A Systematic Review and Pooled Prevalence of Delirium in Critically Ill Children.

OBJECTIVES: Pediatric delirium is a neuropsychiatric disorder with disrupted cerebral functioning due to underlying disease and/or critical care treatment. Pediatric delirium can be classified as hypoactive, hyperactive, and mixed. This systematic review was conducted to estimate the pooled prevalence of pediatric delirium using validated assessment tools in children (Cornell Assessment of Pediatric Delirium, Pediatric Confusion Assessment Method for the ICU, PreSchool Confusion Assessment Method for the ICU, Pediatric Confusion Assessment Method for the ICU Severity Scale, and Sophia Observation Withdrawal Symptoms Pediatric Delirium scale), identify modifiable and nonmodifiable risk factors, and explore the association of pediatric delirium with clinical outcomes. DATA SOURCES: A systematic search of PubMed, EMBASE, and CINAHL databases was undertaken for full articles pertaining to pediatric delirium prevalence. STUDY SELECTION: No language or date barriers were set. Studies were included where the following eligibility criteria were met: study design aimed to estimate pediatric delirium prevalence arising from treatment in the intensive care setting, using a validated tool. Only randomized controlled trials, cross-sectional studies, or cohort studies allowing an estimate of the prevalence of pediatric delirium were included. DATA EXTRACTION: Data were extracted by the primary researcher (D.S.) and accuracy checked by coauthors. DATA SYNTHESIS: A narrative synthesis and pooled prevalence meta-analysis were undertaken. CONCLUSIONS: Pediatric delirium, as determined by the Cornell Assessment of Pediatric Delirium score, is estimated to occur in 34% of critical care admissions. Eight of 11 studies reporting on subtype identified hypoactive delirium as most prevalent (46-81%) with each of the three remaining reporting either hyperactive (44%), mixed (57%), or equal percentages of hypoactive and mixed delirium (43%) as most prevalent. The development of pediatric delirium is associated with cumulative doses of benzodiazepines, opioids, the number of sedative classes used, deep sedation, and cardiothoracic surgery. Increased time mechanically ventilated, length of stay, mortality, healthcare costs, and associations with decreased quality of life after discharge were also found. Multi-institutional and longitudinal studies are required to better determine the natural history, true prevalence, long-term outcomes, management strategies, and financial implications of pediatric delirium.

A REVIEW OF THE USE OF CALCIUM LIQUID VERSUS CALCIUM TABLETS FOR MAINTAINING CORRECTED CALCIUM LEVELS.

AIM: Since the discontinuation of a commercially available liquid calcium medicine, there have been various local strategies to obtain adequate calcium levels, particularly in suspected 22Q11.2 deletion syndrome children post cardiothoracic surgery. Pharmacy obtained on special order a Calcium Liquid food supplement (0.5 mmol calcium/ml) for use in those children whom effervescent tablets did not appear to improve corrected calcium. Anecdotally it was thought that calcium liquid was better tolerated and absorbed, resulting in quicker recovery time of corrected calcium than use of the effervescent tablets. This review of patients was intended to determine if the use of the liquid was associated with a significant improvement in calcium levels compared to the use of tablets. METHOD: A dispense report was undertaken to identify those patients supplied with the calcium liquid product from May 2014 to May 2015.Using the electronic prescribing system, the patients electronic health record was accessed, and the following information recorded; calcium, albumin, intake calcium in fluids, TPN, oral and Intravenous. The data was collected for seven days previous to the first administration of calcium liquid and seven days after where available. Corrected calcium was calculated using an accepted method (calcium=serum calcium+0.02* (normal albumin - patient albumin)). RESULTS: Nine children supplied with calcium liquid between May 2014 and May 2015. Four patients who did not have histories on the electronic prescribing system were excluded for ease of analysis. The electronic medication record of the five remaining patients was used to compare calcium intake from all sources including fluids and feed.As expected calcium levels (and corrected calcium level where relevant) did improve when calcium liquid was added in. However four of the patients received calcium from multiple sources. Of these three received more calcium (mmol/kg/day) in fluids and feeds than from the administered pharmacy product.One single patient did not receive calcium from any other sources (fluids/TPN/feed). However there did not appear to be a significant change in calcium levels when calcium liquid was introduced as opposed to calcium tablets. CONCLUSION: Although based on a small number of patients, from this experience it would not seem that the calcium liquid obtained by pharmacy results in higher calcium serum levels.Further analysis may be required to distinguish the effects from calcium intake in feed/fluid and calcium intake from medicines.