(033) Antipsychotic Treatment Strategies for Delirium in the Pediatric Intensive Care Setting: A Review of the Current Literature

‎

Background: Delirium is a neuropsychiatric condition frequently experienced by patients with critical illness. ‎There has recently been increased awareness of both the existence and significance of delirium in critically ill ‎children,1 as well as the challenges to early identification of delirium in this unique patient population, especially in ‎younger patients and those with developmental delays.2 Delirium has been reported in up to 25% of critically ill ‎children.2 Along with multimodal treatment approaches, antipsychotic medications are currently used off-label in the ‎management of pediatric delirium.3 Because delirium is associated with increased hospital length of stay, longer ‎periods of mechanical ventilation, higher costs and increased rates of neurodevelopmental regression and mortality,4 ‎effective prevention and management strategies are crucial for improving these outcomes in pediatric critical care. ‎Currently, there is a lack of systematic guidance for the use of antipsychotics in managing pediatric delirium.‎

‎

Methods: The aim of this review is to familiarize the practitioner with antipsychotic treatment strategies for ‎delirium in the pediatric intensive care setting. Current literature about the utility of each antipsychotic was reviewed ‎by conducting a PubMed search of studies from 1964 to March 8, 2023. Articles that were excluded from this review ‎included adult studies, survey-based studies, review or meta-analysis articles, articles published as a case report/case ‎series, letter, or editorial. The pharmacokinetics and pharmacodynamics of each antipsychotic were reviewed using ‎the PubChem Compound Database. Data analysis will include descriptive statistics on safety, tolerability, and dosing.‎

‎

Results: In the 12 articles included in this review, the antipsychotic medications of interest were haloperidol ‎‎(n=6), quetiapine (n=6), risperidone (n=3), olanzapine (n=2), and chlorpromazine (n=1). One study showed a ‎statistically significant decrease in opioid and benzodiazepine requirements for patients receiving quetiapine, while ‎two other studies demonstrated greater improvement of delirium symptoms, as measured by the Delirium Rating ‎Scale, Cornell Assessment of Pediatric Delirium, and State Behavioral Scale, with olanzapine and chlorpromazine. ‎Another study found no short-term improvement in delirium scores for patients treated with haloperidol or ‎quetiapine when compared to untreated patients. Despite mixed results (accessible via QR code), antipsychotic ‎medications appear to play an important role in the management of delirium in pediatric intensive care patients.‎

‎

Discussion: Evidence is currently limited by the lack of randomized, placebo-controlled trials of antipsychotics ‎for delirium in pediatric intensive care unit patients. Areas for future research include evaluating the positive and ‎negative long-term effects of short-term antipsychotic use in this patient population, as well as further assessment of ‎the impact of administering antipsychotics on doses of sedatives used.‎

‎

Conclusion: Given that pediatric delirium has been associated with higher rates of adverse outcomes, ‎including mortality and prolonged length of stay, efforts to improve early prevention, identification, and management ‎of delirium are crucial. Ultimately, this review provides clinicians with an overview of current evidence on the utility of ‎antipsychotics in the management of delirium in critically ill children.‎

‎

References: ‎
‎1. Schieveld, doi.org/10.1001/jamapediatrics.2014.125‎
‎2. Traube, doi.org/10.1097/CCM.0000000000002250‎
‎3. Capino, doi.org/10.5863/1551-6776-25.2.81‎
‎4. Patel, doi.org/10.1016/j.pcl.2017.06.009‎