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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Delirium is a neuropsychiatric syndrome of acute or subacute onset and with fluctuating symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> Based on investigation of the delirium phenotypes in adults&#44; the syndrome is characterized by impaired mental functions manifesting when alertness is altered and three nuclear domains are affected&#58; cognitive &#40;attention&#44; orientation&#44; memory&#44; visuospatial capacity&#41;&#59; higher order thought &#40;language&#44; thought process&#44; executive function&#41;&#59; and circadian &#40;sleep&#8211;waking&#44; motor activity&#41;&#46; Psychotic and affective symptoms are accessory&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2&#44;3</span></a> The disorder may have one or more medical or iatrogenic causes&#44; and from the motor perspective it is defined as hyperactive&#44; hypoactive&#44; mixed or neither&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Both the clinical characteristics of the syndrome and its risk factors have been little studied to date in the critically ill pediatric population&#44; where it is often overlooked despite the increased morbidity&#8211;mortality it implies&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5&#44;6</span></a> In the Pediatric Intensive Care Unit &#40;PICU&#41;&#44; delirium prolongs admission and increases the treatment costs&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;8</span></a> Furthermore&#44; it increases parent suffering and stress on the part of the treating professionals&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The present study was designed to evaluate the prevalence and factors associated to delirium in the initial assessment of patients between 5 and 14 years of age admitted to a PICU over a period of one year&#46; A standardized evaluation of delirium was made based on the Pediatric Confusion Assessment Method for the Intensive Care Unit &#40;pCAM-ICU&#41;&#44; as well as of its motor types&#44; and a broad range of possible associated factors were explored&#46; Likewise&#44; we described the individual characteristics assessed by the items of the pCAM-ICU according to the motor type of the disorder&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Type of study and participants</span><p id="par0020" class="elsevierStylePara elsevierViewall">In order to evaluate the clinical characteristics&#44; prevalence and factors associated to delirium in critically ill children&#44; we designed a cross-sectional analytical observational study that was approved by the Ethics Committees of the Universidad Pontificia Bolivariana and Hospital Pablo Tob&#243;n Uribe &#40;Medellin&#44; Colombia&#41;&#46; All the persons in charge of the patients&#44; and the patients capable of doing so&#44; gave written informed consent to participation in the study&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient evaluation period lasted one year&#46; We included those patients between 5 and 14 years of age consecutively admitted to the PICU of Hospital Pablo Tob&#243;n Uribe &#8211; a high complexity university hospital&#46; The PICU has 20 beds for children between 0 and 14 years of age&#46; The Unit is general and open &#40;encouraging the presence of the parents or care givers during admission of the patient&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We excluded patients with stupor or in coma&#44; with communication problems precluding evaluation&#44; receiving deep sedation throughout admission&#44; and those cases in which informed consent could not be obtained&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Instruments</span><p id="par0035" class="elsevierStylePara elsevierViewall">Mortality risk was assessed based on the Pediatric Risk of Mortality Score &#40;PRISM&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">11</span></a> The properties of the neuropsychiatric scales employed are described below&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Pediatric Confusion Assessment Method for the Intensive Care Unit &#40;pCAM-ICU&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">This instrument is an algorithm validated in children aged 5 years or older&#46; It has excellent reliability &#40;kappa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;96&#41; and validity in diagnosing delirium according to the DSM-IV-TR &#40;sensitivity 83&#46;0&#37; and specificity 99&#46;0&#37;&#41;&#46; The pCAM-ICU assesses the following&#58; &#40;a&#41; the clinical course &#40;possible acute changes versus baseline and&#47;or fluctuation of the symptoms&#41;&#59; &#40;b&#41; verbal or non-verbal attention according to the condition of the patient&#44; based on the recognition of sequences of 10 items&#44; where a score &#8804;7 indicates attention impairment&#59; &#40;c&#41; alertness based on the Richmond Agitation Sedation Scale &#40;RASS&#41;&#44; which allows diagnosis of the disorder in the absence of deep sedation &#40;score &#8805;4&#41;&#59; and &#40;d&#41; the thought process&#44; with 5 reasoning questions scored from 0 to 