours (IQR, 22–68 hours) (P=0.001). The same was found in children after cardiothoracic surgery (60.0 hours [IQR, 50–70] vs. 28.0 hours [IQR, 24–58], P=0.02). Several studies have demonstrated that young children are among the most vulnerable groups to develop delirium during critical illness, especially after cardiothoracic surgery [28,29]. Similar findings were demonstrated in a recent study by Michel et al. [25], outlining a non-significant reduction of delirium prevalence after implementation of the delirium bundles but a significant reduction among children after cardiothoracic surgery. Unlike in our study, Michel et al. [25] showed a significant reduction of delirium in subgroups of children younger than 5 years. We were only able to illustrate a reduction in the duration of delirium in children with an admission diagnosis of cardiovascular problems and those after cardiothoracic surgery. This might be due to the complex environment in the PICU setting and the multifactorial etiologies of delirium. Nevertheless, a reduction in the duration of delirium could alleviate the possible cognitive and memory problems after PICU discharge [12,13].

A prolonged stay in the PICU with the use of sedation and mechanical ventilation was associated with the development of delirium [1,5]. Approximately 29.2% of children in our cohort required a PICU stay >7 days, 40% required mechanical ventilation, and 35% required continuous infusion of sedation. Furthermore, children with positive screening for delirium had significantly higher median PRISM III scores, signifying the higher severity and complexity of the conditions. These factors might lead to continuous exposure of factors leading to delirium. Another factor limiting the effectiveness of the delirium protocol might be the pre-existing early mobilization protocol within the unit. A study by Simone et al. [27] showed that sequential implementation of delirium, sedation, and early mobility protocol can reduce the prevalence of delirium. An early mobilization protocol was implemented at our center in June 2020, and might have obscured the magnitude of the overall protocol effectiveness.

This study was one of the first aiming to reduce the prevalence of delirium in critically ill children by implementing the delirium care map protocol. A major strength of this study was that the compliance rate of the screening was as high as 95%. Furthermore, the compliance rate of the patients randomly examined every month was also high at approximately 70%. This compliance rate was comparable with the study by Michel et al. [25] (compliance screening rate of 95% and bundle adherence rate of 72%) and significantly higher than the study by Franken et al. [26] (compliance screening rate of 9%; no report on the compliance rate of the protocol). With the high compliance rate in both screening and protocol adherence, the true effectiveness of the protocol could be evaluated. Nonetheless, the most difficult protocol components to comply with were the reduction of night-time noises and encouragement of a sleep routine. Due to the nature of the university hospital, night-time admission and procedures as well as noises were difficult to control, regardless of the single-room patient status, which might compromise the effectiveness of the protocol. Furthermore, the limited time for a parental visit might also play a role in a non-significant change in the prevalence of delirium.

The other limitations of this study should also be outlined. This was a single-center study in a tertiary care university hospital. Thus, it might not be generalized to all hospital settings. A limited sample size within this cohort made it difficult to perform a subgroup analysis in different groups of children with different conditions. Nevertheless, this sample size was adequately powered for a reduction in the prevalence of delirium by 20% with β error of 0.2 and alpha error of 0.05. Regardless of these limitations, this is a pilot study for larger multicenter studies. More studies, especially multicenter studies, are also warranted to evaluate long-term cognitive decline and memory problems in children with delirium, as well as the validation and long-term effectiveness of the protocol.

Delirium is substantially prevalent among critically ill children in our cohort. The newly implemented protocol was able to reduce the duration of delirium in children with an admission diagnosis of cardiovascular problems and children after cardiothoracic surgery. More studies should be conducted to reduce delirium and prevent long-term morbidity in critically ill children after PICU discharge.

KEY MESSAGES

▪ A total of 50 children (41.7%) screened positive for delirium.

▪ Age less than 2 years, delayed development, use of mechanical ventilation, and pediatric intensive care unit stay >7 days were significantly associated with delirium.

