Antipsychotic Prescribing Practice Patterns for Management of Delirium in a Tertiary Care Children's Hospital...

Delirium in the setting of critical illness occurs in 15%-60% of pediatric patients and is associated with increased duration of hospital admission. Strategies for symptom management include minimizing exposure to deliriogenic medications, optimizing day-night cycles, and in some cases prescribing antipsychotic medications. Symptom management occurs while simultaneously identifying and treating the underlying etiology. Over a 5-year period, our pediatric intensive care units implemented several unit-based initiatives to prevent and minimize the severity of delirium in critically ill children. The objective of this study is to retrospectively characterize antipsychotic prescribing practices over the study period.

Over a 5-year timeframe in our children's hospital, we extracted dispensing data for risperidone, olanzapine, quetiapine, and haloperidol. We used descriptive statistics to characterize patients initiated on an antipsychotic in an ICU area, dosing information, and quantitative change in annual orders over the study period.

During the study period, 533 antipsychotic orders were placed for 165 patients. Most of the identified patients were male (60.6%) and Black (44.2%). Ninety (16.9%) of the medication orders remained active after patient transfer to a general care floor. Risperidone was the most prescribed antipsychotic (54%), with a 413% increase observed between 2016 and 2018, followed by a decline of 89% between 2018 and 2021. Use of other antipsychotics was less than risperidone but consistent during the study period. Risperidone was more commonly prescribed for younger children, and prescribing patterns suggest a preference for nighttime administration.

Implementation of unit-based initiatives to promote delirium screening and awareness led to an initial increase in antipsychotic medication prescribing for critically ill children with delirium. This was followed by a significant decline in antipsychotic prescribing with the inclusion of the child and adolescent psychiatry team in our delirium management and prevention algorithm. This study highlights the importance of collaboration with the child and adolescent psychiatry team in the management of pediatric delirium across the hospital system. Additional research on antipsychotic prescribing practices and the associated impact of nonpharmacologic interventions and multidisciplinary collaboration for delirium treatment is warranted.