Delirium in the Cardiac Intensive Care Unit (CICU)

Delirium is a sudden change in a person's mental state that is connected with a physical illness. When a person is delirious, they may experience:

• confusion

• reduced awareness of their surroundings

• difficulty thinking and focusing

• changes in behavior or emotions

Unlike other changes in mental state, delirium usually:

• appears suddenly, over hours or days

• is worse at night or in the dark

• varies in severity over the course of the day

• is connected with a physical illness

Delirium can be grouped into 3 main types:

1. hyperactive delirium: the person is often restless, highly active, anxious, moody, and may see or hear things that are not really there

2. hypoactive delirium: the person is often drowsy, slow-moving, dazed, inactive, and not interactive with other people

3. mixed delirium: the person shows symptoms of both hyperactive and hypoactive delirium, and may switch back and forth

Clinicians can sometimes have a difficult time recognizing delirium in babies, especially young babies. Learning the signs of delirium in babies can help clinicians and parents to prevent it, identify it, and treat it.

• Unusual drowsiness

• Apathy: not caring or showing interest in things that are usually important to the person

• Anxiety

• Disorientation and confusion

• Seeing and/or hearing things that are not there

Clinicians are usually well-prepared to recognize delirium in adults, although they may associate it more with older adults than younger ones. Family members can also look out for signs of delirium and advocate for their loved one if symptoms appear.

Sick people vary in whether and how they experience delirium. Certain conditions and treatments make delirium more likely, but not every person who has these conditions and treatments will experience delirium.

Generally, delirium arises from multiple interacting risk factors, including:

• underlying conditions

• acute illness

• environmental conditions

• medicines

Clinicians must observe patients closely to see how each individual responds when they are sick and undergoing treatment, and to determine their individual risk of delirium.

Even before they become acutely sick, some young people are already at a higher than typical risk of delirium. Their brains may be less resilient, and less able to tolerate added insults. Children and adults can be at a higher risk of delirium if they have:

• Developmental delays

• A history of mental illness

• Early experiences of delirium

• A history of stroke, seizure, or brain injury

• Differences in their brain development

• A cyanotic form of heart disease (one that causes low oxygen levels)

• Malnutrition

• Dementia (in adults)

People who experience delirium are almost always in the throes of an acute illness. These medical conditions and symptoms can increase the risk of delirium in children and young adults with heart defects:

• Serious infection

• Inflammation

• High fever

• Unmanaged pain

• Withdrawal from a habit-forming medicine, such as an opioid pain reliever

• Low oxygen levels (hypoxia) and a need for supplemental oxygen

• Major surgery

• Seizure

• Stroke

• Problems with the thyroid or adrenal glands

• Electrolytes imbalances, including abnormally low or high levels of sodium, calcium, and.or magnesium in the blood

• Coming out of anesthesia

• Organ failure

• Problems with metabolism, especially kidney failure

• Brain injury

• Serious burn or other serious injury

Generally, young people who have more severe illnesses are at a higher risk of delirium. When young people face multiple illnesses and more serious forms of illness, they are often at the highest risk.

Sometimes, the unusual environment within a hospital can contribute to delirium. For example, delirium may be more likely when:

• A space is too bright or loud

• A person's body is physically restrained

• Children are separated from their parents

• Nothing feels or looks familiar

• A person is unable to sleep

• The sleep-wake cycle is disrupted

• A person is restricted to a bed, or otherwise not allowed to move as they would like

• There are no windows to the outside

• The room looks, sounds, and feels the same throughout the 24 hours, rather than having distinct patterns of day and night

• A person cannot see clocks, calendars, or other indicators of time and location

• A person has a longer hospital stay

Medical care itself can sometimes increase the chance of delirium, even when it is necessary for healing or comfort. Medical treatments that may contribute to delirium include:

• Any major surgery

• Mechanical ventilation (a machine that helps the body to breathe)

• High levels of sedation (medicines that cause drowsiness or sleep)

• Certain medicines that calm the nervous system, such as benzodiazepines

• Certain medicines that block neurotransmitters and reduce nervous system communication (anticholinergic drugs)

• Certain medicines that control the pressure within arteries (vasoactive drugs)

• Opioid pain medicines

• Steroid medicines

• Medicines that cause paralysis (temporary inability to move the body)

• Induced coma

• Cardio-pulmonary bypass

• Extra-corporeal membrane oxygenation (ECMO)

• Red blood cell transfusion

When intensive care unit (ICU) staff and families are aware of children's risk of delirium, they can take steps to try to prevent or reduce it. These strategies may limit delirium in young patients:

• Create a sleep-wake schedule that is appropriate for a child's age and level of development. Keep the room dark and quiet at night, and brighter and more active during the day.