▪ The proportion of children with positive screening was not significantly different after the implementation (before, 39.7% vs. after, 43.5%; P=0.713).

▪ Subgroup analyses revealed a significant reduction in the duration of delirium in children with an admission diagnosis of cardiovascular problems and after cardiothoracic surgery.

NOTES

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

This study was supported by the Research Group in Pediatric Care of the Faculty of Medicine, Thammasat University.

AUTHOR CONTRIBUTIONS

Conceptualization: CC. Methodology: CC. Formal analysis: CC. Data curation: all authors. Visualization: CC. Project administration: all authors. Funding acquisition: CC. Writing–original draft: all authors. Writing–review & editing: all authors.

Acknowledgments

The authors would like to show appreciation to all the residents, faculty, and nursing staff of our hospital as well as the Research Group for Pediatric Care of the Faculty of Medicine, Thammasat University for their strong support and extensive cooperation in making this project successful.

Figure 1.

Protocol for delirium care of critically ill children. PICU: pediatric intensive care unit; SBS: State Behavioral Scale; RASS: Richmond Agitation-Sedation Scale; CAPD: Cornell Assessment of Pediatric Delirium; WAT-1: withdrawal assessment tool; EKG: electrocardiogram; QTC: corrected QT interval.

Figure 2.

The flowchart for the study. All patients were followed until pediatric intensive care unit (PICU) discharge and were included for the final analysis.

Table 1.

Demographic data among intervention groups

Factor	All patients (n=120)	Pre-intervention (n=58)	Post-intervention (n=62)	P-value
Median age (yr)	3.1 (0.9–6.8)	3.1 (0.9–5.0)	3.0 (0.6–7.8)	0.985
Age <2 yr	43 (35.8)	20 (34.5)	23 (37.1)	0.850
Male	68 (56.7)	33 (56.9)	35 (56.5)	1.000
Underlying disease				0.817
None	23 (19.2)	12 (20.7)	11 (17.8)
Cardiovascular	50 (41.7)	22 (37.9)	28 (45.2)
Neurologic	9 (7.5)	7 (12.1)	2 (3.2)
