Abstract
Many critically ill patients suffer from delirium which is associated with significant
morbidity and mortality. There is a paucity of data about the incidence, symptoms,
or treatment of delirium in the pediatric intensive care unit (PICU). Risk factors
for delirium are common in the PICU including central nervous system immaturity, developmental
delay, mechanical ventilation, and use of anticholinergic agents, corticosteroids,
vasopressors, opioids, or benzodiazepines. Hypoactive delirium is the most common
subtype in pediatric patients; however, hyperactive delirium has also been reported.
Various screening tools are validated in the pediatric population, with the Cornell
Assessment of Pediatric Delirium (CAPD) applicable to the largest age range and able
to detect signs and symptoms consistent with both hypo- and hyperactive delirium.
Treatment of delirium should always include identification and reversal of the underlying
etiology, reserving pharmacologic management for those patients without symptom resolution,
or with significant impact to medical care. Atypical antipsychotics (olanzapine, quetiapine,
and risperidone) should be used first-line in patients requiring pharmacologic treatment
owing to their apparent efficacy and low incidence of reported adverse effects. The
choice of atypical antipsychotic should be based on adverse effect profile, available
dosage forms, and consideration of medication interactions. Intravenous haloperidol
may be a potential treatment option in patients unable to tolerate oral medications
and with significant symptoms. However, given the high incidence of serious adverse
effects with intravenous haloperidol, routine use should be avoided. Dexmedetomidine
should be used when sedation is needed and when clinically appropriate, given the
positive impact on delirium. Additional well-designed trials assessing screening and
treatment of PICU delirium are needed.
Keywords
delirium - haloperidol - olanzapine - pediatric - quetiapine - risperidone
