Recurrent delirium after surgery for congenital heart disease in an infant.

OBJECTIVE: The objective of this article is to describe a case of recurrent delirium after cardiac surgery in an infant. DESIGN: Case report. The institutional review board at Children's Hospital Los Angeles waived the need for informed consent. SETTING: Cardiothoracic intensive care unit in a freestanding children's hospital. PATIENT: A male infant with hypoplastic left heart syndrome who developed delirium on consecutive admissions to the cardiothoracic intensive care unit after cardiac surgery. INTERVENTION: Pharmacologic intervention using the atypical antipsychotic olanzapine. MEASUREMENTS AND MAIN RESULTS: The symptoms of delirium resolved with the initiation and continuation of olanzapine on both occasions. CONCLUSION: Delirium is a common, but often unrecognized, diagnosis in the intensive care unit. Its early recognition and treatment may prevent unnecessary use of narcotics and benzodiazepines, decrease length of stay and may improve long-term neurocognitive function. This case report describes an infant who developed discrete, consecutive episodes of delirium following surgery for congenital heart disease. Both episodes were treated effectively with olanzapine.

Alcohol use in congenital central hypoventilation syndrome.

Congenital central hypoventilation syndrome (CCHS) is a rare disorder where there is failure of automatic control of breathing. With improved recognition of CCHS, more children are appropriately diagnosed and treated in infancy, allowing survival into adult years. Because most of these children are able to participate in regular school, they are exposed to common adolescent behaviors, such as abusing alcohol and drugs. Alcohol and many illicit substances are known respiratory depressants. We report on 3 cases of adolescents/young adults with CCHS who had severe adverse events related to alcohol, including coma and death. This series illustrates the dangers of alcohol abuse in CCHS. We speculate that adolescents with CCHS may be less able to perceive the risks of substance abuse and impulsive behavior, leading to increased morbidity and mortality. Patients with CCHS appear to lack anxiety and the awareness that their inability to perceive physiologically dangerous levels of hypercarbia and hypoxia deprives them of important protective mechanisms.

The diagnosis and management of delirium in infancy.

OBJECTIVE: Atypical antipsychotics have been documented to be effective in the management of delirium in adults and older children, but despite considerable need, their use has been less studied in the very young. A retrospective chart review was undertaken to describe the use of atypical antipsychotics in controlling symptoms of delirium in infants and toddlers. METHODS: All psychiatric inpatient consultations performed during a 3 year period were reviewed to identify children <36 months old diagnosed with delirium. Delirium Rating Scale (DRS) scores were retrospectively calculated when the antipsychotic was initiated and discontinued, to confirm the diagnosis of delirium and evaluate symptom severity, and then to assess symptom response to pharmacologic intervention. RESULTS: There were 10 boys and 9 girls in the study population (ages 7-30 months, mean 20.5 months). Olanzapine (n=16) and risperidone (n=3) were used, and length of treatment and response were comparable for both medications. Mean DRS scores decreased significantly (p<0.001) with antipsychotic administration, without significant adverse side effects. CONCLUSIONS: Although randomized placebo controlled studies are needed to better characterize the indications, risks, and benefits, these atypical antipsychotic medications appeared to be effective and safe for managing delirium symptoms in very young pediatric patients.

Olanzapine reduces delirium symptoms in the critically ill pediatric patient.

Delirium is a neuropsychiatric disorder characterized by acute disturbances in attention, consciousness, cognitive processing, perception, and the sleep-wake cycle. The few studies investigating treatment of delirium in critically ill children and adolescents have used differing diagnostic criteria, and have not employed control groups or procedures to blind observations. The objective of this study was to examine the efficacy of olanzapine for the treatment of delirium in the pediatric intensive care unit (ICU) using methodological procedures to reduce bias and allow greater generalization. Psychiatric records of 59 patients admitted to the pediatric ICU or cardiothoracic ICU over a 4 yr period with the diagnosis of delirium were examined. The delirium rating scale was used to assess delirium severity at the time of initial psychiatric evaluation and five days later. Raters were blinded to medication administration. Patients who were diagnosed with delirium, but did not receive olanzapine, or any other antipsychotic medication, served as the control group. Greater improvement of delirium symptoms was found for the olanzapine group (n = 31) than the control group (n = 28) (F (1,40) = 4.86, r = 0.33, 95% confidence interval = 0.020-0.58). This finding remained statistically significant after controlling for initial delirium severity (F (1, 20) = 28.62, r = 0.77, 95% confidence interval = 0.50-0.90). This study demonstrates patients with delirium administered olanzapine had greater reduction of delirium symptom severity than controls. It supplements the existing literature by using a study design that reduces expectancy effects and allows examination of the natural history of delirium symptoms without medication administration.

