Delirium in Pediatrics Intensive Care Unit: Diagnosis and Nursing Management

Yıl 2021, Cilt: 2 Sayı: 1, 92 - 104, 07.06.2021

Damla Özçevik Subaşi

Öz

Delirium is a clinical syndrome with rapid onset and fluctuating course, accompanied by many factors in its etiology, and changes in consciousness, perception, thought, sleep-wake cycle. Although the prevalence of pediatric delirium varies according to the clinical profile of intensive care units, this rate can reach up to 57%. In addition to the most common hypoactive delirium observed in hospitalized children, there are three different types including hyperactive and mixed types. Studies show that the number of children with delirium detected after routine screening in units and units is higher. Diagnosis and management of delirium requires multidimensional nursing assessment. Using pediatric delirium screening tools, nurses should initiate delirium screening of critically ill children from their admission to the intensive care unit and evaluate them regularly 2-3 times a day. It is the key to preventing, managing and mitigating delirium in children by applying major non-pharmacological interventions (cognitive interventions, enabling environmental changes and promoting sleep, ensuring family participation, providing physiological support, providing early mobilization). In this review, nursing interventions for the diagnosis, prevention and management of delirium in children hospitalized in pediatric intensive care units are systematically discussed in the light of the literature.

Anahtar Kelimeler

Child, delirium, ıntensive care, nursing process, nursing care

Pediatrik Yoğun Bakım Ünitesinde Deliryum: Tanılama ve Hemşirelik Yönetimi

Öz

Deliryum hızlı başlangıçlı ve dalgalı seyreden, etiyolojisinde birçok faktörün eşlik ettiği, bilinç, algılama, düşünce, uyku-uyanıklık döngüsünde değişikliklerin görüldüğü klinik bir sendromdur. Pediatrik deliryum prevalansı yoğun bakım ünitelerinin klinik profile göre değişkenlik göstermekle birlikte, bu oran %57’ye kadar çıkabilmektedir. Hastanede yatan çocuklarda en sık hipoaktif deliryum gözlenmesinin yanı sıra hiperaktif ve miks tipler dahil olmak üzere toplam üç farklı çeşidi bulunmaktadır. Çalışmalar, birim ve ünitelerde rutin taramadan sonra deliryum tespit edilen çocuk sayısının rutin tarama öncesi daha fazla olduğunu göstermektedir. Deliryumda tanılama ve yönetim, çok boyutlu hemşirelik değerlendirmesi gerektirir. Pediatrik deliryum tarama araçlarını kullanarak, kritik hasta çocukların yoğun bakım ünitesine yatışından itibaren deliryum taramasını başlatmalı ve düzenli olarak günde 2-3 kez değerlendirmelidir. Hemşireler, başlıca non-farmakolojik girişimleri (bilişsel girişimler, çevresel değişikliklerin sağlanması ve uykunun teşviki, aile katılımının sağlanması, fizyolojik destek sağlanması, erken mobilizasyonun sağlanması) uygulayarak çocuklarda deliryumu önleme, yönetme ve olumsuz sonuçları hafifletebilmenin anahtarıdır. Bu derlemede, çocuk yoğun bakım ünitelerinde yatan çocuklarda deliryumun tanılanması, önlenmesi ve yönetimine yönelik hemşirelik girişimleri sistematik olarak literatür ışığında tartışılmıştır.

