Pediatric Delirium: Combating Brain Dysfunction

As the foundation for patient care was being laid during nursing school, the signs and symptoms of major organ dysfunctions associated with shock and disease processes, such as sepsis, were ingrained in us. However, I don’t remember learning about the concept of brain dysfunction. Altered mental status – yes, coma – yes, obtundation – yes; but it wasn’t like we could do anything about them, right? The first time I heard a patient described as delirious, I thought the word was a facetious way to describe the confusion I was witnessing. Being delirious is indeed a form of confusion, a manifestation of a serious form of acute brain insufficiency or failure. Delirium is defined as a syndrome of an acute change or fluctuation from baseline mental status and the associated inattention. I did not realize at that time that delirium was a significant problem caused by the imbalance of neurotransmitter release or uptake from sick neurons. Delirium in the ICU is a symptom of acute brain dysfunction that can be caused by many factors associated with a patient’s critical illness, including iatrogenic harm (due to the care we are providing for their critical illness). Our care could be hurting.

The Many Masks of Delirium

Nurses must understand that when acute brain dysfunction occurs, it can be assessed and is impacted by our care. Delirium wears many masks; it looks different in every patient. Can a tool help us screen for something that always looks different?

Every patient with delirium shares some features that our tools can help us assess. Consider this point: A patient who is withdrawn may not be able to pay attention to you. And an agitated patient may not be able to pay attention to you either. Both patients are demonstrating inattention, a key feature of delirium. However, they are very different patients wearing very different masks. One is calm (RASS -1), and the other is agitated (RASS +1). The different masks both reflect the same syndrome: manifestations of acute brain dysfunction. We don’t diagnose based on the mask, rather those core features of delirium that are under the surface. When the brain isn’t working correctly, neurons may fire too much or not enough. Remember from pathophysiology class that the brain has sets of stimulation (excitatory) neurons and calming (inhibitory) neurons. When the brain doesn’t function correctly and there is either too much stimulation or too much inhibition we see these different masks, better known as subtypes of delirium. I frequently hear parents describe a child who has delirium as “not being themselves” or “not there” or “not my child.” Parents may become frustrated and upset, because they feel their child is “looking through them” rather than at them, or their once well-mannered and pleasant child is now irritable, withdrawn and uninterested in what typically brings them comfort or makes them laugh.

Delirium Subtypes

The masks or subtypes of delirium are classified as follows:

• Hypoactive delirium subtype is the most common subtype of delirium in children.
  • Patients appear depressed, withdrawn, unresponsive. You might observe a lack of eye contact or decreased level of consciousness.
  • These patients are often labeled as “good patients” because they can be “paired” and need less direct nursing care.
• Hyperactive delirium subtype is the least common subtype in children, but it most closely matches the popular descriptors of delirium.
  • Patients appear agitated, irritable, inconsolable and may become combative.
• Mixed delirium subtype is when a patient fluctuates between hypoactive and hyperactive manifestations.

Detecting Delirium

Experienced ICU nurses can reflect on a time early in their careers when delirium was referred to as ICU psychosis, encephalopathy or ICU syndrome. Some nurses believed it to be an obligatory part of critical illness and hospitalization, thinking they couldn’t do anything about it. Tools to screen for ICU delirium, such as CAM-ICU and ICDSC, only became available for adults about two decades ago. Despite improved identification of delirium with these tools, interventions were lacking and studies showed that delirium was associated with memory and attention problems even a year after discharge to home. Without a clear way to address delirium in adults, it seemed nearly impossible to figure it out for children.

Pediatric Assessment Tools

When I was orienting to pediatrics, a nurse mentor explained that we could now reliably screen for ICU delirium in infants and children. She said they have delirium at very high rates. I was taken aback. Given their developing brains, what was the possible impact of delirium on children, especially given the poor outcomes associated with delirium in adults? What do my patients really experience? How do they communicate their fear, pain or confusion? I had so many questions and few answers. The drive to find answers to these questions and effect possible change to decrease risk of long-term cognitive problems in kids led me to a career in research. If there was a way to prevent or treat this acute brain dysfunction in children, I wanted to help find it.