Genetic	4 (3.3)	2 (3.4)	2 (3.2)
Gastrointestinal	7 (5.8)	3 (5.2)	4 (6.5)
Hematology and oncology	7 (5.8)	3 (5.2)	4 (6.5)
Renal	2 (1.7)	1 (1.7)	1 (1.6)
Pulmonology	5 (4.2)	2 (3.4)	3 (4.8)
Trauma	1 (0.8)	1 (1.7)	-
Allergy	7 (5.8)	5 (8.7)	2 (3.2)
Endocrine	2 (1.7)	-	2 (3.2)
Rheumatology	1 (0.8)	-	1 (1.6)
Infectious disease	2 (1.7)	-	2 (3.2)
Admission diagnosis				0.165
Cardiovascular	46 (38.2)	20 (34.6)	26 (41.9)
Gastrointestinal	16 (13.3)	8 (13.8)	8 (12.9)
Pulmonology	15 (12.5)	8 (13.8)	7 (11.3)
Neurologic	12 (10.3)	7 (12.1)	5 (8.1)
Asthmatic attack	10 (8.3)	9 (15.5)	1 (1.6)
Renal	6 (5.0)	2 (3.4)	4 (6.5)
Endocrine	6 (5.0)	1 (1.7)	5 (8.1)
Septic shock	2 (1.7)	2 (3.4)	-
Oncology	2 (1.7)	1 (1.7)	1 (1.6)
Trauma	1 (0.8)	-	1 (1.6)
Dental	1 (0.8)	-	1 (1.6)
Genetic	1 (0.8)	-	1 (1.6)
Orthopedics	1 (0.8)	-	1 (1.6)
Rheumatology	1 (0.8)	-	1 (1.6)
Delayed development	37 (30.8)	18 (31.0)	19 (30.6)	1.000
All-cause postoperative care	56 (46.7)	26 (44.8)	30 (48.4)	0.718
Median PRISM III	2.0 (0.0–5.0)	0.0 (0.0–5.0)	2.0 (0.0–7.0)	0.294
Median CAPD	7.0 (3.0–12.0)	7.0 (2.0–11.2)	7.0 (3.0–12.0)	0.874
Delirium	50 (41.7)	23 (39.7)	27 (43.5)	0.713
Delirium duration (hr)	40.0 (24.0–74.0)	56.0 (32.0–72.0)	32.0 (18.0–80.0)	0.274
Inotropes	47 (39.2)	21 (36.2)	26 (41.9)	0.577
Median vasoactive inotropic score [23]	14.0 (7.0–24.0)	16.0 (5.0–25.0)	13.0 (7.8–21.4)	0.192
ECMO support	4 (3.3)	1 (1.7)	3 (4.8)	0.619
Respiratory support				0.453
None	25 (20.8)	9 (15.5)	16 (25.8)
Cannula	23 (19.2)	12 (20.7)	11 (17.7)
HFNC	24 (20.0)	14 (24.1)	10 (16.1)
MV	48 (40.0)	23 (39.7)	25 (40.3)
Median MV days	2.5 (1.0–8.8)	3.0 (1.0–9.0)	2.0 (1.0–5.5)	1.000
MV >7 days	13/48 (27.1)	9/23 (39.1)	4/25 (16.0)	0.106
Sedation	42 (35.0)	19 (32.8)	23 (37.1)	0.703
Sedation >7 days	11/42 (26.2)	7/19 (36.8)	4/23 (17.4)	0.180
NMB	9 (7.5)	4 (6.9)	5 (8.1)	1.000
Withdrawal	5 (4.2)	3 (5.2)	2 (3.2)	0.672
Median PICU days	3.0 (1.0–8.0)	3.0 (1.0–7.2)	3.0 (1.0–8.0)	0.436
PICU >7 days	35 (29.2)	16 (27.6)	19 (30.6)	0.841
Mortality	3 (2.5)	1 (1.7)	2 (3.2)	1.000

