Neuro-psychiatric complications in pediatric ICU Ri???

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Neuro-psychiatric complications in pediatric
ICURi???
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• Delirium
• Seizure

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Delirium

• serious neuropsychiatric disorder frequently seen
  in severely ill adult and geriatric patients
• clinical picture in adults well known, as are
  the negative prognostic implications length of
  hospital stay, morbidity, and mortality
• less appreciated delirium frequently occurs in
  severely ill children
• its seriousness often underestimated and not
  treated

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Delirium

• DSM IV definition
• disturbance of consciousness
• inattention accompanied by a change in cognition
  or perceptual disturbance
• Changes in cognition memory impairment,
  disorientation, and rambling or irrelevant speech
• Perceptual changes hallucinations (usually
  visual), illusions
• develops during a short period (hours to days)
  and fluctuates over time

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Delirium

• categorized according to level of alertness and
  level of psychomotor activity
• hyperactive
• hypoactive (more prevalent, worse prognosis )
• mixed

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Delirium
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Delirium

• clinical signs of delirium considerable
  variation in children and adults
• older children may be the same as adults
• young children the childs age and
  developmental stage may influence the clinical
  picture
• Formal psychiatric assessment may not be possible
  
• observed behavior and caretaker information are
  important

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Delirium-symptomatology

• Psychomotor retardation or agitation, anxiety,
  difficulty getting the childs attention, and
  regression with loss of previously acquired
  skills
• An acute onset of symptoms and the fact that the
  child may be inconsolable
• The caretakers opinion is important more
  readily recognize abnormal behavior in the child

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Delirium

• no reliable estimates of the incidence of
  delirium in children
• The pathophysiology of delirium not clear, but
  it is assumed that alterations in different
  neurotransmitter systems

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Delirium-etiology

• metabolic disturbances, electrolyte imbalances,
  medication (withdrawal/intoxication), acute
  infection (intracranial and systemic), seizures,
  head trauma, vascular disorders, and intracranial
  space-occupying lesions
• In children, infections and medication use are
  the most frequent causes
• often not one single factor , but multiple
  factors contribute to the etiology, such as
  somatic disorder(s), prescribed medication,
  and/or medication withdrawal effects.

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Delirium-assessment
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Delirium-assessment
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Delirium-treatment

• should be treated actively and not conservatively
  
• related to a longer hospital stay and a higher
  mortality
• control psychomotor agitation to prevent the
  child from harming
• restores quality of life and reduce the incidence
  of posttraumatic stress

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Delirium-treatment

• psychosocial and pharmacological interventions
• Psychosocial interventions directed at
  restoring orientation and comfort
• psychoeducation for the family, the presence of a
  family member, bringing in favorite toys and
  pictures of the home and family, and restoration
  of the usual day and night rhythm

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Delirium-treatment

• Find and reverse the underlying medical problems
• Control behavioral disturbance

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Delirium-treatment

• haloperidol preferred for pharmacological
  treatment ( risperidone for use in children gt 4
  years )
• wide clinical experience with haloperidol also in
  children
• Suggested dosages for children lt 4 years of age
  0.25 mg slowly intravenously over 30 to 45
  minutes as a loading dose and 0.05 to 0.5
  mg/kg/24 h intravenously as a continuing dose
• impact of delirium on the child and caretaker
  pharmacological treatment should be part of the
  routine care of delirious young children.