Anahtar Kelimeler

Çocuk, Deliryum, Yoğun bakım, hemşirelik süreci, hemşirelik bakımı

Kaynakça

• 1. American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Publishing. 2013;5(128-129).
• 2. Kudchadkar SR, Yaster M, Punjabi NM. Sedation, sleep promotion, and delirium screening practices in the care of mechanically ventilated children: a wake-up call for the pediatric critical care community. Critical care medicine. 2014;42(7):1592-600.
• 3. Smith HA, Boyd J, Fuchs DC, Melvin K, Berry P, Shintani A, et al. Diagnosing delirium in critically ill children: Validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit. Critical care medicine. 2011;39(1):150.
• 4. Flaigle MC, Ascenzi J, Kudchadkar SR. Identifying barriers to delirium screening and prevention in the pediatric ICU: evaluation of PICU staff knowledge. Journal of pediatric nursing. 2016;31(1):81-4.
• 5. Karadaş C. Yoğun bakımda yatan 65 yaş ve üstü bireylerde eklem açıklığı hareketlerinin deliryumu önlemedeki etkisi.Yayınlanmamış Tez: Hacettepe Üniversitesi, Sağlık Bilimleri Enstitüsü, Yüksek Lisans Tezi, Ankara. 2015.
• 6. Akıncı S, Şahin A. Yoğun bakımda deliryum. Yoğun Bakım Dergisi. 2005;5(1):26-35.
• 7. Doğu Ö, Kaya H. Yoğun Bakımda deliryum ve hemşirelik bakımı. J Hum Rhythm. 2017;3(2):81-4.
• 8. Siegel EJ, Traube C. Pediatric delirium: epidemiology and outcomes. Current opinion in pediatrics. 2020;32(6):743-9.
• 9. Smith HA, Gangopadhyay M, Goben CM, Jacobowski NL, Chestnut MH, Savage S, et al. The Preschool Confusion Assessment Method for the ICU (psCAM-ICU): Valid and Reliable Delirium Monitoring for Critically Ill Infants and Children. Critical care medicine. 2016;44(3):592.
• 10. Traube C, Silver G, Kearney J, Patel A, Atkinson TM, Yoon MJ, et al. Cornell Assessment of Pediatric Delirium: a valid, rapid, observational tool for screening delirium in the PICU. Critical care medicine. 2014;42(3):656.
• 11. Alvarez RV, Palmer C, Czaja AS, Peyton C, Silver G, Traube C, et al. Delirium is a common and early finding in patients in the pediatric cardiac intensive care unit. The Journal of pediatrics. 2018;195:206-12.
• 12. Traube C, Silver G, Reeder R, Doyle H, Hegel E, Wolfe H, et al. Delirium in Critically Ill Children: An International Point Prevalence Study. Crit Care Med. 2017;45(4):584-90.
• 13. Kahraman Berberoğlu B, Çalışır H. Pediatrik Yoğun Bakım Ünitesinde Yatan Hastalarda Deliryumun Tanılanması ve Hemşirelik Yönetimi. Ebelik ve Sağlık Bilimleri Dergisi. 2020;3(3):233-43.
• 14. Hatherill S, Flisher AJ. Delirium in children and adolescents: a systematic review of the literature. Journal of psychosomatic research. 2010;68(4):337-44.
• 15. Traube C, Silver G, Gerber LM, Kaur S, Mauer EA, Kerson A, et al. Delirium and Mortality in Critically Ill Children: Epidemiology and Outcomes of Pediatric Delirium. Crit Care Med. 2017;45(5):891-8.
• 16. Porter S, Holly C, Echevarria M. Infants with delirium: a primer on prevention, recognition, and management. Pediatric nursing. 2016;42(5):223.
• 17. Traube C, Silver G, Gerber LM, Kaur S, Mauer EA, Kerson A, et al. Delirium and mortality in critically ill children: epidemiology and outcomes of pediatric delirium. Critical care medicine. 2017;45(5):891-8.
• 18. Maldonado JR. Neuropathogenesis of delirium: review of current etiologic theories and common pathways. The American Journal of Geriatric Psychiatry. 2013;21(12):1190-222.
• 19. Hughes CG, Patel MB, Pandharipande PP. Pathophysiology of acute brain dysfunction: what's the cause of all this confusion? Current opinion in critical care. 2012;18(5):518-26.
• 20. Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y. Incidence, risk factors and consequences of ICU delirium. Intensive care medicine. 2007;33(1):66-73.
