(921) Evaluation of Antipsychotic Use for Treatment of Acute Pediatric ICU Delirium at a Single Center

Introduction: Up to 66% of pediatric ICU (PICU) admissions are complicated by acute delirium. Treatment generally focuses on nonpharmacologic measures, and when medications are needed, antipsychotics (AP) are often prescribed. Studies describing the use and timing of initiation of AP for the treatment of PICU delirium are limited. As part of a larger quality improvement initiative, this study aimed to describe baseline AP use in a single center PICU.

Methods: A retrospective review of patients treated in the PICU from July 2019 to July 2022 and prescribed AP for at least 24 hours for the diagnosis of acute delirium was conducted. Patients were excluded if AP was a home medication, AP use < 24 hours or only as needed, or AP used for indication other than acute delirium. Demographic data were collected in addition to known risk factors for delirium. Exposure to opiates, benzodiazepines, melatonin, dexmedetomidine, and adjunct anesthetics on the day of AP initiation to day 3 of AP treatment were compared.

Results: Seventy-one patients for 72 unique AP courses were included. For all patients the diagnosis of acute delirium was made clinically. Median time from PICU admission to initiation of AP was 9.5 days. Median duration of AP usage was 13.5 days. At the time of AP initiation, 44/72 (61%) of patients were receiving melatonin, 47/72 (65%) were receiving benzodiazepines, and 23/72 (32%) received an adjunct anesthetic. There was no difference in median max infusion rate between day of AP initiation and day 3 of AP treatment for fentanyl, dexmedetomidine, or midazolam. Median max infusion rate of morphine decreased slightly on day 3 compared to day of AP initiation (0.163 mg/kg/hr to 0.115 mg/kg/hr). There was a 40 % decrease in median daily PRN usage for fentanyl, dexmedetomidine, midazolam, and morphine.

Conclusions: In this single center descriptive study, AP for the treatment of acute PICU delirium was associated with a decrease in PRN sedation and analgesia medication use without changing rates of continuous infusions. A clinical diagnosis of delirium likely underestimated the true incidence of delirium. Future directions include standardizing sedation and delirium scoring using validated screening tools to objectively assess the incidence of PICU delirium and further assess the impact of AP.