Delirium Clinical Pathway, CICU, PICU, and PCU – Trial of Pharmacological Therapy

Delirium Clinical Pathway — CICU, PICU, and PCU

Trial of Pharmacological Therapy

  • Psychotropic medications may be useful to treat symptoms of agitated delirium when nonpharmacologic treatments are not sufficient and the child’s behaviors put them at risk for harm or are causing significant distress.
  • These medications may treat the symptoms of delirium and improve behaviors but will not resolve the underlying cause (e.g., infection, stroke).
  • Antipsychotics should not be used to decrease the duration of delirium or attempt to prevent it.
  • Symptoms generally resolve as underlying disease improves.
  • Currently, delirium is not an FDA approved indication for use of psychotropic medications in children. Prior to initiating treatment, discuss the risk/benefit ratio with the family.
    • Ensure family understands that these medications are not approved for children by the FDA, but that in our experience they may benefit some children.

Special Considerations

  • Children < 2 yrs consider Psychiatry consult prior to initiating therapy
  • Complete informed consent form for children < 4 yrs

When indicated, a trial of pharmacological therapy should only be initiated after:

  • Full medical assessment
  • Any modifiable risk factors have been addressed

Prior to initiation of antipsychotic medications below, obtain:

  • Baseline ECG
  • Baseline labs: BMP, magnesium, creatinine phosphokinase (CPK), CBC with differential, and liver function tests (LFTs)
  • Review medication list for possible drug-drug interactions
Indication for Initiation Medication Route/Formulation Comments
Delirium with Imminent Risk of Harm
No enteral access		 Haloperidol IV/IM  
Delirium
Able to tolerate enteral		 Quetiapine Enteral/tablet Preferred enteral agent
Risperidone Enteral/tablet, ODT, oral solution
  • Preferred for:
    • Autism spectrum disorder
    • Children < 7 kg
Olanzapine Enteral/tablet, ODT  

Monitoring Recommendations

Parameter Baseline After Initiation and
Subsequent Dose Increase(s)		 Maintenance
(If Continued)
EKG × 48 hrs
  • Enteral agents: Monthly
  • IV haloperidol: Weekly
BMP ×
Magnesium ×
CPK × Weekly x 2 Monthly
CBC with Diff ×
LFTs ×
Triglycerides Consider monthly maintenance monitoring
Fasting Glucose and Prolactin

 

 

Common Side Effects

Common Side Effects Serious, but Less Common, Side Effects
  • Hypertension
  • Increased cholesterol/triglycerides
  • Increased liver enzymes
  • Dyskinesias
  • Dry mouth
  • Lethargy
  • Akathisia
  • Hypertonia
  • Extrapyramidal symptoms (EPS)
  • Restless leg syndrome
  • Increased weight gain with long-term use
  • QTc prolongation
  • Neutropenia
  • Leukopenia
  • Thrombocytopenia
  • Neuroleptic malignant syndrome (NMS)
  • Seizures
  • Tardive dyskinesia
  • Allergic reactions
See AACAP Practice Parameters for Atypical Antipsychotic Medications for more guidance on EPS and NMS

Adverse Drug Event Management

Adverse Event Management Recommendations
QTc > 500 ms
or
QTc increase by > 60 ms
  • Discontinue antipsychotic agent and consult Cardiology to weigh risks and benefits of continuing therapy
  • Prolonged QTc Pathway
QTc Increased by ≥ 470-499 ms
Muscle Stiffness or Abnormal/Involuntary Movement Problems or Extrapyramidal Symptoms (EPS)
  • Give diphenhydramine 1 mg/kg/dose PO/IM/IV (max 50 mg)
  • Consider Psychiatry consult
  • Discuss risks versus benefit and consider discontinuing antipsychotic agent
Persistent Movement Symptoms
  • Consider 2nd dose of diphenhydramine
  • Consider benztropine in coordination with Psychiatry consult
  • Discuss risks versus benefit and consider discontinuing antipsychotic agent

Weaning Recommendations

  • Evaluate ability to wean/discontinue no later than 5-7 days after initiation of therapy to determine if underlying disease process is improving and behaviors are well-controlled
  • Begin weaning as soon as appropriate; frequency of weans should be dictated by drug pharmacokinetics and duration of exposure
  • Generally, duration of wean should not exceed duration of antipsychotic therapy
  • If transferred out of ICU, consult Psychiatry to manage medication wean
  • Do not discharge to home on medication for the treatment of delirium