Consideraciones diagnósticas sobre delirio en pediatría. Revisión y propuesta de un algoritmo para las UCIs pediátricas
Diagnostic considerations regarding pediatric delirium: a review and a proposal for an algorithm for pediatric intensive care units.
Schieveld JN, van der Valk JA, Smeets I, Berghmans E, Wassenberg R, Leroy PL, Vos GD, van Os J.
Division of Child and Adolescent Psychiatry, Department of Psychiatry and Psychology, European Graduate School of Neuroscience, SEARCH, Maastricht University Medical Centre, 6202 AZ Maastricht, The Netherlands.jan.schieveld@mumc.nl
Intensive Care Med. 2009 Nov;35(11):1843-9. doi: 10.1007/s00134-009-1652-8.
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 predelirious states at the PICU, daily evaluation is mandatory. Future algorithmic refinement is urgently required.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2765651/pdf/134_2009_
Article_1652.pdf
Sobre la utilidad de los instrumentos de diagnóstico del delirio en niños graves: evaluación de la escala Pediatric Anesthesia Emergence Delirium, de Delirium Rating Scale 88, y de Delirium Rating Scale-Revised R-98.
On the utility of diagnostic instruments for pediatric delirium in critical illness: an evaluation of the Pediatric Anesthesia Emergence Delirium Scale, the Delirium Rating Scale 88, and the Delirium Rating Scale-Revised R-98.
Janssen NJ, Tan EY, Staal M, Janssen EP, Leroy PL, Lousberg R, van Os J, Schieveld JN.
Division of Child and Adolescent Psychiatry and Psychology, Department of Psychiatry and Psychology, European Graduate School of Neuroscience, Maastricht University Medical Centre, SEARCH, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
Intensive Care Med. 2011 Aug;37(8):1331-7. doi: 10.1007/s00134-011-2244-y. Epub 2011 May 13.
Abstract
PURPOSE: Delirium is a poor-prognosis neuropsychiatric disorder. Pediatric delirium (PD) remains understudied, particularly at pediatric intensive care units (PICU). Although the Pediatric Anesthesia Emergence Delirium (PAED) scale, the Delirium Rating Scale (DRS-88), and the Delirium Rating Scale-Revised (DRS-R-98) are available, none have been validated for use in PICU settings. The aim of the present study was to investigate the use of the DRS/PAED instruments as diagnostic tools for PD in the PICU. METHODS: A prospective panel study was conducted, under circumstances of routine clinical care, investigating the diagnostic properties of the PAED, DRS-88, and DRS-R-98 in PICU patients at a tertiary university medical center. A total of 182 non-electively admitted, critically ill pediatric patients, aged 1-17 years, were included between November 2006 and February 2010. Sensitivity, specificity, and receiver operating characteristic (ROC) curves were calculated. Three psychometric properties were analyzed: (1) internal consistency (2) proportion of items not rateable, and (3) discriminative ability. RESULTS: The PAED could be completed in 144 (93.5%) patients, much more frequently than either the DRS-88 (66.9%) or the DRS-R-98 (46.8%). Compared with the clinical gold standard diagnosis of delirium, the PAED had a sensitivity of 91% and a specificity of 98% (AUC 0.99). The optimal PAED cutoff score as a screening instrument in this PICU setting was 8. Cronbach's alpha was 0.89; discriminative ability was high. CONCLUSIONS: The PAED is a valid instrument for PD in critically ill children, given its reliance on routinely rateable observational signs and symptoms.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3136686/pdf/134_2011_
Article_2244.pdf
Delirio; Una frontera emergente en el manejo de los niños graves
Delirium: an emerging frontier in the management of critically ill children.
Smith HA, Fuchs DC, Pandharipande PP, Barr FE, Ely EW.
Pediatrics and Anesthesiology Division of Critical Care, Department of Pediatrics, 5121 Doctor's Office Tower, 2200 Children's Way, Nashville, TN 37232-9075, USA. heidi.smith@vanderbilt.edu
Crit Care Clin. 2009 Jul;25(3):593-614, x. doi: 10.1016/j.ccc.2009.05.002.
Abstract
The objectives of this article are (1) to introduce pediatric delirium and provide understanding of acute brain dysfunction with its classification and clinical presentations (2) to understand how delirium is diagnosed and discuss current modes of delirium diagnosis in the critically ill adult population and translation to pediatrics (3) to understand the prevalence and prognostic significance of delirium in the adult and pediatric critically ill population (4) to discuss the pathophysiology of delirium as currently understood, and (5) to provide general management guidelines for delirium.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2793079/pdf/nihms135370.pdf
Delirio en los niños graves: fenomenología, correlación clínica y respuesta terapéutica
Pediatric delirium in critical illness: phenomenology, clinical correlates and treatment response in 40 cases in the pediatric intensive care unit.
Schieveld JN, Leroy PL, van Os J, Nicolai J, Vos GD, Leentjens AF.
University Hospital Maastricht, Division of Child and Adolescent Psychiatry, Department of Psychiatry, 5800, 6202, AZ Maastricht, The Netherlands.jan.schieveld@spsy.azm.nl
Intensive Care Med. 2007 Jun;33(6):1033-40. Epub 2007 Apr 25.
Abstract
OBJECTIVE: To study the phenomenology, clinical correlates, and response to treatment of delirium in critically ill children in the pediatric intensive care unit (PICU). DESIGN, SETTING AND PATIENTS: Descriptive study of a cohort of child psychiatric consultations from a tertiary PICU between January 2002 and December 2005. Demographic data, clinical presentation, and response to treatment of children subsequently diagnosed with delirium were analyzed. RESULTS: Out of 877 admissions (age distribution 0-18 years) arose 61 requests for psychiatric assessment. Of the 61 children, 40 (15 girls and 25 boys) were diagnosed with delirium (cumulative incidence 5%; mean age 7.6 years). Age-specific incidence rates varied from 3% (0-3 years) to 19% (16-18 years). In addition to the classical hypoactive and hyperactive presentations, a third presentation was apparent, characterized mainly by anxiety, with a higher prevalence in boys. All but 2 of the 40 children received antipsychotic medication: 27 (68%) haloperidol, 10 (25%) risperidone, and 1 both in succession. Two children treated with haloperidol experienced an acute torticollis as side effect. All children made a complete recovery from the delirium; five, however, died of their underlying disease. CONCLUSION: The rate of delirium in critically ill children on a PICU is not negligible, yet prospective studies of the phenomenology, risk factors and treatment of childhood delirium are very rare. Once pediatric delirium has been recognized, it generally responds well to treatment.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1915613/pdf/134_2007_
Article_637.pdf
Atentamente
Dr. Enrique Hernández-Cortez
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org
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