key: cord-0937360-cfklqm44
authors: de Castro, Roberta Esteves Vieira; Rodríguez-Rubio, Miguel; de Magalhães-Barbosa, Maria Clara; Prata-Barbosa, Arnaldo
title: Pediatric delirium in times of COVID-19
date: 2021
journal: Rev Bras Ter Intensiva
DOI: 10.5935/0103-507x.20210070
sha: 3549b0542769d7cdb770de648bcef8fd5b66a73f
doc_id: 937360
cord_uid: cfklqm44

nan

Due to the development of valid and reliable tools for the diagnosis of delirium in pediatrics, it is now known that one in four children hospitalized in the ICU is likely to present it. (5) Its prevalence may be higher in special subgroups, such as patients undergoing cardiac surgery or extracorporeal membrane oxygenation. (5, 16) The recognition of delirium in pediatrics is extremely relevant because it has been independently associated with increased costs in the pediatric ICU, prolonged hospital stays and increased in-hospital mortality. (5, 17, 18) 

Often, delirium is triggered by more than one risk factor. The probability of its occurrence increases with the increase in the number of these factors, and an understanding of this association is essential for identifying potentially reversible causes. Delirium emerges as the result of an intricate relationship between vulnerability factors and precipitating factors, i.e., a patient with high vulnerability may develop it in the presence of a minor injury, while one with few predisposing factors may require more intense injuries to develop it. (19) Important factors that predispose pediatric patients to the development of delirium include age less than 2 years and a history of neurodevelopmental delay. Patients with immature or abnormal brains are more prone to developing delirium, as are elderly individuals and patients with underlying dementia. (20) Other predisposing factors are previous comorbidities, the severity of the underlying disease, malnutrition (associated with a serum albumin level below 3.0g/dL) and MV dependence. Predisposing factors are inherent to the patient and cannot be modified. The most frequent precipitating factors in pediatrics include the use of benzodiazepines and anticholinergic drugs, cardiac bypass surgeries, bed immobilization, prolonged hospitalization in the pediatric ICU, use of physical restraints, pain and withdrawal syndrome. These factors act as triggers and can be modified by the health team in many cases. (20, 21) The development of delirium is closely related to the severity of the disease. In the context of SARS-CoV-2 infection, recent studies have shown that delirium may be triggered by factors such as hypoxia and the resulting deficiency in cerebral oxygenation; neuronal inflammation due to the cytokine storm resulting from an unbalanced immune system activation; and/or direct invasion of the central nervous system by the virus, which has neuronal toxicity. (15) In addition to factors associated with COVID-19, such as neuroinflammation, multiple organ failure and increased risk of thrombosis, treatment-related factors may increase the risk of delirium. These factors include the use of prolonged MV with deep sedation and the iatrogenic environment of the pediatric ICU, which is marked by intense sleep deprivation. (8, 22) In addition to these factors, there is the need for isolation imposed by COVID-19 to reduce the exposure of health professionals, which decreases contact with the team and may be aggravated by the scarcity of personal protective equipment (PPE). Although this isolation is understandable given the intensity of the pandemic, this reality increases patients' isolation and immobility and, when associated with the numerous complications of the disease, produces an extremely iatrogenic environment with a high risk of delirium. (23) 

The measures adopted to prevent the spread of SARS-CoV-2, such as the use of PPE and restrictive visitation policies, in addition to the scarcity of professionals available for care (which reduces the time available for evaluations), may hinder the recognition of delirium and create barriers for the implementation of recommended nonpharmacological strategies. In addition, these measures may impair patient orientation and are a significant risk factor for the development of delirium. (22) Although extremely relevant, delirium is often unrecognized, and the pandemic has presented numerous obstacles to its diagnosis. (12, 22, 23) A team effort is required to adopt strategies that reduce these barriers. One of the most efficient resources is the adequate use of validated tools for screening for delirium in critically ill children. (8) The diagnostic criteria for delirium represent a valid and operationalized construct with high reliability and remarkable clinical application. The use of homogeneous and validated nomenclature can help the team avoid vague terms, such as "altered mental state", thus enabling the incorporation of standardized strategies for the management of delirium while facilitating communication with patients, family members and among themselves and other health professionals. (7) Table 1 presents some proposed measures for the prevention and management of delirium in pediatric patients that have been adapted to the context of the pandemic. These measures do not require the implementation of complex actions and do not increase the risk of exposure for health professionals. It is believed that, as with any serious childhood disorder, the prevention, evaluation and treatment of delirium should be part of the approach taken for pediatric patients with COVID-19. Investing time in this approach can avoid costs and associated complications.

