The Role of Dexmedetomidine in Pediatric Patients Presenting with an Anticholinergic Toxidrome

Background. We report two pediatric cases of anticholinergic toxidrome, including the youngest reported to date, in which standard therapeutic strategies were either contraindicated or ineffective, while treatment with dexmedetomidine was rapidly efficacious with no adverse effects. Moreover, with the recent shortage of physostigmine, we highlight an alternative treatment in this clinical setting. Case Summaries. In case 1, a two-year-old had an overdose presenting with an anticholinergic toxidrome. However, his hypopnea precluded the use of benzodiazepines due to the high likelihood of intubation. In case 2, a 14-year-old had a polypharmacy overdose inducing agitated delirium that was refractory to high-dose benzodiazepines. Due to the unknown ingestion, physostigmine was avoided. In both cases, dexmedetomidine helped the patient remain calm and metabolize the ingestions. Conclusion. Our experience suggests that dexmedetomidine may be a useful adjunct in anticholinergic presentations in the setting of polypharmacy, when standard therapy is proven ineffective, contraindicated, or unavailable.

Is "behavioural disturbance" a clinically more useful concept than "delirium" for trials in intensive care medicine?

“Delirium is common in critically ill patients and is associated with adverse outcomes”: an almost universal introduction to studies of delirium in intensive care medicine. Regrettably, each element of this statement is misleading. Delirium is indeed common in the intensive care unit (ICU), but is present in so many forms (hypoactive, agitated, mixed;1 related to different aetiologies; sedation-related or not) and so dependent on study population and method of assessment as to make studies using unqualified definitions difficult to interpret. Further, this statement is commonly invoked as the rationale for trials of delirium prophylaxis or treatment, with the implicit assumptions that the association with adverse outcomes is causative, and that any negative consequences of intervening will be outweighed by the benefit of breaking this causal link. Neither of these assumptions has been proven, potentially explaining the failure of almost every trial of a pharmacological critical care delirium prevention or treatment strategy. Illustrating this point, a protocol of no sedation in mechanically ventilated patients, in comparison to primarily propofol-based standard care, resulted in more agitated delirium (incidence 20% v 7%) but more ventilator-free days. If there is to be any progress in ICU delirium management, a more sophisticated approach to diagnosis is a good place to start.

Extrapyramidal Symptoms Induced by Treatment for Delirium: A Case Report

Introduction Antipsychotics are a treatment option for delirium in the intensive care unit. Atypical antipsychotics are preferred over first-generation antipsychotics because of their lower incidence of extrapyramidal adverse effects. The most common such effect is akathisia or restlessness. This report describes a case of atypical antipsychotic–induced akathisia and addresses the clinical distinction between extrapyramidal movements and movements due to intensive care unit delirium. Clinical Findings A 56-year-old man who had a prolonged hospital stay after orthotopic liver transplant complicated by multisystem organ failure, primary graft failure requiring a second transplant, and enterocutaneous fistula developed agitated delirium on hospital day 28. Initial treatment included intravenous haloperidol and scheduled sublingual olanzapine (5 mg daily). His delirium and insomnia persisted, requiring dexmedetomidine infusion. Olanzapine dosing was increased to 10 mg daily on hospital day 34 and 15 mg daily on hospital day 45. The following day, his mentation improved; however, he exhibited asynchronous, nonrhythmic, involuntary rolling motions of his hands and choreiform gait. Diagnosis and Outcomes Antipsychotics were immediately discontinued owing to acute akathisia. All symptoms resolved within 2 days, and the patient was transferred out of the intensive care unit on hospital day 52. Conclusion Although extrapyramidal adverse effects are less common with olanzapine than with typical antipsychotics, they sometimes occur and can mimic manifestations of delirium. Restlessness should alert the nurse to assess for possible extrapyramidal adverse effects. If they are suspected, antipsychotic medications should be reduced or discontinued to prevent progression to functional disability.

Dynamic Predictive Scores for Cardiac Surgery-Associated Agitated Delirium: a single-center retrospective observational study

Background Prevention, screening, and early treatment are the mainstays of postoperative delirium management. Score system is an objective and effective tool to stratify potential delirium risk for patients undergoing cardiac surgery Methods Patients undergoing cardiac surgery from January 1, 2012, to January 1, 2019, were enrolled in our retrospective study. The patients were divided into a derivation cohort (n = 45,744) and a validation cohort (n = 11,436). The agitated delirium (AD) predictive systems were formulated using multivariate logistic regression analysis at three time points: preoperation, ICU admittance, and 24 hours after ICU admittance. Results The prevalence of AD after cardiac surgery in the whole cohort was 3.6% (2,085/57,180). The dynamic scoring system included preoperative LVEF ≤ 45%, serum creatinine > 100 umol/L, emergency surgery, coronary artery disease, hemorrhage volume > 600 mL, intraoperative platelet or plasma use, and postoperative LVEF ≤ 45%. The area under the receiver operating characteristic curve (AUC) values for AD prediction of 0.68 (preoperative), 0.74 (on the day of ICU admission), and 0.75 (postoperative). The Hosmer-Lemeshow test indicated that the calibration of the preoperative prediction model was poor (P = 0.01), whereas that of the pre- and intraoperative prediction model (P = 0.49) and the pre-, intra- and postoperative prediction model (P = 0.35) was good. Conclusions Using perioperative data, we developed a dynamic scoring system for predicting the risk of AD following cardiac surgery. The dynamic scoring system may improve early recognition of and interventions for AD.