5&#44; where a cut-off point &#8804;3 indicates alteration&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The pCAM-ICU is positive for delirium if there are alterations in the first and second characteristic&#44; and in either of the other two&#46; In this study we used the version in Spanish&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a> and for each motor type we recorded the frequency of acute onset&#44; symptoms fluctuation and alteration of the RASS&#44; as well as the median of the two clinical characteristics &#40;attention and thought process&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Items of the Delirium Rating Scale &#8211; Revised-98 &#40;DRS-R98&#41; for the evaluation of motor function</span><p id="par0050" class="elsevierStylePara elsevierViewall">The Delirium Rating Scale &#8211; Revised-98 &#40;DRS-R98&#41; explores different clinical aspects of delirium&#44; with response options ranging from 0 &#40;normal&#41; to 3 &#40;maximum severity&#41;&#46; Items &#35;7 and &#35;8 respectively evaluate increased and decreased motor activity&#44; and can be combined to define mixed cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">14&#44;15</span></a> In this study we only used the motor items&#46; A score &#8805;1 in either of the two items defines hyperactive and hypoactive cases&#44; respectively&#59; cases with a score &#8805;1 in both items are mixed cases&#59; and those scoring 0 in both items have no motor alterations&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Procedures</span><p id="par0055" class="elsevierStylePara elsevierViewall">A pilot survey was carried out in which the study instruments were applied to 10 patients in order to standardize the procedures&#46; The investigators held a meeting before the pilot survey&#44; another meeting after the survey&#44; and another two during the patient evaluation period&#44; in order to maintain standardization&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The group conducting the field work consisted of four nurses&#44; 5 psychiatrists and a pediatric intensivist&#46; The patients of the study were evaluated during the first 24 and 72<span class="elsevierStyleHsp" style=""></span>h of admission to the PICU&#46; A psychiatrist and a nurse jointly compiled the sociodemographic and clinical data of the patients&#44; applied the pCAM-ICU and classified the motor subtype of delirium with the DRS-R98&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Those patients administered deep sedation upon admission to the Unit &#40;RASS<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>3&#41; were monitored daily until their condition allowed us to determine whether they suffered delirium &#40;RASS<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>3&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The main diagnoses leading to admission to the PICU were grouped according to the Delirium Etiology Checklist &#40;DEC&#41;&#46; The DEC allows the reporting of mutually excluding diagnostic categories that avoid data dispersion due to the low prevalences of all the individual medical conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a> This and the rest of the independent variables studied as possible risk factors related to delirium are defined in the section below&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Independent variables and statistical analysis</span><p id="par0075" class="elsevierStylePara elsevierViewall">We defined a large group of factors for analysis&#44; and controlled variables related to the study design&#46; The independent variables were&#58; age in years&#44; gender&#44; educational level&#44; administration of deep sedation upon admission &#40;yes&#47;no&#44; depending on whether the RASS score was &#8804;3&#41;&#44; PRISM score&#44; history of intellectual disability&#44; epilepsy&#44; vision problems or hearing problems&#44; and each of the 6 most frequent main diagnoses upon admission according to the DEC&#46; Furthermore&#44; we determined whether any of the following characteristics had been recorded in the case history during the last 24&#8211;72<span class="elsevierStyleHsp" style=""></span>h&#58; postoperative condition&#44; mechanical ventilation&#44; respiratory failure&#44; ineffective clearing of the airway&#44; altered heart rate or blood pressure &#40;tachycardia&#44; bradycardia&#44; hypertension or hypotension according to the criteria of the American Heart Association&#41;&#44; hyperthermia &#40;temperature<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>38&#46;0<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; hypothermia &#40;temperature<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>36&#46;0<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; hypoxemia &#40;PaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#44; pain scored from 0 to 10 based on a visual analog scale &#40;VAS&#41;&#44; acidosis&#44; electrolytic alterations&#44; anemia&#44; nutritional imbalances&#44; neurological diseases of any kind&#44; seizures&#44; intoxication&#44; heart&#44; kidney or liver failure&#44; metabolic disorders &#40;e&#46;g&#46;&#44; blood