• 21. Silver G, Traube C, Gerber LM, Sun X, Kearney J, Patel A, et al. Pediatric delirium and associated risk factors: a single-center prospective observational study. Pediatric critical care medicine: a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2015;16(4):303.
• 22. Bettencourt A, Mullen JE. Delirium in Children: Identification, Prevention, and Management. Crit Care Nurse. 2017;37(3):e9-e18.
• 23. Grover S, Ghosh A, Kate N, Malhotra S, Mattoo SK, Chakrabarti S, et al. Do motor subtypes of delirium in child and adolescent have a different clinical and phenomenological profile? Gen Hosp Psychiatry. 2014;36(2):187-91.
• 24. Staveski SL, Pickler RH, Lin L, Shaw RJ, Meinzen-Derr J, Redington A, et al. Management of pediatric delirium in pediatric cardiac intensive care patients: an international survey of current practices. Pediatric Critical Care Medicine. 2018;19(6):538-43.
• 25. Schieveld J, Ista E, Knoester H, Molag M. Pediatric delirium: a practical approach. In: Rey J, ed. IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva, Switzerland: International Association for Child and Adolescent Psychiatry and Allied Professions; 2015:chap1.5:1-17. . 2015.
• 26. Dechnik A, Mauer EA, Gerber LM, Traube C. C-Reactive protein and procalcitonin levels may not predict delirium in critically ill children. Pediatric Critical Care Medicine. 2020;21(11):e967-e71.
• 27. Smith HA, Berutti T, Brink E, Strohler B, Fuchs DC, Ely EW, et al., editors. Pediatric critical care perceptions on analgesia, sedation, and delirium. Seminars in respiratory and critical care medicine; 2013: Thieme Medical Publishers.
• 28. Smeets IA, Tan EY, Vossen HG, Leroy PL, Lousberg RH, Van Os J, et al. Prolonged stay at the paediatric intensive care unit associated with paediatric delirium. European child & adolescent psychiatry. 2010;19(4):389-93.
• 29. Sarman A, Sarman E. Deliryumdaki Pediatrik Yoğun Bakım Hastalarına Hemşirelik Yaklaşımı. İnönü Üniversitesi Sağlık Hizmetleri Meslek Yüksekokulu Dergisi. 2020;8(3):964-72.
• 30. Patel AK, Bell MJ, Traube C. Delirium in pediatric critical care. Pediatric Clinics. 2017;64(5):1117-32.
• 31. American Association of Critical-Care Nurses. AACN practice alert: assessment and management of delirium across the life span. Crit Care Nurse. 2016;36(5):14-9.
• 32. Norman S, Taha AA, Turner HN. Delirium in the critically ill child. Clinical Nurse Specialist. 2017;31(5):276-84.
• 33. Amirnovin R, Sanchez-Pinto LN, Okuhara C, Lieu P, Koh JY, Rodgers JW, et al. Implementation of a risk-stratified opioid and benzodiazepine weaning protocol in a pediatric cardiac ICU. Pediatric Critical Care Medicine. 2018;19(11):1024-32.
• 34. Gaillard-Le Roux B, Liet J-M, Bourgoin P, Legrand A, Roze J-C, Joram N. Implementation of a nurse-driven sedation protocol in a PICU decreases daily doses of midazolam. Pediatric Critical Care Medicine| Society of Critical Care Medicine. 2017;18(1):e9-e17.
• 35. Karadaş C, Özdemir L. Nursing responsibilities and non-pharmacological approaches in delirium management. Journal of Psychiatric Nursing. 2019;10(2):137-42.
• 36. Harris J, Ramelet A-S, van Dijk M, Pokorna P, Wielenga J, Tume L, et al. Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals. Intensive care medicine. 2016;42(6):972-86.
• 37. Winsnes K, Sochacki P, Eriksson C, Shereck E, Recht M, Johnson K, et al. Delirium in the pediatric hematology, oncology, and bone marrow transplant population. Pediatric blood & cancer. 2019;66(6):e27640.
• 38. Kawai Y, Weatherhead JR, Traube C, Owens TA, Shaw BE, Fraser EJ, et al. Quality improvement initiative to reduce pediatric intensive care unit noise pollution with the use of a pediatric delirium bundle. Journal of intensive care medicine. 2019;34(5):383-90.
• 39. Silver G, Traube C. A systematic approach to family engagement: Feasibility pilot of a pediatric delirium management and prevention toolkit. Palliative & supportive care. 2019;17(1):42-5.