• Open window shades during the day.

• Parents stay in the child's room as much as possible, rooming-in if they are able. Parents directly care for the child as much as they can.

• When the child is awake, parents talk to the child, touch them gently, and make sure the child can see and hear them.

• At all times, use strategies to keep children well-regulated and calm.

• For older children, decorate the room and bed space with familiar items from home.

• For babies, provide a shirt or blanket that smells like their parent.

• During the day, provide age-appropriate activities such as music therapy, play with other children, games, interaction with therapy animals, and art.

• Use services such as physical therapy (PT), occupational therapy (OT), speech and language therapy, and home-hospital instruction, whenever possible.

• Monitor children's pain, and treat it effectively with behavioral strategies and medicine as needed.

• Encourage children to sit up, change position, walk, move, and change location whenever possible.

• When possible, bring children outside.

• For older children, make sure they can always see a clock, the date, and signs indicating where they are.

• Preserve as much of a child's regular routine as possible.

• If a child is having trouble communicating, consult with an augmentative communication specialist so that the child can express their thoughts and needs.

• When possible, limit the use of medicines and procedures that are associated with delirium. Consider the risk of delirium when developing a treatment plan.

When a child is experiencing delirium, caregivers can take steps to treat and reduce it. In most cases, delirium resolves within a few days. Sometimes, it may last as long as a couple of weeks. Even when a child remains delirious, caregivers may be able to reduce the frequency and severity of delirium.

Many treatments for delirium can also be used to prevent it. However, doctors typically do not use medicines to prevent delirium, while they may use medicines to treat it.

These strategies may help to resolve delirium:

• Treat the underlying illness.

• Remove lines and tubes as soon as it is safe to do so

• Extubate the child as early as possible.

• Consider substituting medicines that are less likely to lead to delirium.

• Consider alternatives to medicines to manage some symptoms.

• Parents stay in the room as much as possible, rooming-in if they can.

• Parents directly participate in care as much as they are able, and make sure the child can see and hear parents.

• Establish a sleep-wake routine that is appropriate for the child's age and developmental level. Make sure the room is dark and quiet at night, and brighter and more active during the day.

• Work to ensure that the child is sleeping well through the night, and during any defined nap times.

• During the day, open window shades. Look out the window and go outside when possible.

• Preserve or reestablish as much of the child's normal routine as possible.

• As soon as possible, help the child to move, sit, get up, change positions, and change locations.

• When the child is awake, engage them in age-appropriate activities such as Music Therapy, play with toys, games, puzzles, songs, books, and interactions with other people.

• When the child is awake, talk to them and touch them gently. Hold them when possible.

• If a child is having trouble communicating, consult with an augmentative communication specialist to help them to express their needs and thoughts.

• Bring in services and therapies daily, including physical therapy (PT), occupational therapy (OT), speech and language therapy, and home-hospital instruction.

• Give babies something that smells like their parents. Bring in familiar items and decorations for older children.

• Make sure older children can always see a clock, the date, and signs that indicate their location.

• When talking to older children, remind them where they are, what is going on, who everybody is, and that they are safe.

• Tell children before you touch them.

Delirium is fairly common among acutely ill children, especially in the days after a major heart surgery. However, hospital staff are not always well-prepared to recognize and manage delirium in their young patients. When providers and families educate themselves about the risks of delirium in children, they can use strategies to predict, prevent, diagnose, and treat it effectively. Reducing delirium can lead to better outcomes for children and the people who love them.

Developmental care is best when it is local. Families local to Boston can receive care from the Cardiac Neurodevelopmental Program (CNP). Families from other regions can use the link below to find their local care team.