Review of delirium in the pediatric intensive care unit.

Delirium is an acute neuropsychiatric syndrome reflecting serious cerebral dysfunction. The characteristic core symptoms of delirium include the inability to direct, focus, sustain, and shift attention; abnormalities of the sleep-wake cycle; impaired consciousness and awareness; disturbance of thought processes; and behavioral dyscontrol. Delirium is particularly prevalent in critically ill and post-operative patients in the intensive care unit, and may result from hypoxia or infection. It is most likely in the most severely ill, and length of stay is prolonged, and morbidity and mortality and higher with delirium. A variety of clinical instruments have been developed to facilitate the diagnosis of delirium. The Delirium Rating Scale, and its 1998 revision (DRS and DRS-R98) are for psychiatrists to use and are based on DSM criteria. The Pediatric Confusion Assessment Method, adapted for pediatric patients in the ICU (pCAM-ICU), is designed for non-psychiatrists and nurses in the intensive care unit. The Pediatric Anesthesia Emergence Delirium scale (PAED) is the basis for the Cornell Assessment of Pediatric Delirium (CAP-D), and both are for nurses and doctors in the pediatric ICU to use to identify delirium in their patients. Delirium is typically multifactorial and its pathogenesis reflects neurotransmitter changes associated with metabolic and inflammatory processes. Benzodiazepines and anticholinergic drugs, including opioids and antihistamines, are widely used in the pediatric ICU and may precipitate or exacerbate delirium. Benzodiazepines especially are best used sparingly, in the lowest dose possible, if at all. The treatment of delirium is predicated on detecting and addressing its underlying cause, which usually results in its rapid resolution. Environmental interventions may ameliorate the risk for delirium, and drugs which may precipitate or worsen delirium should be avoided. Antipsychotics can provide benefit in managing agitation, perceptual disturbances, sleep-wake cycle abnormalities, and behavioral dyscontrol. Atypical antipsychotics, including olanzapine, risperidone, and quetiapine, have largely replaced haloperidol in newer approaches to management because of lower risk for adverse side effects. The risk for delirium may be mitigated by vigilance, and awareness of its presentation, pathogenesis, and management. Its prevention will be of significant benefit in reducing morbidity, improving outcome, and providing comfort to these very ill and fragile children.

Atypical antipsychotic medications to control symptoms of delirium in children and adolescents.

BACKGROUND: Atypical antipsychotics have been documented to be effective in the management of delirium in adults, but despite considerable need, their use has been less studied in pediatric patients. OBJECTIVE: A retrospective chart review was done to describe the use of atypical antipsychotics in controlling symptoms of delirium in children and adolescents. METHODS: Pharmacy records at Children's Hospital Los Angeles were reviewed to identify patients to whom antipsychotic agents were dispensed over a 24-month period. Psychiatric inpatient consultations during the same 24-month period were reviewed. Patients 1-18 years old diagnosed with delirium given antipsychotics constituted the study population. Delirium Rating Scale-Revised-98 (DRS-R98) scores were retrospectively calculated, when possible, at time antipsychotic was started to confirm the initial diagnosis of delirium and evaluate symptom severity, and again when antipsychotic was stopped, to assess symptom response. RESULTS: Olanzapine (n=78), risperidone (n=13), and quetiapine (n=19) were used during the 2 years of the study. Mean patient age, length of treatment, and response were comparable for the three medications. For patients with two DRS-R98 scores available (n=75/110), mean DRS-R98 scores decreased significantly (p<0.001) with antipsychotic without significant adverse side effects. CONCLUSION: Although randomized placebo-controlled studies are needed, atypical antipsychotic medications appeared to be effective and safe for managing delirium symptoms in pediatric patients while underlying etiology was addressed.