• 40. Staveski SL, Boulanger K, Erman L, Lin L, Almgren C, Journel C, et al. The impact of massage and reading on children’s pain and anxiety after cardiovascular surgery: A pilot study. Pediatric critical care medicine: a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2018;19(8):725.
• 41. Schieveld JN, Leroy PL, van Os J, Nicolai J, Vos GD, Leentjens AF. Pediatric delirium in critical illness: phenomenology, clinical correlates and treatment response in 40 cases in the pediatric intensive care unit. Intensive care medicine. 2007;33(6):1033-40.
• 42. Smith HA, Brink E, Fuchs DC, Ely EW, Pandharipande PP. Pediatric delirium: monitoring and management in the pediatric intensive care unit. Pediatric Clinics. 2013;60(3):741-60.
• 43. Young J, Murthy L, Westby M, Akunne A, O’Mahony R. Diagnosis, prevention, and management of delirium: summary of NICE guidance. Bmj. 2010;341.
• 44. Irwin SA, Pirrello RD, Hirst JM, Buckholz GT, Ferris FD. Clarifying delirium management: practical, evidenced-based, expert recommendations for clinical practice. Journal of Palliative Medicine. 2013;16(4):423-35.
• 45. Hipp DM, Ely EW. Pharmacological and nonpharmacological management of delirium in critically ill patients. Neurotherapeutics. 2012;9(1):158-75.
• 46. Rivosecchi RM, Kane-Gill SL, Svec S, Campbell S, Smithburger PL. The implementation of a nonpharmacologic protocol to prevent intensive care delirium. Journal of critical care. 2016;31(1):206-11.
• 47. Özdemir L. Yoğun bakım hastasında deliryumun yönetimi ve hemşirenin sorumlulukları. Hacettepe Üniversitesi Hemşirelik Fakültesi Dergisi. 2014;1:90-8.
• 48. Gürhan N. Ruh sağlığı ve psikiyatri hemşireliği. 1. Baskı. Ankara: Nobel Tıp Kitabevi; 2016. s. 695–713. 2016.
• 49. Kratz T, Heinrich M, Schlauß E, Diefenbacher A. Preventing postoperative delirium: a prospective intervention with psychogeriatric liaison on surgical wards in a general hospital. Deutsches Ärzteblatt International. 2015;112(17):289.
• 50. Öz F, Demiralp M. Psikososyal Hemşirelik Genel Hasta Bakımı. 3. Baskı. Ankara: Akademisyen Kitabevi. 2014.
• 51. Birol L. Hemşirelik süreci- Hemşirelik bakımında sistematik yaklaşım. 8. Baskı. İzmir: Etki matbaacılık; 2007.
• 52. Schieveld JN, Leentjens AF. Delirium in severely ill young children in the pediatric intensive care unit (PICU). Journal of the American Academy of Child and Adolescent Psychiatry. 2005;44(4):392.
• 53. Hatherill S, Flisher AJ, Nassen R. The diagnosis and treatment of delirium in children. Journal of Child & Adolescent Mental Health. 2009;21(2):157-65.
• 54. Kudchadkar SR, Aljohani OA, Punjabi NM. Sleep of critically ill children in the pediatric intensive care unit: a systematic review. Sleep medicine reviews. 2014;18(2):103-10.
• 55. Davies A, Waghorn M, Boyle J, Gallagher A, Johnsen S. Alternative forms of hydration in patients with cancer in the last days of life: study protocol for a randomised controlled trial. Trials. 2015;16(1):464.
• 56. Balas MC, Vasilevskis EE, Olsen KM, Schmid KK, Shostrom V, Cohen MZ, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility (ABCDE) bundle. Critical care medicine. 2014;42(5):1024.
• 57. Chanques G, Sebbane M, Barbotte E, Viel E, Eledjam J-J, Jaber S. A prospective study of pain at rest: incidence and characteristics of an unrecognized symptom in surgical and trauma versus medical intensive care unit patients. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2007;107(5):858-60.
• 58. Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical care medicine. 2013;41(1):263-306.
• 59. Hashem MD, Nelliot A, Needham DM. Early mobilization and rehabilitation in the ICU: moving back to the future. Respiratory care. 2016;61(7):971-9.
• 60. Wieser M, Gisler S, Sarabadani A, Ruest RM, Buetler L, Vallery H, et al. Cardiovascular control and stabilization via inclination and mobilization during bed rest. Medical & biological engineering & computing. 2014;52(1):53-64.