Barnes SS, Gabor C, Kudchadkar SR. Epidemiology of Delirium in Children: Prevalence, Risk Factors, and Outcomes. In: Hughes C, Pandharipande P, Ely EW (eds) Delirium. Cham: Springer; 2020. p. 93-102.

Smith HA, Williams SR. Pediatric delirium assessment, prevention, and management. In: Hughes C, Pandharipande P, Ely EW, editors. Delirium. Acute brain dysfunction in the critically ill. Cham, Switzerland: Springer; 2020. p. 73-92.

Oldham MA, Slooter AJ, Cunningham C, Rahman S, Davis D, Vardy ER, et al. Characterising neuropsychiatric disorders in patients with COVID-19. Lancet Psychiatry. 2020;7(11):932-3.

Schieveld JN, Janssen NJ, Strik JJ. On the importance of addressing pediatric delirium phenotypes and neurocognitive functioning: pediatric critical illness brain injury in COVID times. Crit Care Med. 2020;48(12):1911-3. Nonpharmacological measures (1,25-31) Consider environmental changes: provide a calm and peaceful environment that is consistent and predictable; consider moving patients with hyperactive or mixed delirium to a bed in a quieter location and moving patients with hypoactive delirium to a bed in a location with greater interaction; verify the possibility of letting the child have an object that is familiar to him or her; use physical restraints as a last resort; provide glasses or hearing aids to children who use these devices; explore the use of electronic devices (smartphones or tablets) for communication with the family if the child is alone Adopt communication strategies: speak calmly and slowly using short and clear sentences, explaining to the child where he or she is and why he or she needs to stay there; identify oneself and describe what is being done; tell the child the time of day and day of the week; do not discuss visual or auditory hallucinations with child, and instead simply explain that their perceptions are different; when possible, talk to the child about real people and events

Promote sleep: wake the child at the same time every morning; leave the bed in a chair-like position similar when possible according to the child's age and tolerance; discourage daytime sleep, except for scheduled naps or periods of silent rest; use a weak night light to reduce the child's misperceptions and fears at night; use masks to block light during sleep and earplugs or white noise for sound masking; avoid overstimulation, especially before scheduled sleep or rest times; try to concentrate team activities during the day to avoid sleep interruptions at night; make a calendar and clock available for identifying the date and time

Encourage mobilization and cognitive stimulation activities: adopt consistent daily routines for hygiene, mobility, range of motion exercises, therapies, interventions and play

Cluster care: concentrate interventions to be performed with the patient to minimize interruptions and noise during rest periods Behavioral therapies: directed relaxation techniques that use cognitive behavioral resources and can be applied by qualified professionals on the multidisciplinary team, such as psychological therapy, occupational therapy, music therapy, aromatherapy, pet therapy and play therapy

Breastfeeding and non-nutritive sucking with oral solutions of sucrose and/or glucose in patients with an oral diet whose clinical condition allows it. These strategies can be used with neonates and infants undergoing mildly to moderately painful procedures alone or in combination with other pain relief strategies. Start 5 minutes before the painful procedure and, if possible, continue during the procedure Other non-pharmacological strategies, such as facilitated tucking (a technique that provides comfort and pain relief and that consists of keeping the extremities of the neonates or infants flexed and contained during a painful procedure), curling/swaddling (wrapping the body of the newborn or infant up to 6 months of age in a blanket/blankets, considering the clinical conditions, while keeping the arms close to the body to promote pain relief during painful procedures), and skin-to-skin contact and sensory stimulation (massage, caregiving) have been shown to be useful for reducing pain scores during short-term mildly to moderately painful procedures and should be used consistently

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