Delirium Clinical Pathway, CICU, PICU, and PCU – Brain Maps

Delirium Clinical Pathway — CICU, PICU, and PCU

BRAIN MAPS: Common Causes of Delirium

Within 2-4 hrs of a positive screen, the clinical team assesses potential causes for delirium and completes a medical evaluation, including neurologic exam. After completing the history and medical assessment, the clinical team should consider these causes and recommendations using the BRAIN MAPS acronym.

Consider the following:

EEG

  • If concern for seizures, follow the EEG Monitoring Pathway and Neurology consult
  • If no concern for clinical seizures, an EEG may be a helpful tool in a workup of the diagnosis of altered mental status in conjunction with Neurology

Neuro Imaging

  • If indicated by physical and neurologic exam, consider brain MRI or head CT, although brain imaging will likely not be necessary for most children
  Assessment Evaluation Recommendations
B Bring Oxygen
  • Evaluate for:
    • Hypoxemia
    • Low cardiac output
    • Anemia
  • Improve oxygenation via:
    • O2 delivery
    • Resolution of anemia (PRBCs)
R Remove/Reduce Drugs Evaluate for use of anticholinergics and sedative medications Discontinue if possible
A Atmosphere
  • Room setup — lights, noise levels
  • Restraint use
  • Caregiver presence
  • Schedule/routine
  • Use of adaptive equipment and/or communication aids (e.g., glasses/hearing aids)
  • Encourage normal day/night routine
  • Encourage consistent and familiar caregiver presence
I Infection/Mobilization/Inflammation Infectious workup Treat infection and fever

N


M

New Organ Dysfunction

and

Metabolic Disturbance
  • Consider all systems: CNS, CV, pulmonary, hepatic, renal, endocrine
  • Evaluate with CMP and ABG for:
    • Hypo/hypernatremia
    • Hypo/hyperkalemia
    • Hypocalcemia
    • Alkalosis/acidosis
  • Normalize electrolytes
  • See information below on emergence agitation and NMDA encephalitis
A Awake
  • No bedtime routine
  • Sleep-wake cycle disturbance
  • Establish day/night cycles
P Pain
  • Untreated or undertreated pain
  • Over-treated (sedated)
  • Adjust analgesia regimen if appropriate
S Sedation
  • Consider weaning or discontinuing benzodiazepines
  • Consider adding dexmedetomidine with
    appropriate hemodynamics.

References

  1. Pediatric Delirium: Monitoring and Management in the Pediatric Intensive Care Unit  
  2. Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium: A Randomized Clinical Trial  

Types of Delirium

There are several types of delirium and children may alternate between types.

Type Clinical Manifestations Risk for Self-Harm Immediate Recommendations
Hypoactive
  • Non-interactive
  • Sleepy
  • Comatose
 Low
  • Identify cause and treat
  • Continue prevention measures
Hyperactive
  • Agitated
  • Excitable
 May be a risk to self
Mixed A state in which the patient alternates between hypo- and hyperactive delirium

Diagnoses with Initial Presenting Symptom of Delirium

Additional Differential Diagnostic Considerations

Emergence Agitation
  • Phenomenon noted in recovery from anesthesia
  • Impacts many children after surgery or non-painful procedures (e.g., MRI)
  • Generally resolves once anesthetic wears off
Anti-NMDA Encephalitis-Associated Delirium
  • Rare cause of delirium and acute agitation in children
  • Diagnosis made in conjunction with Neurology, Psychiatry and Oncology based off of CSF studies
  • Best treated in consultation with psychiatry; treatment may include benzodiazepines, clonidine and olanzapine
Post-Traumatic Amnesia
  • Often secondary to brain injury
  • Consider PMR in addition to Psychiatry consult

Reference

Treatment of Delirium in the Context of Anti–N-Methyl-D-Aspartate Receptor Antibody Encephalitis