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• Delirium
• Seizure

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Seizure

• Nonconvulsive seizures (NCS), also known as
  subclinical seizures ( lack of motor
  manifestation) underrecognized
• require electroencephalographic confirmation for
  diagnosis
• defined as a disorder manifested by impaired
  consciousness
• EEG shows electrographic seizure activity lasting
  at least 10 s in duration

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Seizure

• retrospective review
• Inclusion all pediatric patients admitted or
  transferred to the PICU
• the Hospital for Sick Children
• January 2000 to December 2003
• unexplained decrease in the level of
  consciousness, no overt seizure activity
• EEG recording performed within 24 h of the onset
  of altered level of consciousness

Non convulsive seizure in the pediataric
intensive care unit etiology, EEG and brain
imaging findings Epilepsia 47(9)1510-1518, 2006
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Seizure

• 141 patients fulfilled the inclusion criteria
• 23 (16.3) diagnosed with NCS
• mean age 40.1 months (range 1 month to 18
  years)
• no preexisting disease in 10 (43), a history of
  a seizure disorder in eight (35), congenital
  heart disease in two (9), and other underlying
  diseases in three (13)

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Seizure-etiology

• most common etiology acute structural brain
  lesion in 11 (48)
• six (26) cerebral infarction, three (13)
  subdural hematoma, one (4) cerebral
  hemorrhage, one (4) arterio venous
  malformations (AVM).
• second most common etiology acute nonstructural
  brain lesion in five children (22)
• three (13) meningitis, one (4)
  encephalitis, and one (4) hepatic
  encephalopathy.
• seizure disorder in three (13), two (9)
  generalized epilepsy, one (4 )
  localization-related epilepsy.
• Other etiologies four (17) including sepsis
  (8) and pneumonia (8)

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Seizure-discussion

• not a rare condition in the pediatric population.
  
• 16 of patients admitted to the PICU with an
  altered state of consciousness NCS
• two differences between our pediatric population
  and adult

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Seizure

• almost half of the patients (43) in this study
  previously healthy ( especially those under 6
  months of age )
• important to be aware of the possibility of a NCS
  in a child lt6 months of age who has no
  preexisting medical history.

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Seizure

• etiology of NCS differ
• Cerebral infarction the most common NCS
  etiology in our study
• NCS should be treated expeditiously because
  -acute neurological impairment
• -the attendant morbidity
• -risk of evolving into generalized convulsions
  
• An early EEG study useful in detecting NCS in
  children with deterioration of consciousness of
  unknown origin.

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Seizure-symptomatology lt3y/o

• included all patients younger than 3 years
• recorded epileptic seizures during prolonged
  video-EEG
• monitoring at the authors institution from 1988
  to 1998
• 76 patients
• aged 27 days to 35 months (mean, 15.1 months)

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Seizure-symptomatology lt3y/o

• 1. Tonic seizures characterized by sustained
  muscle contractions, usually lasting gt3-5 s, with
  stiffening and positioning of the body or one or
  more limbs.
• 2. Myoclonic seizures sudden, shock- like
  muscle jerks for a fraction of a second.

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Seizure-symptomatology lt3y/o

• 3. Clonic seizures series of myoclonic
  contractions at a regular interval, typically in
  the range of 0.5-5 per second
• 4. Epileptic spasms began with an abrupt axial
  move- ment leading to briefly sustained
  posturing, most often truncal and neck flexion
  with pronounced arm extension and abduction
• 5. Hypomotor seizures main manifestation was a
  striking reduction or arrest of behavioral motor
  activity as compared with baseline without other
  motor manifestations

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References

• Delirium in Severely Ill Young Children in the
  Pediatric Intensive Care Unit (PICU) Journal of
  the american academy of child and adolescemt
  psychiatry April 2005)
• Monitoring Delirium in Critically Ill Patients
  -Using the Confusion Assessment Method for the
  Intensive Care Unit critical care nurse Vol 23
  no. 2 april 2003 p25-37
• Intensive Care Unit Syndrome A Dangerous
  Misnomer Arch Intern Med.2000160906-909
• Non convulsive seizure in the pediataric
  intensive care unit etiology, EEG and brain
  imaging findings Epilepsia 47(9)1510-1518, 2006
  
• Symptomatology of Epileptic Seizures in the First
  Three Years of Life Epilepsia 4o(7)873-844, 1999

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• Thanks for your attention!