Sean Barnes, MD, MBA
Sapna Kudchadkar, MD, PhD
What do delirium and early mobilization in the pediatric CICU have in common? That sounds like the start of a bad joke! However, these two integral components of the ICU Liberation Bundle are often the last to be implemented and consistently practiced in pediatric units. The ICU Liberation Bundle, also known as the ABCDEF bundle, integrates core aspects of ICU care including Assessing Pain (A), Both Spontaneous Awakening and Breathing Trials (B), Choice of Sedation (C), Delirium Monitoring/Management (D), Early Exercise/Mobility (E), and Family Engagement/Empowerment (F).1 In adult populations, ICU Liberation Bundles have demonstrated a dose-response effect, in which better compliance with the bundle correlates with superior clinical outcomes. So why are delirium and early mobilization the least commonly addressed elements in pediatrics?2
To be fair, the application of the ICU Liberation bundle is relatively new in pediatric critical care. It requires interprofessional buy-in, time, resources, and effort to change a unit’s culture. Most pediatric ICUs have implemented tools to rate a patient’s pain, some have tools to assess sedation, but few are routinely screening for delirium or prioritizing early mobilization. To achieve the “dose-response effect’ seen in adult studies, we must include these often-overlooked components of the bundle. In fact, pediatric CICU patients may have the most to gain.
Hospitalized children with underlying cardiac pathology are especially susceptible to developing delirium in the ICU. A recent multicenter point prevalence study found the prevalence of ICU delirium in postoperative pediatric cardiac surgery patients to be 40%.3 Delirium screening, with validated tools, should be the standard of care in all pediatric ICUs. The most commonly used validated delirium screening tools are the Cornell Assessment of Pediatric Delirium (CAPD), Pediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU), and the PreSchool Confusion Assessment Method for the ICU (psCAM-ICU). Using the CAPD or the pCAM-ICU and psCAM-ICU allows for screening of all ages. Routine screening is necessary because hypoactive or mixed (features of both hyperactive and hypoactive) delirium subtypes are more common and go unrecognized because the patient is not posing harm to themself or staff.
Delirium prevention and management are best addressed with nonpharmacological strategies. While the pathophysiology of delirium is unknown, poor sleep is likely on the causal pathway to developing delirium. Structured routines in patient care can promote day-night cycling. Being awake during the day and participating in activities will result in a patient who is more likely to have quality sleep at night. Additionally, maximizing exposure to sunlight (shades up by medical team rounds!) and minimizing exposure to artificial light and noise at night (turn the TV off!) are very helpful in maintaining a normal circadian rhythm and promoting restorative sleep.
Many pediatric studies have highlighted the impact of medications that contribute to delirium. Sedative regimens with polypharmacy in mechanically ventilated patients can be a major risk factor. Most sedatives inhibit restorative sleep and increase the likelihood of patients developing delirium. Avoiding or minimizing exposure to benzodiazepines and anticholinergic agents is critical to combatting delirium. At one point antipsychotic medications were thought to be beneficial in the prevention and management of delirium. More recent studies have shown that routine use of antipsychotic medications is not beneficial. Antipsychotic medications should generally be reserved for patients who are experiencing symptoms of delirium that are distressing or resulting in poor sleep. Child Psychiatry can be an additional resource for a child with severe delirium, especially when considering the initiation of an antipsychotic medication. Beyond assisting with the acute episode of delirium, Child Psychiatry can facilitate continuity of care to patients after they have left the ICU4.
As mentioned above when discussing the promotion of a healthy day-night cycle, physical activity is one of the most effective ways to ensure our patients are ready for a good night’s sleep. To achieve this safely, it is important to individualize the level of mobilization each patient should target on a given day. Similar to assessing delirium, pediatric early mobilization programs require a screening tool. The early mobilization screening tool should stratify the highest level of mobility a patient can safely achieve at that given moment. The expectation is not to have every intubated and mechanically ventilated patient walking laps around the ICU. In our youngest patients, the mobility goal for the day might include ‘therapeutic cuddles’ where the goal is simply to facilitate a parent or caregiver holding the patient. When mobilization is framed in this way, it highlights how even simple mobilization activities can impact the recovery of our patients.5
The PICU Up! program developed at Johns Hopkins was one of the first pediatric programs to focus on early mobilization6. It showed that an early mobilization program in the pediatric ICU was feasible and resulted in no adverse events. Any early mobilization program will need to address the concerns associated with accidental device disconnection or dislodgement specific to the patient population and environment. Additionally, the PICU Up! early mobilization program increased physical therapy and occupational therapy involvement in the children’s care, which may impact the quality of our patients’ recovery.
The ICU Liberation Bundle is a powerful intervention, yet it is critical to address each of the key components – including those related to delirium and early mobilization – to achieve optimal results. The blueprint for successful implementation exists. As pediatric cardiac ICU clinicians, it is our responsibility to see these plans through.
- Ely EW. The ABCDEF Bundle: Science and Philosophy of How ICU Liberation Serves Patients and Families. Crit Care Med 2017;45:321-30.
- Liu K, Nakamura K, Katsukawa H, et al. Implementation of the ABCDEF Bundle for Critically Ill ICU Patients During the COVID-19 Pandemic: A Multi-National 1-Day Point Prevalence Study. Front Med (Lausanne) 2021;8:735860.
- Staveski SL, Pickler RH, Khoury PR, et al. Prevalence of ICU Delirium in Postoperative Pediatric Cardiac Surgery Patients. Pediatr Crit Care Med 2021;22:68-78.
- Barnes SS, Grados MA, Kudchadkar SR. Child Psychiatry Engagement in the Management of Delirium in Critically Ill Children. Crit Care Res Pract 2018;2018:9135618.
- Ista E, Redivo J, Kananur P, et al. ABCDEF Bundle Practices for Critically Ill Children: An International Survey of 161 PICUs in 18 Countries. Crit Care Med 2022;50:114-25.
- Wieczorek B, Ascenzi J, Kim Y, et al. PICU Up!: Impact of a Quality Improvement Intervention to Promote Early Mobilization in Critically Ill Children. Pediatr Crit Care Med 2016;17:e559-e66.