I felt a jolting transition from direct patient care to becoming immersed with a team of researchers on a mission to find answers. Delirium epidemiology in the pediatric population lags behind that in adults, meaning that roughly a decade ago, delirium was par for the course during an ICU stay. Deep sedation or even coma induced by lots of sedation and pain medicine for days if not weeks in children on mechanical ventilation was a common and repetitive picture, bed after bed. To be fair, many intelligent and caring nurses and physicians thought that sedating kids saved them from the ICU experience of tubes, intravenous lines, suctioning, positioning, wound care, further procedures, noise, lights, strangers and alarms. So many alarms.

But pediatric psychologists began to recognize the long-term effects of sedatives and the ICU environment caused post-traumatic stress symptoms in many of the kids who we thought we were saving. It was no longer enough that a patient could breathe, eat, and move their arms and legs. Brain recovery, personality recovery, mental health and happiness became our goals. Quality versus quantity was the new norm, along with the understanding that we can, in fact, do something about delirium.

A small cohort of physicians, nurses, pharmacists and therapists took up the battle against the status quo. The pediatric confusion assessment method for the ICU (pCAM-ICU) was the first valid and reliable bedside tool to assess for delirium in children developmentally 5 years of age and older, adapted from the adult CAM-ICU. With this tool and a handful of other validated screening tools, bedside nurses are in a key position to impact these patients. Assessing pain. Treating pain. Reassessing pain. Assessing for level of consciousness and delirium. Determining where the patient is now (sedated/obtunded?) in light of where they should be (was that the optimal dose of sedation/analgesia?). Is something out of place? The pCAM-ICU enables each of us to assess for delirium in the moment. I want to know now: Is there something wrong? I want to reassess my patient. I would do it if it were my child – why would I do less for someone else?

Pediatric Development and Delirium

As our patients develop, pediatric nurses know what to anticipate regarding communication, language and even social-emotional responses. These developmental changes affect what we expect to see with delirium assessment as well. A second version of the delirium tool was developed to address limitations in language and cognition in infants and younger children. The preschool confusion assessment method for the ICU or psCAM-ICU can be used in all children developmentally less than 5 years of age, including neonates, for the assessment of ICU delirium. With the pCAM-ICU and the psCAM-ICU incorporated into my electronic medical record (EMR) documentation system, I can communicate with the medical team regarding brain dysfunction and help meld the medical plan to address and support brain health.

When either the pCAM-ICU or psCAM-ICU demonstrates that delirium is present, I am empowered to impact the care of this child and discuss an approach, a change of care, a new search for a possible complication (BRAIN MAPS) or worsening of current disease processes that need intervention. Knowing that my patient has delirium does not tie my hands, even though I may not be able to do much to treat it in the moment. However, this knowledge helps me tailor care that limits the effect on the brain as much as possible.

Delirium Screening

Delirium diagnosis requires the presence of certain criteria based on the “Diagnostic and Statistical Manual of Mental Disorders” (DSM 5). While there are several tools available, I will share a quick overview of the CAM tools. Both the psCAM-ICU and pCAM-ICU assess for the main features of delirium, including:

1. Acute alteration or fluctuation from baseline mental status (key criterion)
2. Inattention (key criterion)
3. Acute altered level of consciousness
4. Disorganized systems/thinking

Delirium is present when a patient has features 1 and 2 plus either feature 3 or 4.

Delirium Treatment

Step #1: Start with the causes. Here are a few important points:

• Delirium is commonly caused by the same disease process that led to the need for ICU care.
• BRAIN MAPS is an acronym that summarizes the most common causes or triggers of delirium:
  • B – Bring oxygen (hypoxemia, decreased cardiac output, anemia)
  • R – Remove or Reduce deliriogenic medications (anticholinergics, benzodiazepines)
  • A – Atmosphere (i.e., lights, noise, restraints, absent family, “strangers,” no schedule)
  • I – Infection, Immobilization, Inflammation
  • N – New organ dysfunction (CNS, CV, PULM, hepatic, renal, endocrine)
    
    
  • M – Metabolic disturbances: alkalosis, acidosis, increase or decrease in sodium and/or potassium, decrease in glucose or calcium
  • A – Awake (no bedtime routine, sleep-wake cycle disturbance)
  • P – Pain (too much pain without enough medication or pain adequately treated and now medication dose is too much)
  • S – Sedation (assess need and set sedation target)

Step #2: What can you modify? Here’s where things get complicated.