Values are presented as median (interquartile range) or number (%).

PRISM: Pediatric Risk for Mortality; CAPD: Cornell assessment for pediatric delirium; ECMO: extracorporeal membrane oxygenator; HFNC: high-flow nasal cannula; MV: mechanical ventilation; NMB: neuromuscular blocker; PICU: pediatric intensive care unit.

Table 2.

Associating factors for positive delirium screening

Factor	Delirium (n=50)	No delirium (n=70)	P-value
Median age (yr)	2.2 (0.8–6.5)	3.6 (1.4–8.0)	0.115
Age <2 yr	24 (48.0)	19 (27.1)	0.022
Male	29 (58.0)	39 (55.7)	0.853
Underlying disease			0.819
None	9 (18.0)	14 (20.0)
Cardiovascular	28 (56.0)	22 (31.5)
Neurologic	3 (6.0)	6 (8.6)
Genetic	2 (4.0)	2 (2.9)
Gastrointestinal	-	7 (10.0)
Hematology and oncology	2 (4.0)	5 (7.1)
Renal	1 (2.0)	1 (1.4)
Pulmonology	2 (4.0)	3 (4.3)
Trauma	-	1 (1.4)
Allergy	2 (4.0)	5 (7.1)
Endocrine	-	2 (2.9)
Rheumatology	-	1 (1.4)
Infectious disease	1 (2.0)	1 (1.4)
Admission diagnosis			0.026
Cardiovascular	28 (56.0)	18 (25.8)
Gastrointestinal	2 (4.0)	14 (20.0)
Pulmonology	8 (16.0)	7 (10.0)
Neurologic	4 (8.0)	8 (11.5)
Asthmatic attack	1 (2.0)	9 (12.9)
Renal	2 (4.0)	4 (5.7)
Endocrine	1 (2.0)	5 (7.1)
Septic shock	1 (2.0)	1 (1.4)
Oncology	1 (2.0)	1 (1.4)
Trauma	1 (2.0)	-
Dental	-	1 (1.4)
Genetic	1 (2.0)	-
Orthopedics	-	1 (1.4)
Rheumatology	-	1 (1.4)
Delayed development	26 (52.0)	11 (15.7)	<0.001
All-cause postoperative care	23 (46.0)	33 (47.1)	1.000
PRISM III	3.0 (0–7.2)	0 (0–4.0)	0.006
CAPD	12.5 (11.0 -17.0)	3.0 (0–5.2)	<0.001
Inotropes	29 (58.0)	18 (25.7)	0.001
Vasoactive inotropic score [23]	14.0 (8.0–25.0)	14.5 (5.0 -21.4)	0.853
ECMO support	4 (8.0)	-	0.028
Respiratory support			<0.001
None	6 (12.0)	19 (27.1)
Cannula	4 (8.0)	19 (27.1)
HFNC	7 (14.0)	17 (24.3)
MV	33 (66.0)	15 (21.5)
MV duration	5.0 (2.0–9.0)	1.0 (1.0–1.5)	0.013
MV >7 days	12/33 (36.4)	1/15 (6.7)	0.040
Sedation	29 (58.0)	13 (18.6)	<0.001
Sedation >7 days	10/29 (34.5)	1/13 (7.7)	0.127
Neuromuscular blocker	9 (18.0)	-	<0.001
Withdrawal	5 (10.0)	-	0.011
Median PICU stay	7.5 (3.0–13.0)	2.0 (1.0–4.0)	<0.001
PICU >7 days	28 (56.0)	7 (10.0)	<0.001
Mortality	1 (2.0)	2 (2.7)	1.000

Values are presented as median (interquartile range) or number (%).

PRISM: Pediatric Risk for Mortality [22]; CAPD: Cornell assessment for pediatric delirium; VIS: vasoactive inotropic score [23]; ECMO: extracorporeal membrane oxygenator; HFNC: high-flow nasal cannula; MV: mechanical ventilation; PICU: pediatric intensive care unit.

Table 3.

Univariate analyses for associating factors of positive delirium screening

Factor	Crude odds ratio (95% CI)	P-value
Age <2 yr	2.48 (1.15–5.32)	0.022
Male	1.10 (0.53–2.28)	0.853
Presence of UD	1.14 (0.45–2.88)	0.819
All-cause postoperative care	0.96 (0.46–1.98)	1.000
Cardiovascular admission diagnosis	3.61 (1.66–7.83)	0.001
Delayed development	5.81 (2.48–13.59)	<0.001
Inotropic support	3.99 (1.84–8.67)	0.001
MV	7.12 (3.14–16.12)	<0.001
Prolonged MV >7 days	8.00 (0.93–68.62)	0.040
Sedation	6.06 (2.66–13.80)	<0.001
Prolonged sedation >7 days	6.32 (0.72–55.81)	0.127
Neuromuscular blocker	32.28 (1.83–569.05)	<0.001
Prolonged PICU stay >7 days	11.46 (4.39–29.91)	<0.001

CI: confidence interval; UD: underlying disease; MV: mechanical ventilation; PICU: pediatric intensive care unit.

Table 4.

Multivariate analyses for associating factors of positive delirium screening

Factor	Adjusted odds ratio (95% CI)	P-value
Age <2 yr	3.41 (1.19–9.73)	0.014
Cardiovascular admission diagnosis	2.92 (0.78–10.91)	0.112
Delayed development	5.03 (1.73–14.59)	0.004
Inotropic support	0.26 (0.05–1.36)	0.112
MV	4.32 (0.47–40.12)	0.197
Prolonged MV >7 days^a)	-	-
Sedation	2.05 (0.18–23.75)	0.565
Prolonged sedation >7 days	-	-
Neuromuscular blocker^a)	-	-
Prolonged PICU stay >7 days	11.58 (2.90–46.23)	0.001

Adjusted for age <2 years, inotropic support, MV, prolonged PICU stay, and sedation.

