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Validity of Different Delirium Assessment Tools for Critically Ill Children: Covariates Matter
Alawi Luetz1, Dennis Gensel, Judith Müller
11Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitaetsmedizin Berlin, Germany. 2Department of Pediatrics, Division of Pneumonology, Immunology, and Intensive Care Medicine, Campus Virchow-Klinikum, Charité-Universitaetsmedizin Berlin, Berlin, Germany. 3Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité-Universitaetsmedizin Berlin, Berlin, Germany. 4Department of Medical Biometry, Campus Charité Mitte, Charité-Universitaetsmedizin Berlin, Berlin, Germany.
Insights
The severity scale for the Pediatric Confusion Assessment Method for the ICU demonstrated the best test validity for detecting delirium in critically ill children aged 5 and older. Patient-specific factors, such as sedation and ventilation, significantly influence delirium screening tool accuracy.
Area of Science:
- Pediatric Critical Care Medicine
- Neuroscience
- Psychiatry
Background:
- Pediatric delirium is a significant concern in intensive care settings, impacting patient outcomes.
- Accurate and reliable screening tools are crucial for timely diagnosis and management of pediatric delirium.
- Existing tools like the Pediatric Confusion Assessment Method for the ICU (PEM-ICU) and Pediatric Anesthesia Emergence Delirium (PAED) scale have varying degrees of validity.
Purpose of the Study:
- To evaluate the test validity of the PEM-ICU, the PAED scale, and a newly developed severity scale for the PEM-ICU.
- To prospectively assess covariates influencing the test validity of these pediatric delirium assessment scores.
Main Methods:
- A prospective observational cohort study was conducted in a tertiary care medical center's Pediatric Intensive Care Unit (PICU).
- Critically ill patients aged 5 years or older, ventilated or non-ventilated, with an ICU stay of at least 24 hours were included.
- Delirium assessments were performed daily using the PEM-ICU and PAED scale, with validity compared against expert diagnosis based on DSM-IV-TR criteria.
Main Results:
- Initial assessments showed the severity scale for the PEM-ICU had the highest sensitivity (84.9%), followed by PEM-ICU (76.9%) and PAED scale (69.2%), with specificities of 98% for all.
- With repeated measurements, sensitivities decreased for PAED scale (35.9%) and PEM-ICU (52.3%).
- The severity scale for the PEM-ICU maintained higher sensitivity (71.8%) than the PAED scale (p = 0.0008), though sedation and mechanical ventilation negatively impacted validity for both.
Conclusions:
- The severity scale for the Pediatric Confusion Assessment Method for the ICU exhibits superior test validity in critically ill children aged 5 and older.
- The accuracy of delirium screening is influenced by patient-specific factors, including age, gender, sedation, and mechanical ventilation.
- Consideration of these covariates is essential when selecting a delirium screening instrument for pediatric intensive care patients.
Objectives:
To evaluate test validity of the Pediatric Confusion Assessment Method for the ICU, the Pediatric Anesthesia Emergence Delirium scale, and the newly developed severity scale for the Pediatric Confusion Assessment Method for the ICU; to prospectively assess covariates and their influence on test validity of the scores.
Design:
Prospective observational cohort study.
Setting:
PICU of a tertiary care medical center.
Patients:
Critically ill patients 5 years old or older ventilated or nonventilated with an ICU length of stay of at least 24 hours.
Interventions:
None.
Measurements And Main Results:
Patients were scored with the Pediatric Confusion Assessment Method for the ICU and the Pediatric Anesthesia Emergence Delirium scale once daily for a maximum of 21 days. Validity was determined by comparing scoring results with the evaluations of the delirium experts who used the criteria of the Diagnostic and Statistical Manual, 4th Edition, Text Revision, for delirium diagnosis. Sixty-four patients were enrolled and 214 assessments were conducted and included in data analysis. The first assessments within each patient revealed sensitivities of 69.2% for the Pediatric Anesthesia Emergence Delirium scale, 76.9% for the Pediatric Confusion Assessment Method for the ICU, and 84.9% for the severity scale for the Pediatric Confusion Assessment Method for the ICU. Specificities were 98% for all scores. Considering repeated measurements, sensitivities decreased to 35.9% for the Pediatric Anesthesia Emergence Delirium scale and to 52.3% for the Pediatric Confusion Assessment Method for the ICU. The sensitivity of the severity scale for the Pediatric Confusion Assessment Method for the ICU dropped to 71.8%, which was significantly higher compared to the Pediatric Anesthesia Emergence Delirium scale (p = 0.0008). Receiver operator characteristic regression unveiled that sedation and mechanical ventilation had a significant negative effect on the validity of the Pediatric Anesthesia Emergence Delirium scale and the severity scale for the Pediatric Confusion Assessment Method for the ICU. Age and gender had a significant impact on the receiver operator characteristic curve of the severity scale for the Pediatric Confusion Assessment Method for the ICU.
Conclusions:
The severity scale for the Pediatric Confusion Assessment Method for the ICU showed the best test validity when used in critically ill children of 5 years old or older. Nevertheless, validity of delirium screening itself depends on patient specific factors. These factors should be taken into consideration when choosing a delirium screening instrument.
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