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Validity of Different Delirium Assessment Tools for Critically Ill Children: Covariates Matter*

Luetz, Alawi MD; Gensel, Dennis MD; Müller, Judith MD; Weiss, Bjoern MD; Martiny, Viktoria MD; Heinz, Andreas MD; Wernecke, Klaus-Dieter PhD; Spies, Claudia MD

doi: 10.1097/CCM.0000000000001840
Pediatric Critical Care

Objectives: To evaluate test validity of the Pediatric Confusion Assessment Method for the ICU, the Pediatric Anesthesia Emergence Delirium scale, and the newly developed severity scale for the Pediatric Confusion Assessment Method for the ICU; to prospectively assess covariates and their influence on test validity of the scores.

Design: Prospective observational cohort study.

Setting: PICU of a tertiary care medical center.

Patients: Critically ill patients 5 years old or older ventilated or nonventilated with an ICU length of stay of at least 24 hours.

Interventions: None.

Measurements and Main Results: Patients were scored with the Pediatric Confusion Assessment Method for the ICU and the Pediatric Anesthesia Emergence Delirium scale once daily for a maximum of 21 days. Validity was determined by comparing scoring results with the evaluations of the delirium experts who used the criteria of the Diagnostic and Statistical Manual, 4th Edition, Text Revision, for delirium diagnosis. Sixty-four patients were enrolled and 214 assessments were conducted and included in data analysis. The first assessments within each patient revealed sensitivities of 69.2% for the Pediatric Anesthesia Emergence Delirium scale, 76.9% for the Pediatric Confusion Assessment Method for the ICU, and 84.9% for the severity scale for the Pediatric Confusion Assessment Method for the ICU. Specificities were 98% for all scores. Considering repeated measurements, sensitivities decreased to 35.9% for the Pediatric Anesthesia Emergence Delirium scale and to 52.3% for the Pediatric Confusion Assessment Method for the ICU. The sensitivity of the severity scale for the Pediatric Confusion Assessment Method for the ICU dropped to 71.8%, which was significantly higher compared to the Pediatric Anesthesia Emergence Delirium scale (p = 0.0008). Receiver operator characteristic regression unveiled that sedation and mechanical ventilation had a significant negative effect on the validity of the Pediatric Anesthesia Emergence Delirium scale and the severity scale for the Pediatric Confusion Assessment Method for the ICU. Age and gender had a significant impact on the receiver operator characteristic curve of the severity scale for the Pediatric Confusion Assessment Method for the ICU.

Conclusions: The severity scale for the Pediatric Confusion Assessment Method for the ICU showed the best test validity when used in critically ill children of 5 years old or older. Nevertheless, validity of delirium screening itself depends on patient specific factors. These factors should be taken into consideration when choosing a delirium screening instrument.

Supplemental Digital Content is available in the text.

1Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitaetsmedizin Berlin, Germany.

2Department of Pediatrics, Division of Pneumonology, Immunology, and Intensive Care Medicine, Campus Virchow-Klinikum, Charité—Universitaetsmedizin Berlin, Berlin, Germany.

3Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité—Universitaetsmedizin Berlin, Berlin, Germany.

4Department of Medical Biometry, Campus Charité Mitte, Charité—Universitaetsmedizin Berlin, Berlin, Germany.

*See also p. 2117.

Trial Registration: ClinicalTrials.gov (NCT01416675).

Dr. Luetz is a participant in the Charité Clinical Scientist Program funded by the Charité—Universitaetsmedizin Berlin and the Berlin Institute of Health.

Drs. Luetz and Spies have full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Dr. Luetz disclosed other support (he has a patent pending outside of the submitted work [grant number: 10 2014 215 211.9]), and he received funding from Köhler Chemie (payment for lecture [outside of the submitted work]) and Orion-Pharma (payment for lecture [outside of the submitted work]). Dr. Weiss received funding from Paion UK, Orion Pharma UK, and the German Academic Exchange Service. Dr. Spies disclosed other support (outside of the submitted work, she received additional grants from Grünenthal, Roche, MSD, Outcome Europe Sàrl, B. Braun Melsungen, BDA, BMBF, DKH, DLR, German Research Society, GIZ, Inner University Grants, Stifterverband, and European Commission; personal fees from ConvaTec International Service GmbH, Pfizer Pharma, Vifor Pharma, Fresenius Kabi, and Georg Thieme Verlag. Outside the submitted work, she has a patent [10 2014 215 211.9] pending). Her institution received funding from Köhler Chemie (outside of the submitted work), Orion Pharma (outside of the submitted work), and German Federal Ministry of Economics MMWi (AiF) (outside the submitted work). The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: claudia.spies@charite.de

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