CI: confidence interval; MV: mechanical ventilation; PICU: pediatric intensive care unit; UD: underlying disease.

^a)Prolonged MV and neuromuscular blocker were not used for the final adjustment due to inadequate cells for the non-delirium group.

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References

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Implementation and effectiveness of a delirium care protocol in Thai critically ill children

Acute Crit Care. 2023;38(4):488-497. Published online November 28, 2023

DOI: https://doi.org/10.4266/acc.2023.00045

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Implementation and effectiveness of a delirium care protocol in Thai critically ill children

Figure 1. Protocol for delirium care of critically ill children. PICU: pediatric intensive care unit; SBS: State Behavioral Scale; RASS: Richmond Agitation-Sedation Scale; CAPD: Cornell Assessment of Pediatric Delirium; WAT-1: withdrawal assessment tool; EKG: electrocardiogram; QTC: corrected QT interval.

Figure 2. The flowchart for the study. All patients were followed until pediatric intensive care unit (PICU) discharge and were included for the final analysis.

Figure 1.

Figure 2.

Implementation and effectiveness of a delirium care protocol in Thai critically ill children

Factor	All patients (n=120)	Pre-intervention (n=58)	Post-intervention (n=62)	P-value
Median age (yr)	3.1 (0.9–6.8)	3.1 (0.9–5.0)	3.0 (0.6–7.8)	0.985
Age <2 yr	43 (35.8)	20 (34.5)	23 (37.1)	0.850
Male	68 (56.7)	33 (56.9)	35 (56.5)	1.000
Underlying disease				0.817
None	23 (19.2)	12 (20.7)	11 (17.8)
Cardiovascular	50 (41.7)	22 (37.9)	28 (45.2)
Neurologic	9 (7.5)	7 (12.1)	2 (3.2)
Genetic	4 (3.3)	2 (3.4)	2 (3.2)
Gastrointestinal	7 (5.8)	3 (5.2)	4 (6.5)
Hematology and oncology	7 (5.8)	3 (5.2)	4 (6.5)
Renal	2 (1.7)	1 (1.7)	1 (1.6)
Pulmonology	5 (4.2)	2 (3.4)	3 (4.8)
Trauma	1 (0.8)	1 (1.7)	-
Allergy	7 (5.8)	5 (8.7)	2 (3.2)
Endocrine	2 (1.7)	-	2 (3.2)
Rheumatology	1 (0.8)	-	1 (1.6)
Infectious disease	2 (1.7)	-	2 (3.2)
Admission diagnosis				0.165
Cardiovascular	46 (38.2)	20 (34.6)	26 (41.9)
Gastrointestinal	16 (13.3)	8 (13.8)	8 (12.9)
Pulmonology	15 (12.5)	8 (13.8)	7 (11.3)
Neurologic	12 (10.3)	7 (12.1)	5 (8.1)
Asthmatic attack	10 (8.3)	9 (15.5)	1 (1.6)
Renal	6 (5.0)	2 (3.4)	4 (6.5)
Endocrine	6 (5.0)	1 (1.7)	5 (8.1)
Septic shock	2 (1.7)	2 (3.4)	-
Oncology	2 (1.7)	1 (1.7)	1 (1.6)
Trauma	1 (0.8)	-	1 (1.6)
Dental	1 (0.8)	-	1 (1.6)
Genetic	1 (0.8)	-	1 (1.6)
Orthopedics	1 (0.8)	-	1 (1.6)
Rheumatology	1 (0.8)	-	1 (1.6)
Delayed development	37 (30.8)	18 (31.0)	19 (30.6)	1.000
All-cause postoperative care	56 (46.7)	26 (44.8)	30 (48.4)	0.718
Median PRISM III	2.0 (0.0–5.0)	0.0 (0.0–5.0)	2.0 (0.0–7.0)	0.294
Median CAPD	7.0 (3.0–12.0)	7.0 (2.0–11.2)	7.0 (3.0–12.0)	0.874
Delirium	50 (41.7)	23 (39.7)	27 (43.5)	0.713
Delirium duration (hr)	40.0 (24.0–74.0)	56.0 (32.0–72.0)	32.0 (18.0–80.0)	0.274
Inotropes	47 (39.2)	21 (36.2)	26 (41.9)	0.577
Median vasoactive inotropic score [23]	14.0 (7.0–24.0)	16.0 (5.0–25.0)	13.0 (7.8–21.4)	0.192
ECMO support	4 (3.3)	1 (1.7)	3 (4.8)	0.619
Respiratory support				0.453
None	25 (20.8)	9 (15.5)	16 (25.8)
Cannula	23 (19.2)	12 (20.7)	11 (17.7)
HFNC	24 (20.0)	14 (24.1)	10 (16.1)
MV	48 (40.0)	23 (39.7)	25 (40.3)
Median MV days	2.5 (1.0–8.8)	3.0 (1.0–9.0)	2.0 (1.0–5.5)	1.000
MV >7 days	13/48 (27.1)	9/23 (39.1)	4/25 (16.0)	0.106
Sedation	42 (35.0)	19 (32.8)	23 (37.1)	0.703
Sedation >7 days	11/42 (26.2)	7/19 (36.8)	4/23 (17.4)	0.180
NMB	9 (7.5)	4 (6.9)	5 (8.1)	1.000
Withdrawal	5 (4.2)	3 (5.2)	2 (3.2)	0.672
Median PICU days	3.0 (1.0–8.0)	3.0 (1.0–7.2)	3.0 (1.0–8.0)	0.436
PICU >7 days	35 (29.2)	16 (27.6)	19 (30.6)	0.841
Mortality	3 (2.5)	1 (1.7)	2 (3.2)	1.000