glucose or thyroid alterations&#41;&#44; infection&#44; loss of skin integrity&#44; constipation and restricted mobility&#46; Lastly&#44; we determined whether any of the following drug groups had been administered in the last 72<span class="elsevierStyleHsp" style=""></span>h&#58; analgesics&#44; corticosteroids&#44; opioids&#44; antibiotics&#44; anticholinergic agents&#44; benzodiazepines&#44; antipsychotics and &#8211; as a single variable &#8211; other psychotropic agents&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Discrete variables were reported as frequencies and percentages &#40;&#37;&#41; and were compared using the chi-squared test &#40;<span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span>&#41;&#46; Continuous variables in turn were reported as the median and interquartile range &#40;IQR&#41; and were compared using the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span>-test &#40;2 variables&#41; or analysis of variance &#40;ANOVA&#41; with the Kruskal&#8211;Wallis test &#40;more than 2 variables&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The analysis of the relationship between the independent variables and delirium was based on the evaluation of each individual variable &#40;univariate analysis&#41; and on the multivariate logistic analysis reported according to the recommendations of the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">17</span></a> We calculated the odds ratio &#40;OR&#41; and 95&#37; confidence interval &#40;95&#37;CI&#41; of those variables found to be associated to delirium in the univariate analysis&#46; The variables found to be significant were entered in the logistic regression model using the conditional backward approach &#40;we chose the strict probability criterion of &#8804;0&#46;05 as entry condition and &#62;0&#46;05 as exclusion criterion&#41;&#46; Fitting of the model was evaluated with the Hosmer and Lemeshow test&#46; We reported the Wald statistic with its <span class="elsevierStyleItalic">p</span>-value for each beta-coefficient&#44; as well as the OR and 95&#37;CI of each variable&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Results</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Sample characteristics</span><p id="par0090" class="elsevierStylePara elsevierViewall">A total of 172 patients aged between 5 and 14 years of age were admitted in the course of the study period&#46; The study sample consisted of 156 of these patients &#40;90&#46;7&#37;&#41;&#46; Thirteen children presented some exclusion criterion and were not evaluated&#44; while another three were excluded because they had been discharged before evaluation proved possible&#44; or due to breaches in protocol&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the patient flow in the study&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Twenty-nine of the 156 patients included in the study developed delirium &#40;18&#46;6&#37;&#41;&#46; The median age of the global sample was 11&#46;0 years &#40;range&#58; 5&#8211;14&#41;&#46; The median PRISM score was 1&#46;8 &#40;range&#58; 0&#46;3&#8211;62&#46;0&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the sociodemographic and clinical characteristics of the 156 patients evaluated&#46; Eighteen received deep sedation upon admission &#40;11&#46;5&#37;&#41;&#44; and the median time elapsed to reach RASS<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>3 was three days &#40;IQR&#58; 1&#46;0&#8211;5&#46;2&#41;&#46; Only mechanical ventilation and a history of cognitive impairment were more frequent in the group of patients with delirium&#46; There were no differences between the two groups in terms of the PRISM score&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Clinical characteristics of delirium</span><p id="par0100" class="elsevierStylePara elsevierViewall">Most of the 29 patients with delirium &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#59; 55&#46;2&#37;&#41; were hypoactive&#44; while 7 were mixed cases &#40;24&#46;1&#37;&#41; and 6 were hyperactive &#40;20&#46;7&#37;&#41;&#46; There were no patients without motor alterations&#46; In the hypoactive cases the median RASS score was &#8211;1 &#40;IQR&#58; &#8211;1 to &#8211;1&#59; range&#58; &#8211;3 to 0&#41;&#44; versus &#8211;2 in the mixed cases &#40;IQR&#58; &#8211;3 to &#8211;2&#59; range&#58; &#8211;3 to &#8211;1&#41; and &#43;2 in the hyperactive patients &#40;IQR&#58; 0 to &#43;2&#46;25&#59; range&#58; 0 to &#43;3&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows that there were no significant differences in the frequency of the acute form of onset&#44; in symptoms fluctuation or in alterations of the RASS &#40;score other than 0&#41; among the three motor types of delirium&#46; Likewise&#44; there were no significant differences in the median of the two clinical characteristics &#40;attention and thought process&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Analysis of delirium risk</span><p id="par0110" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> reports the variables found to be associated to delirium in the univariate analysis&#44; while <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> shows the multivariate logistic regression model &#40;<span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#46;567&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;103 for the Hosmer and Lemeshow goodness of fit test&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">In the univariate analysis&#44; a history of intellectual disability&#44; deep sedation upon admission&#44; hypertension&#44; liver failure&#44; neurological impairment&#44; mechanical ventilation and the use of benzodiazepines yielded the highest ORs&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Seven of the 16 variables found to be significant in the univariate analysis also proved significant in the univariate model&#44; though deep sedation&#44; hypertension and the use of benzodiazepines were excluded&#46; In contrast&#44; other variables entered the model&#44; such as the presence of tachycardia and the use of anticholinergic agents or other psychotropic drugs&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">Approximately one-fifth of the children evaluated in the first 24&#8211;72<span class="elsevierStyleHsp" style=""></span>h of admission to the PICU&#44; or evaluated as soon as it became possible&#44; presented delirium&#46; Over one-half of the cases were hypoactive&#44; and the three motor groups or types did not differ in any of the individual features of delirium evaluated by the pCAM-ICU&#46; Of the large series of clinical &#40;past or current alterations&#41; and pharmacological variables studied&#44; mechanical ventilation&#44; the administration of different psychotropic agents and the use of anticholinergic drugs were associated to delirium according to the multivariate analysis&#46;</p><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Prevalence</span><p id="par0130" class="elsevierStylePara elsevierViewall">According to a systematic review published in 2014&#44; the data on the prevalence of delirium in critically ill children have historically varied by over 20 percentage points &#40;from 5&#46;0 to 28&#46;0&#37;&#41;&#46; The reason for such variability could be the fact that some of the diagnostic methods used are scantly reliable &#40;e&#46;g&#46;&#44; based on subjective suspicion on the part of the clinicians&#41; or pose validity problems &#40;e&#46;g&#46;&#44; utilization of the Pediatric Anesthesia Emergence Delirium &#91;PAED&#93;&#44; designed for the detection of emergent delirium and scantly sensitive to hypoactive cases&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">18</span></a> In more recent studies carried out with tools for the PICU setting&#44; such as the pCAM-ICU<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a> or the Cornell Assessment of Pediatric Delirium &#40;CAP-D&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;20&#44;21</span></a> the prevalence &#8211; in coincidence with our own series &#8211; has consistently been found to be about 20&#37;&#44; independently of the age range considered&#46; The largest prevalence study is an international survey published in 2017&#44; and which reported a figure of 23&#46;3&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Clinical characteristics</span><p id="par0135" class="elsevierStylePara elsevierViewall">Three tools are available for the standardized clinical diagnosis of delirium in critically ill children&#46; On one hand we have the PAED&#44; designed to explore 5 behavioral aspects in emergent delirium&#44; which is generally hyperactive &#40;eye contact&#44; movements with a certain purpose&#44; noticing the surroundings&#44; restlessness and inconsolability&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">22</span></a> In turn&#44; the CAP-D is based on the PAED with the addition of two further items to evaluate hypoactive cases &#40;scantly active&#44; with few movements while awake&#44; and slow response to stimuli&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">23</span></a> Lastly&#44; we have the version of the pCAM-ICU for patients over 5 years of age &#40;published in 2011&#41;&#44; which has been available in Spanish since 2013&#46; This instrument is based on the clinical evaluation of the onset and course of the symptoms and the degree of alertness&#44; as well as on the quantification of symptoms of two of the three nuclear domains&#58; attention &#40;cognitive&#41; and the thought process &#40;higher order thought&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">12&#44;13</span></a> The Preschool-CAM-ICU &#40;psCAM-ICU&#41; for patients under 5 years of age appeared in 2016&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">In this study and in others based on the application of standardized tools&#44; approximately one-half of all the cases seen in the PICU are hypoactive&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">19&#44;20</span></a> This type of delirium is also the most common presentation among adults admitted to intensive care&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a> In both critical children<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a> and adults&#44;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a> hypoactive