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Anticholinergic Medication Burden in Pediatric Prolonged Critical Illness: A Potentially Modifiable Risk Factor for
Kate Madden1, Kinza Hussain2, Robert C Tasker1,3
1Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA.
Insights
Pediatric intensive care unit (PICU) patients on prolonged mechanical ventilation receive many anticholinergic medications, potentially increasing delirium risk. This exposure is higher than in adults, warranting further investigation.
Area of Science:
- Pediatric critical care medicine
- Clinical pharmacology
- Neuroscience
Background:
- Delirium is a critical illness syndrome with potential long-term consequences.
- Anticholinergic medications are implicated as a contributing factor to delirium.
- Understanding anticholinergic burden in pediatric intensive care units (PICUs) is crucial for managing delirium risk.
Purpose of the Study:
- To quantify anticholinergic medication exposure in pediatric patients requiring prolonged mechanical ventilation in the PICU.
- To assess the relationship between anticholinergic burden and patient characteristics or outcomes.
- To identify common medications contributing to anticholinergic exposure.
Main Methods:
- Retrospective cohort study of 88 pediatric patients admitted to a single academic medical center PICU from January 2011 to December 2015.
- Daily Anticholinergic Drug Scale (ADS) scores were calculated for the first 15 days of admission.
- ADS scores were analyzed in relation to demographic data, severity of illness, and medication use.
Main Results:
- The median daily ADS score was 5 (interquartile range, 3-7) across 1,320 PICU days.
- ADS scores did not correlate with age, sex, medical history, severity of illness, length of stay, ventilator hours, or mortality.
- Morphine, midazolam, vancomycin, steroids, and furosemide were frequently associated with high ADS scores; high-dose midazolam infusion correlated with significantly higher ADS scores.
Conclusions:
- Pediatric patients on prolonged mechanical ventilation in the PICU receive a substantial number of medications with anticholinergic effects.
- This anticholinergic exposure appears higher than reported in adult intensive care populations.
- Further research into anticholinergic exposure and its association with delirium in PICU patients is necessary.
Objectives:
It is important to describe and understand the prevalence and risk factors for the syndrome of delirium in critical illness. Since anticholinergic medication may contribute to the development of delirium in the PICU, we have sought to quantify anticholinergic medication exposure in patients with prolonged admission. We have used Anticholinergic Drug Scale scores to quantify the magnitude or extent of this burden.
Design:
Retrospective cohort study, January 2011 to December 2015.
Setting:
Single academic medical center PICU.
Patients:
Children under 18 years old with a PICU admission of 15 days or longer, requiring mechanical ventilation.
Interventions:
None.
Measurements And Main Results:
Daily Anticholinergic Drug Scale scores for the first 15 days of admission, in each of 88 subjects (total of 1,320 PICU days), were collected and assessed in relation to demographic data, severity of illness, and medication use. Median (interquartile range) of daily Anticholinergic Drug Scale score was 5 (interquartile range, 3-7). Anticholinergic Drug Scale score was not associated with age, sex, medical history, presenting Severity of Illness score, PICU length of stay, ventilator hours, or hospital mortality. Medications most frequently associated with high Anticholinergic Drug Scale score were low potency anticholinergic drugs such as morphine, midazolam, vancomycin, steroids, and furosemide, with the exception of ranitidine (Anticholinergic Drug Scale score 2). Patients receiving high doses of midazolam infusion had significantly higher Anticholinergic Drug Scale scores compared with those receiving lower or no midazolam dosing.
Conclusions:
A high number of medications with anticholinergic effects are administered to PICU patients receiving prolonged mechanical ventilation. These exposures are much higher than those reported in adult intensive care patients. Since anticholinergic drug exposure is associated with delirium, further study of this exposure in PICU patients is needed.
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