Factor	Delirium (n=50)	No delirium (n=70)	P-value
Median age (yr)	2.2 (0.8–6.5)	3.6 (1.4–8.0)	0.115
Age <2 yr	24 (48.0)	19 (27.1)	0.022
Male	29 (58.0)	39 (55.7)	0.853
Underlying disease			0.819
None	9 (18.0)	14 (20.0)
Cardiovascular	28 (56.0)	22 (31.5)
Neurologic	3 (6.0)	6 (8.6)
Genetic	2 (4.0)	2 (2.9)
Gastrointestinal	-	7 (10.0)
Hematology and oncology	2 (4.0)	5 (7.1)
Renal	1 (2.0)	1 (1.4)
Pulmonology	2 (4.0)	3 (4.3)
Trauma	-	1 (1.4)
Allergy	2 (4.0)	5 (7.1)
Endocrine	-	2 (2.9)
Rheumatology	-	1 (1.4)
Infectious disease	1 (2.0)	1 (1.4)
Admission diagnosis			0.026
Cardiovascular	28 (56.0)	18 (25.8)
Gastrointestinal	2 (4.0)	14 (20.0)
Pulmonology	8 (16.0)	7 (10.0)
Neurologic	4 (8.0)	8 (11.5)
Asthmatic attack	1 (2.0)	9 (12.9)
Renal	2 (4.0)	4 (5.7)
Endocrine	1 (2.0)	5 (7.1)
Septic shock	1 (2.0)	1 (1.4)
Oncology	1 (2.0)	1 (1.4)
Trauma	1 (2.0)	-
Dental	-	1 (1.4)
Genetic	1 (2.0)	-
Orthopedics	-	1 (1.4)
Rheumatology	-	1 (1.4)
Delayed development	26 (52.0)	11 (15.7)	<0.001
All-cause postoperative care	23 (46.0)	33 (47.1)	1.000
PRISM III	3.0 (0–7.2)	0 (0–4.0)	0.006
CAPD	12.5 (11.0 -17.0)	3.0 (0–5.2)	<0.001
Inotropes	29 (58.0)	18 (25.7)	0.001
Vasoactive inotropic score [23]	14.0 (8.0–25.0)	14.5 (5.0 -21.4)	0.853
ECMO support	4 (8.0)	-	0.028
Respiratory support			<0.001
None	6 (12.0)	19 (27.1)
Cannula	4 (8.0)	19 (27.1)
HFNC	7 (14.0)	17 (24.3)
MV	33 (66.0)	15 (21.5)
MV duration	5.0 (2.0–9.0)	1.0 (1.0–1.5)	0.013
MV >7 days	12/33 (36.4)	1/15 (6.7)	0.040
Sedation	29 (58.0)	13 (18.6)	<0.001
Sedation >7 days	10/29 (34.5)	1/13 (7.7)	0.127
Neuromuscular blocker	9 (18.0)	-	<0.001
Withdrawal	5 (10.0)	-	0.011
Median PICU stay	7.5 (3.0–13.0)	2.0 (1.0–4.0)	<0.001
PICU >7 days	28 (56.0)	7 (10.0)	<0.001
Mortality	1 (2.0)	2 (2.7)	1.000

