Sage Lachman

Learning Objectives: Delirium is a well-defined complication of critical illness in adults and has been shown to be associated with long-term cognitive dysfunction. Pediatric critical care is now beginning to diagnose delirium, but its effect on cognitive function is unknown. The primary objective of this study was to investigate the incidence of delirium in the pediatric intensive care unit (PICU) and the relation to long-term cognitive dysfunction.

Methods: Children (5–17 years) with an anticipated PICU stay of > 24 hours without significant developmental delay or neurologic injury were recruited. Daily screens for delirium were conducted with the Cornell Assessment of Pediatric Delirium (CAPD) and Pediatric Confusion Assessment Method for the ICU (PCAM). The Children’s Memory Scale (CMS) was administered on all children at time of transfer from the PICU and 3 months later.

Results: Seventeen children completed the 3 month follow up: mean age = 12.1 years, 53% male, and 59% Latino. The mean PICU length of stay was 8.1 days (SD=11.6) and 59% were intubated. At time of transfer from the PICU 82% of the children were categorized as normal on the Pediatric Cerebral Performance Category (PCPC) and 18% as mild disability. During their PICU stay 53% of children screened positive on at least one delirium screener; mean days positive screen = 1.4 (SD=1.9). At time of transfer children scored at < 50th percentile on all domains of the CMS: attention-concentration mean = 35.1% and 42.1%; visuospatial 41.4% and 34.9%; memory 11.5% and 35.1%. There was no significant difference between children with or without delirium on cognitive function. At follow up children’s cognitive function had improved: attention- concentration mean = 47.3% and 48.6%; visuospatial 50.4% and 59.4%; memory 21.2% and 53.3%; again there was no association with delirium status. Overall there was a significant positive correlation between children’s cognitive function at baseline and at follow up.

Conclusions: More than half of children in this population screened positive for delirium during their PICU stay. At time of transfer from the PICU children show impairment in multiple areas of cognitive function, but this is not associated with delirium. While children’s cognitive function improves over time, children with worse function continue to have worse function 3 months later. Long-term investigation into the neurocognitive effects of pediatric critical illness and its treatment must continue beyond 3 months.

Objectives: Delirium, as defined in the DSM-5, is an acute disturbance in
attention and awareness and is a well-described adverse outcome following
adult critical illness. It is less understood in pediatrics. The primary objective of
this study was to evaluate the incidence of delirium in a pediatric intensive
care unit (PICU) and diagnostic associations.

Methods: Children (ages 5–17 years) with an anticipated PICU stay of >24
hours without significant developmental delay or neurologic injury were
recruited. Daily screens for delirium were conducted with the Cornell
Assessment of Pediatric Delirium (CAPD) and Pediatric Confusion Assessment
Method for the ICU (PCAM). Delirium positive children were referred to
psychiatry. All children had cognitive testing done at time of transfer with the
Children’s Memory Scale (CMS). Other medical data were collected via chart
review.

Results: Children (N ¼ 53) were recruited (mean age ¼ 11 years, 51% male),
with a variety of ethnic backgrounds. Forty-two percent of children screened
positive for delirium. Psychiatry confirmed the diagnosis in 54 percent of them
(23% of the total number). Children performed at <50th percentile in all domains of the CMS: 1) attention/concentration (mean ¼ 28.0%ile); 2) visual/
nonverbal memory (mean ¼ 30.9 and 41.7%ile); and 3) auditory/verbal memory (mean ¼ 41.4 and 14.3%ile). There were no group differences based on
age or gender in the screen of children’s delirium; however, children who
screened positive had higher opiate and benzodiazepine use and longer
lengths of stay (t ¼ 4.01, P ¼ 0.00; t ¼ 1.9, P ¼ 0.06; t ¼ 3.7, P ¼ 0.00).
Irrespective of delirium status, both groups performed poorly on the CMS
without significant group differences.

Conclusions: The incidence of delirium in this population was 42 percent by
screener and 23 percent after psychiatric evaluation. The new DSM-5
criteria for delirium focus on cognitive dysfunction. The children in this
study had significantly impaired cognitive function in the diagnostic domains of delirium, regardless of delirium status. Thus, although delirium assessments capture some of the children with delirium, both the screeners
and psychiatry are still missing a significant proportion of children who have
ongoing cognitive dysfunction. Pediatric healthcare needs to improve its
evaluation of delirium to minimize ongoing cognitive deficits after admission to the PICU.