presentations imply a poorer prognosis than the other motor types&#46; Furthermore&#44; in contrast to hyperactive or mixed delirium&#44; hypoactive presentations do not imply disruptive behavioral disorders&#44; and in many cases are not detected in pediatric units&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a> In this respect it is advisable to establish routine assessment with appropriate tools for detecting all motor types of delirium&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The phenotypes of delirium have been widely studied in the literature referred to adult patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2&#44;3&#44;15&#44;27&#8211;29</span></a> making it possible to identify their nuclear domains &#40;cognitive&#44; higher thought control and circadian&#41;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">2</span></a> and to design research criteria fundamented upon the phenotype&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a> In adults it has been seen that cognitive performance is similar independently of the motor type involved&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a> In children&#44; the pCAM-ICU allows us to quantify two symptoms of two different nuclear domains &#40;attention&#44; which in all cases must be altered in order to establish the diagnosis with the algorithm&#44; and the thought process&#41;&#44; contextualized within the clinical course of the patient and the alteration of alertness&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">12&#44;13</span></a> It should be noted that the intensity of the items attention and thought process was very low in all the patients with delirium&#44; independently of the motor type involved &#40;ranges between 0&#47;10 and 4&#46;5&#47;10 and between 0&#47;10 and 2&#46;5&#47;5&#44; respectively&#41;&#46; Longitudinal studies are needed&#44; evaluating more features of the three domains of delirium and their evolution over time in larger samples of PICU patients&#46; Such studies would allow us to further our knowledge of the semiologic characteristics of the disorder and to monitor its possible neuropsychological consequences&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Associated factors</span><p id="par0150" class="elsevierStylePara elsevierViewall">The univariate analysis showed different preventable and non-preventable factors to be related to delirium&#46; Seven variables were finally retained in the multivariate model&#46; Characteristics such as respiratory failure&#44; seizures or systemic infections&#44; which proved significant in the univariate analysis but not in the logistic regression model in our PICU&#44; in which the highest PRISM score was 62&#46;0&#44; possibly may be more relevant in Departments with even more seriously ill patients or in concrete monographic Units&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Cognitive disability&#44; mechanical ventilation&#44; liver failure and tachycardia were the clinical conditions with the strongest correlation to delirium in this model&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Both previous studies and our own series associate intellectual disability with the syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;20&#44;21</span></a> Likewise&#44; previous neurocognitive disorder &#40;dementia&#41; is an important predisposing factor for delirium in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">31</span></a> A parallelism can be established between cognitive dysfunction in both basal functional defect conditions in children &#40;intellectual disability&#41; and in adults &#40;dementia&#41;&#44; where brain vulnerability makes it potentially possible for different causal factors with an impact upon metabolism to give rise to the acute cerebral failure known as delirium&#46; In this same line&#44; it is noteworthy that the existence of some neurological disease was also seen to be a factor associated to delirium in the multivariate analysis&#46; It is necessary to explore whether a differential risk exists according to the neurological diagnosis&#44; since children with critical conditions affecting brain areas implicated in delirium &#40;such as the frontal and parietal cortex or thalamus&#41;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a> could be at greater risk than other neurological patients&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In this study&#44; mechanical ventilation was seen to be associated to delirium&#46; This has also been evidenced by two other recent studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;21</span></a> Although aspects such as immobilization&#44; or factors related to oxygenation&#44; contribute to explain the relationship between mechanical ventilation and delirium&#44; the use of different types of psychotropic agents &#8211; also found to be significant in our sample and in another risk factor study<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a> &#8211; offers a more plausible explanation&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">33</span></a> In an attempt to improve