Infant Delirium in Pediatric Critical Care Settings
Pathophysiology
Evaluation of Delirium in the PICU
Clinical Evaluation
Screening Instruments
Treatment
Sedation in Pediatric Critical Care
Drug Class and Agents | Effects | Benefits | Adverse Effects |
---|---|---|---|
Opiates: fentanyl, morphine, hydromorphone | Analgesia, sedation, no amnesia | Fentanyl: minimal cardiovascular effects, decrease in sympathetic response, minimal pulmonary vascular resistance effects | Fentanyl: rigid chest; morphine: histamine release, hypotension |
Benzodiazepines: midazolam, lorazepam, diazepam | Sedation, amnesia, anxiolysis, seizure control, no analgesia | Midazolam: short-acting; lorazepam and diazepam: seizure control | Lorazepam (continuous infusion): lactic acidosis, renal failure, rhabdomyolysis, mental status changes |
Barbiturates: thiopental, methohexital, pentobarbital | Sedation, seizure control, intracranial pressure control | Seizure control, intracranial pressure control | Hypotension, apnea |
General anesthetics: propofol | Sedation, anesthesia, seizure control, no analgesia | Short-acting, seizure control, intracranial pressure control | Hypotension, apnea, hypertriglyceridemia, propofol infusion syndromea |
Dissociative anesthetics: ketamine | Amnesia, analgesia | Maintains heart rate, blood pressure, and respirations; bronchodilation | Increases intracranial pressure, increase in intraocular pressure, negative inotropy, emergence reactions, increase in pulmonary vascular resistance |
α2 Adrenergic agonists: dexmedetomidine | Sedation, anxiolysis | Sedation, anxiolysis | Hypotension, hypertension, bradycardia, sinus arrest |
Treatment of Pediatric Delirium
Pharmacologic Strategies
Drug | Dosing | Forms Available | Frequencies of Adverse Effectsb | Cardiac Effectsc |
---|---|---|---|---|
Haloperidol | Age 3–12 years, 0.05–0.15 mg/kg per day divided into two or three doses; dosing interval, 2–12 hours | Oral (tablet, solution), intravenous, intramuscular (immediate release and depot), subcutaneous | >30%: extrapyramidal side effects; >10%: agitation, insomnia, weight gain, hyperglycemia; >2%: sedation, anticholinergic effects, hyperlipidemia, orthostasis; <2%: blood dyscrasias,d hepatic impairment, seizure, skin reaction; rare: neuroleptic malignant syndrome (highest potency antipsychotic, thus highest risk) | Abnormal ECG, <2%; QTc prolongation, >2%; tachycardia, <2% |
Chlorpromazine | Oral: age 6 months–12 years, 2.5–6.0 mg/kg per day, with dosing every 4–6 hours; maximum dosage: age 6 months–5 years, 50 mg/day; age 5–12 years, 200 mg/day. Intramuscular: 2.5–4 mg/kg per day, with dosing every 6–8 hours; maximum, 40 mg/day | Oral, intravenous, intramuscular | >30%: sedation, anticholinergic effects, orthostasis, weight gain, hyperglycemia, hyperlipidemia, abnormal skin pigmentation; >10%: photosensitivity, other rashes; 2%–10%: extrapyramidal side effects; <2%: agitation, blood dyscrasias,d hepatic impairment, seizures | Abnormal ECG, >30%; QTc prolongation, >2%; tachycardia, >10% |
Risperidone | Age 5–16 years, 0.5 mg–2.5 mg/day p.o., divided into two to four doses; maximum dosage: <20 kg, 1 mg/day, 20–45 kg, 2.5 mg/ day, >45 kg, 3 mg/day | Oral (tablets, orally disintegrating tablets, solution), intramuscular (depot) | >30%: weight gain; >10%: sedation, agitation, extrapyramidal side effects (akathisia/parkinsonism > dystonia), anticholinergic effects, hyperglycemia, hyperlipidemia, orthostasis; <2%: skin reactions, blood dyscrasias,d seizures, hepatic impairment | Abnormal ECG, >2%; QTc prolongation, <2%; tachycardia, >10% |
Olanzapine | Age 13–17 years, 2.5–10 mg/day; dosing every 12–24 hours; recommended maximum, 20 mg/day | Oral (tablets, orally disintegrating tablets), intramuscular | >30%: sedation, anticholinergic effects, weight gain, hyperlipidemia, hyperglycemia; >10%: insomnia, agitation; 2%–10%: extrapyramidal side effects (akathisia > dystonia/parkinsonism); >2%: orthostasis, hepatic impairment; <2%: skin reaction, blood dyscrasia, seizure | Abnormal ECG, <2%; QTc prolongation, <2%; tachycardia, <2% |
Quetiapine | Age 10–17 years, 12.5–400 mg; dosing every 12–24 hours (usually 12 hours); recommended maximum, 750 mg/day | Oral (tablets; immediate release, extended release) | >30%: sedation, anticholinergic effects, hyperglycemia; >10%: agitation, orthostasis, weight gain, hyperlipidemia; >2%: extrapyramidal side effects (akathisia > parkinsonism/dystonia), hepatic impairment; <2%: seizure, skin reaction (no data for rate of blood dyscrasias with quetiapined) | Abnormal ECG, <2%; QTc prolongation, <2%; tachycardia, >2% |
Ziprasidone | Adults, 5–100 mg/day, usually with dosing every 12 hours | Oral, intramuscular | >30%: agitation; >10%: sedation, anticholinergic effects, orthostasis; >2%: extrapyramidal side effects, weight gain, hyperglycemia; <2%: seizure, skin reaction; rare: priapism reported in adults | Abnormal ECG, >2%; QTc prolongation, <2%; tachycardia, >2% |
Aripiprazole | Age 6–17 years, 2–15 mg/day; dosing interval, 12–24 hours | Oral (tablets, orally disintegrating tablets, solution), intramuscular | >10%: sedation, agitation; 2%–10%: extrapyramidal side effects (akathisia > parkinsonism/dystonia); >2%: anticholinergic effects, weight gain, rash; <2%: hyperglycemia, hyperlipidemia, blood dyscrasia, hepatic impairment (other: dopamine stabilizing, possibly good for hypoactive delirium) | Abnormal ECG, <2%; QTc prolongation, <2%; tachycardia, >2% |
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