Factor	Crude odds ratio (95% CI)	P-value
Age <2 yr	2.48 (1.15–5.32)	0.022
Male	1.10 (0.53–2.28)	0.853
Presence of UD	1.14 (0.45–2.88)	0.819
All-cause postoperative care	0.96 (0.46–1.98)	1.000
Cardiovascular admission diagnosis	3.61 (1.66–7.83)	0.001
Delayed development	5.81 (2.48–13.59)	<0.001
Inotropic support	3.99 (1.84–8.67)	0.001
MV	7.12 (3.14–16.12)	<0.001
Prolonged MV >7 days	8.00 (0.93–68.62)	0.040
Sedation	6.06 (2.66–13.80)	<0.001
Prolonged sedation >7 days	6.32 (0.72–55.81)	0.127
Neuromuscular blocker	32.28 (1.83–569.05)	<0.001
Prolonged PICU stay >7 days	11.46 (4.39–29.91)	<0.001

Factor	Adjusted odds ratio (95% CI)	P-value
Age <2 yr	3.41 (1.19–9.73)	0.014
Cardiovascular admission diagnosis	2.92 (0.78–10.91)	0.112
Delayed development	5.03 (1.73–14.59)	0.004
Inotropic support	0.26 (0.05–1.36)	0.112
MV	4.32 (0.47–40.12)	0.197
Prolonged MV >7 days^a)	-	-
Sedation	2.05 (0.18–23.75)	0.565
Prolonged sedation >7 days	-	-
Neuromuscular blocker^a)	-	-
Prolonged PICU stay >7 days	11.58 (2.90–46.23)	0.001

Table 1. Demographic data among intervention groups

Values are presented as median (interquartile range) or number (%).

Table 2. Associating factors for positive delirium screening

Values are presented as median (interquartile range) or number (%).

Table 3. Univariate analyses for associating factors of positive delirium screening

CI: confidence interval; UD: underlying disease; MV: mechanical ventilation; PICU: pediatric intensive care unit.

Table 4. Multivariate analyses for associating factors of positive delirium screening

Adjusted for age <2 years, inotropic support, MV, prolonged PICU stay, and sedation.

CI: confidence interval; MV: mechanical ventilation; PICU: pediatric intensive care unit; UD: underlying disease.

Prolonged MV and neuromuscular blocker were not used for the final adjustment due to inadequate cells for the non-delirium group.