• A. No medication treats delirium. First, treat the medical illness.

Interventions ultimately treat acute brain dysfunction, including care directed toward the critical illness. When a child presents with septic shock, your “spidey senses” go off when you hear that in addition to being hypotensive and poorly perfused, the patient has altered mental status. The patient likely has delirium. The brain is sensitive to lack of perfusion pressure and oxygenation. Consider delirium the fifth vital sign after heart rate, saturation, blood pressure and respiratory rate. The point here: Treat the problem (shock), and don’t do anything that may worsen brain dysfunction. Limit sedation as needed and choose wisely. Some medications, such as midazolam, can exacerbate delirium. In renal failure, you limit use of certain antibiotics while monitoring medication levels. You can take the same approach with delirium. But it is not always that simple, especially when a parent desperately wants answers. BRAIN MAPS also helps us think through other conditions that may not be the main cause but could improve the situation if we address them. The recently released PANDEM guidelines also offer nurses and other clinicians suggestions on best practice in the ICU.

• A. Use of haloperidol or atypical antipsychotics may manage manifestations (agitation, being withdrawn) but does not “cure” delirium.

Haloperidol or atypical antipsychotics work by regulating either excitatory or inhibitory neurotransmission. Therefore, when a patient is agitated, haloperidol can lead to calmness. If a patient is withdrawn, atypical antipsychotics may improve their mood. But using these medications is like putting a bandage on a cut. While they may help decrease the severity of symptoms or manifestations, we still must focus on managing the main problem that led to delirium in the first place.

• B. Incorporate pain, agitation and delirium assessment while targeting sedation, and focus on early mobility and family involvement as they may liberate patients from the ventilator and the ICU.

The ABCDEF bundle, an ICU liberation tool from the Society of Critical Care Medicine, is used around the world in adult and pediatric populations. Implementation of this bundle has proven to increase the chances of survival, and reduce the amount of time a patient is on mechanical ventilation, length of stay in the hospital, chances of delirium and costs of care in adults. We look forward to understanding the impact on children.

The components of the ABCDEF bundle are:

• A – Assess, prevent and manage pain
• B – Both spontaneous awakening trials and spontaneous breathing trials
• C – Choice of analgesia and sedation
• D – Delirium: assess, prevent and manage
• E – Early mobility and exercise
• F – Family engagement and empowerment

Why Delirium Efforts Matter

Delirium is associated with longer ICU and hospital lengths of stay and costs. We do not yet know whether ICU delirium is associated with poorer long-term outcomes such as cognition, attention or post-traumatic stress symptoms. It is amazing to see once critically ill pediatric patients recover and return home to live a full life, including going back to school, playing sports and being involved in social activities. However, when a child survives critical illness but faces a life full of struggle, it is heartbreaking. Children may have newfound fear about physicians/nurses or anxiety, nightmares or lability in their mood. Even more, survivors of critical illness may have behavioral issues at home – the once straight-A student is now barely passing. Behavior or learning disabilities may be exhibited due to problems with attention or executive dysfunction that may occur after having delirium. The mind is so complex and, in addition to the core functional components, there is a social-emotional piece that either allows a child to fly or clips their wings. Younger children may not be able to express what they are feeling or going through. As pediatric nurses, we know that each healthy year during childhood is formative; it is when the groundwork is being laid. But what if this development is interrupted? There is so much more to learn.

The Value of Research

As a nurse, I have learned to keep an open mind and allow data to drive new understanding and interests. The delirium story is just that, an opportunity to watch a complete transition in how we think about brain dysfunction, how we assess it and what we should do to preserve the brain. A career in research? Something I never thought I’d do, or be good at. I realized it just takes heart and the desire to tackle a problem.

Don’t miss the opportunity to join the ride. You have an important role in providing excellence in care, challenging the care we provide and promoting change when needed. When you are at the bedside, do me a favor: High-five research nurses, as they are already high-fiving you.

If you want to learn more about ICU delirium, visit the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center.

How do you assess the many masks of delirium in your patient population?