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Published on: August 25, 2014
Delirium and Benzodiazepines Associated With Prolonged ICU Stay in Critically Ill Infants and Young Children
Heidi A B Smith1, Maalobeeka Gangopadhyay, Christina M Goben
11Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN. 2Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN. 3Department of Psychiatry, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY. 4Department of Pediatrics, University of South Carolina School of Medicine Greenville, Greenville, SC. 5Department of Psychiatry, Children's Hospital of Philadelphia, Philadelphia, PA. 6Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN. 7Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN. 8Department of Internal Medicine, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN. 9Tennessee Valley Veterans Administration (VA) Geriatric Research Education Clinical Center (GRECC), Nashville, TN. 10Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN.
Insights
Pediatric delirium in the ICU is linked to poorer discharge outcomes. Reducing benzodiazepine exposure may decrease delirium duration and improve patient recovery.
Area of Science:
- Pediatric Critical Care Medicine
- Neuroscience
- Pharmacology
Background:
- Delirium is common in critically ill children but its outcomes and risk factors are not fully understood.
- Identifying modifiable risk factors is crucial for improving care in pediatric intensive care units (PICUs).
Purpose of the Study:
- To investigate the association between pediatric delirium and modifiable risk factors, specifically benzodiazepine exposure.
- To determine the impact of delirium on short-term outcomes in critically ill children.
Main Methods:
- Secondary analysis of data from a prospective validation study of the Preschool Confusion Assessment Method for the ICU.
- Included critically ill patients aged 6 months to 5 years in a tertiary-level PICU.
- Used Cox regression, negative binomial regression, and multinomial logistic regression to analyze risk factors and outcomes.
Main Results:
- Delirium was diagnosed in 44% of the 300-patient cohort, with a median duration of 1-2 days.
- Delirium significantly decreased the likelihood of ICU discharge in preschool-aged children.
- Increased benzodiazepine exposure correlated with lower ICU discharge likelihood, longer delirium duration, and increased daily delirium risk.
Conclusions:
- Pediatric delirium is associated with reduced likelihood of ICU discharge.
- Benzodiazepine exposure is a significant risk factor for delirium development, duration, and poorer outcomes.
- Reducing benzodiazepine exposure is a potential strategy to mitigate harm in critically ill pediatric patients.
Objectives:
Delirium is prevalent among critically ill children, yet associated outcomes and modifiable risk factors are not well defined. The objective of this study was to determine associations between pediatric delirium and modifiable risk factors such as benzodiazepine exposure and short-term outcomes.
Design:
Secondary analysis of collected data from the prospective validation study of the Preschool Confusion Assessment Method for the ICU.
Setting:
Tertiary-level PICU.
Patients:
Critically ill patients 6 months to 5 years old.
Interventions:
None.
Measurements And Main Results:
Daily delirium assessments were completed using the Preschool Confusion Assessment Method for the ICU. Associations between baseline and in-hospital risk factors were analyzed for likelihood of ICU discharge using Cox proportional hazards regression and delirium duration using negative binomial regression. Multinomial logistic regression was used to determine associations between daily risk factors and delirium presence the following day. Our 300-patient cohort had a median (interquartile range) age of 20 months (11-37 mo), and 44% had delirium for at least 1 day (1-2 d). Delirium was significantly associated with a decreased likelihood of ICU discharge in preschool-aged children (age-specific hazard ratios at 60, 36, and 12 mo old were 0.17 [95% CI, 0.05-0.61], 0.50 [0.32-0.80], and 0.98 [0.68-1.41], respectively). Greater benzodiazepine exposure (75-25th percentile) was significantly associated with a lower likelihood of ICU discharge (hazard ratio, 0.65 [0.42-1.00]; p = 0.01), longer delirium duration (incidence rate ratio, 2.47 [1.36-4.49]; p = 0.005), and increased risk for delirium the following day (odds ratio, 2.83 [1.27-6.59]; p = 0.02).
Conclusions:
Delirium is associated with a lower likelihood of ICU discharge in preschool-aged children. Benzodiazepine exposure is associated with the development and longer duration of delirium, and lower likelihood of ICU discharge. These findings advocate for future studies targeting modifiable risk factors, such as reduction in benzodiazepine exposure, to mitigate iatrogenic harm in pediatric patients.
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