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Diagnostic accuracy of delirium diagnosis in pediatric intensive care: a systematic review
Insights
Pediatric delirium screening in the pediatric intensive care unit (PICU) lacks high-quality evidence. Further research is needed to validate tools like the Pediatric Anesthesia Emergence Delirium Scale (PAED) and the Pediatric Confusion Assessment Method for the Intensive Care Unit (p-CAM-ICU) for accurate diagnosis and management.
Area of Science:
- Pediatric Critical Care Medicine
- Neuroscience
- Diagnostic Accuracy Research
Background:
- Delirium is a frequent complication in adult intensive care units (ICUs), with established measurement tools, risk factors, and neurocognitive outcomes.
- The understanding of pediatric delirium within the pediatric intensive care unit (PICU) setting remains limited.
Purpose of the Study:
- To systematically review existing literature on the accuracy of delirium diagnostic tools in the PICU.
- To explore the prevalence, risk factors, and outcomes associated with pediatric delirium.
Main Methods:
- A systematic search and review of studies evaluating delirium diagnostic accuracy in children within PICUs were conducted.
- Screening and data collection tools were developed based on established recommendations.
- Five studies, assessing the Pediatric Anesthesia Emergence Delirium Scale (PAED), Pediatric Confusion Assessment Method for the Intensive Care Unit (p-CAM-ICU), Cornell Assessment of Pediatric Delirium (CAP-D), revised Cornell Assessment of Pediatric Delirium (CAP-D(R)), and clinical suspicion, were included.
Main Results:
- All five included studies exhibited a high risk of bias in at least one domain according to the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2).
- Performance metrics (sensitivity, specificity, effectiveness) varied across tools, with some requiring data imputation.
- Prevalence rates of delirium ranged from 5% to 28% across the studies. Only one study identified statistically significant risk factors and outcomes.
Conclusions:
- High-quality research is essential to accurately determine the prevalence, risk factors, and outcomes of pediatric delirium in the PICU.
- Further studies are required to validate delirium screening tools before routine implementation can be recommended.
- Direct comparative studies of the p-CAM-ICU and CAP-D(R) are recommended.
Introduction:
Delirium is common in adult intensive care, with validated tools for measurement, known risk factors and adverse neurocognitive outcomes. We aimed to determine what is known about pediatric delirium in the pediatric intensive care unit (PICU).
Methods:
We conducted a systematic search for and review of studies of the accuracy of delirium diagnosis in children in the PICU. Secondary aims were to determine the prevalence, risk factors and outcomes associated with pediatric delirium. We created screening and data collection tools based on published recommendations.
Results:
After screening 145 titles and abstracts, followed by 35 full-text publications and reference lists of included publications, 9 reports of 5 studies were included. Each of the five included studies was on a single index test: (1) the Pediatric Anesthesia Emergence Delirium Scale (PAED; for ages 1 to 17 years), (2) the Pediatric Confusion Assessment Method for the Intensive Care Unit (p-CAM-ICU; for ages ≥ 5 years), (3) the Cornell Assessment of Pediatric Delirium (CAP-D; a modification of the PAED designed to detect hypoactive delirium), (4) the revised Cornell Assessment of Pediatric Delirium (CAP-D(R)) and (5) clinical suspicion. We found that all five studies had a high risk of bias on at least one domain in the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). Sample size, sensitivity, specificity, and effectiveness (correct classification divided by total tests done) were: PAED 144, 91%, 98%, <91% (>16% of scores required imputation for missing data); p-CAM 68, 78%, 98%, 96%; CAP-D 50, 91%, 100%, 89%; CAP-D (R) 111, and of assessments 94%, 79%, <82% (it is not clear if any assessments were not included); and clinical suspicion 877, N/A (only positive predictive value calculable, 66%). Prevalence of delirium was 17%, 13%, 28%, 21%, and 5% respectively. Only the clinical suspicion study researchers statistically determined any risk factors for delirium (pediatric risk of mortality, pediatric index of mortality, ventilation, age) or outcomes of delirium (length of stay and mortality).
Conclusion:
High-quality research to determine the accuracy of delirium screening tools in the PICU are required before prevalence, risk factors and outcomes can be determined and before a routine screening tool can be recommended. Direct comparisons of the p-CAM-ICU and CAP-D(R) should be performed.
