Pediatric delirium in the pediatric intensive care unit: a systematic review and an update on key issues and research questions.

There was a dearth in awareness and knowledge regarding pediatric delirium (PD) at the pediatric intensive care unit (PICU). The aim of this study is to highlight the most recent and up-to-date findings of current literature -by means of a systematic review (SR) method-, and to present the key issues and research questions. A SR of the literature published between 24 March 2009 and 10 March 2011. Eight new articles were identified which included (literature) reviews, journal commentaries, and observational studies. There still is a dearth of literature on PD, with also a variable level of evidence (1b - 5), especially in relation to critical illness. To be able to further clarify PD in the PICU, additional research questions are provided for future research.

Adherence to safety guidelines on paediatric procedural sedation: the results of a nationwide survey under general paediatricians in The Netherlands.

OBJECTIVES: Following two fatal accidents during paediatric procedural sedation (PS), the authors investigated the level of adherence to established safety standards on PS in a nationwide cohort of fully trained general paediatricians, entrusted with PS. STUDY DESIGN AND METHODS: Sample survey Safety guidelines on PS were split into four domains ("Presedation Assessment", "Monitoring during PS", "Recovery after PS" and "Facilities and Competences for Emergencies and Rescue"). Each domain was operationalised into sub-domains and items. Items were presented within a questionnaire list as procedural points of attention on which respondents could give their personal adherence score. Percentages of full adherence were calculated. Non-adherence was defined as gradual deviation from full adherence. After factor and reliability analysis, observed scores were summed up to scales, and results were transformed to a 0-10 report mark (RM). An RM of ≥9 is considered as a satisfactory level of adherence while an RM <6 is considered as unacceptably low. RESULTS: Full adherence was rare. For most (sub) domains, only a minority of respondents achieved a satisfactory level of adherence. Large numbers of respondents had scores below 6. CONCLUSIONS: Potentially unsafe PS practices are common under Dutch general paediatricians, despite the availability of guidelines. The design of guidelines should include a goal-directed plan for implementation including training, initiatives for continuous quality assurance and improvement and repeated measurements of adherence to guidelines.

Procedural sedation and analgesia in children by non-anesthesiologists in an emergency department.

Procedural sedation and analgesia (PSA) is a standard of care for the management of acute procedural pain and anxiety in the emergency department (ED). However, there is evidence that PSA practice is still ineffective and potentially unsafe in many pediatric settings. PSA has to be regarded as a separate medical act that should be provided only by well-trained and credentialized professionals, within a context of transparency, registration and ongoing quality control. Only by maintaining strict criteria regarding professional competences, safety precautions, monitoring, recovery and rescue facilities an optimal patient safety can be guaranteed. Besides, ED professionals have a duty to deliver effective PSA, not only from a procedural point of view (i.e. guaranteeing predictable procedural success and timing) but also from a patient's perspective (i.e. achieving optimal procedural comfort). An effective PSA program on a pediatric ED means that a professional is easily available at all times who is trained in the safe use of highly controllable drugs that match the sedation need and guarantee an optimal level of comfort without the need for forced immobilization or restraint. A high-quality PSA service includes the adequate use of local or topical anesthesia, the systematic application of non-pharmacologic techniques, the availability of effective PSA drugs and the possibility of rescue anesthesia in case PSA is unsuccessful or is expected to be ineffective or unsafe in a given patient. PSA for children, including deep sedation, should be formally incorporated in the training program for emergency physicians.

[Delirium in critically ill children in a paediatric intensive care unit]. / Delier bij kritisch zieke jonge kinderen op een pediatrische intensivecareafdeling.

Two critically ill girls, aged 2.3 years and 3.5 years respectively, developed delirium in the Paediatric Intensive Care Unit (PICU). The first child, admitted with meningococcal meningitis and septic shock with respiratory failure, suffered from hyperactive delirium which started 2 hours post-extubation. The second child, admitted due to an exacerbation of cystic fibrosis with the threat of respiratory failure, suffered from hypoactive delirium with regression, inconsolability, dyspraxia and dysphasia. Both patients responded well to a single intravenous dose of haloperidol. Although delirium occurs in critically ill children, it often goes unrecognized, particularly in its hypoactive form. It should nevertheless be considered as a medical emergency, particularly in a PICU setting, and should be treated accordingly. Physicians are generally reluctant to consider psychopharmacological treatment of childhood delirium. Haloperidol is considered as the drug of choice, but risperidone can also be used successfully.