the wellbeing of patients subjected to mechanical ventilation&#44; more psychotropic agents than necessary can be administered&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a> In this respect&#44; a useful measure for reducing the risk of delirium could be optimization of the prescription of psychotropic agents in children both with and without mechanical ventilation&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">As evidenced in our study of pediatric patients&#44; there is a close correlation between altered liver function and delirium&#46; Hepatic encephalopathy is very characteristic of liver failure&#44; and delirium is often its first manifestation&#46; Furthermore&#44; since delirium and encephalopathy have a number of neurocognitive features in common&#44; the clinical difficulty of establishing the limits between both conditions makes it necessary to resort to validated tools such as the pCAM-ICU to screen for delirium&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">35</span></a> The association between these disorders could be due to that fact that both share a number of physiopathological characteristics&#44; such as impaired neuronal respiration and oxidative stress &#40;a consequence of inflammatory factors&#41;&#44; or excess dopaminergic action together with a decrease in gabaergic transmission&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">32&#44;35</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Diminished cholinergic activity is fundamental in the physiopathology of delirium&#46; The imbalance in dopaminergic &#40;relative increase&#41; and cholinergic activity &#40;relative decrease&#41; at central level constitutes the common neuronal pathway for the different etiologies&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">16&#44;32</span></a> The association between anticholinergic drugs and delirium observed in this study confirms the data reported in both critically ill adults<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a> and children&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a> Many drugs&#44; or their metabolites&#44; exert anticholinergic effects that may exert cumulative actions when several of them are used&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a> Rationalization of drug use is therefore an obviously needed measure&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Lastly&#44; regarding the causes of sinus tachycardia&#44; which in this study was found to be associated to delirium&#44; mention must be made of increased physical activity&#44; the effects of drugs such as anticholinergic agents&#44; or the physiological response to fever&#44; disease or stress&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a> Accordingly&#44; the relationship between delirium and tachycardia may be dual&#46; On one hand&#44; the increase in motor activity characteristic of hyperactive or mixed delirium may increase the heart rate&#44; and on the other hand different health and treatment conditions of the patients may also lead to tachycardia&#46; In this way&#44; tachycardia within the logistic regression model could represent an epiphenomenon related to different causes of delirium and to the increase in motor activity of some patients with this disorder&#46; A longitudinal study could clarify whether the presence of tachycardia may be useful as a clinical predictor of delirium in children admitted to the PICU&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Limitations and conclusions</span><p id="par0185" class="elsevierStylePara elsevierViewall">The results of this study should be interpreted taking a number of limitations into account&#58; &#40;a&#41; We explored the relationship between different clinical factors and delirium on a cross-sectional basis&#46; This design does not allow us to assess the time relationship between the variable of interest &#40;delirium&#41; and the studied factors&#46; On the other hand&#44; the problem addressed in our article has been little studied to date&#44; and this first approach considers associations between different variables that need to be replicated through subsequent longitudinal studies&#46; &#40;b&#41; Although we evaluated patients during one year on a consecutive basis and the prevalence of delirium was high&#44; a sample size limited to 29 cases does not allow us to draw firm conclusions regarding the relative importance of the factors related with delirium &#8211; the risk of both qualitative &#40;variable independently associated to the disorder&#41; and quantitative &#40;magnitude of the association&#41; error being high&#46; Larger studies are therefore needed&#46; &#40;c&#41; The lack of instruments for evaluating patients under 5 years of age and the absence of patients over 14 years of age prevented us from studying these population groups&#46; The results obtained therefore cannot be extrapolated to them&#46; &#40;d&#41; According to the PRISM score&#44; we did not study patients in the uppermost third of mortality risk&#46; The policy of the hospital favors the early admission of critical patients to the Unit&#44; in order to guarantee the opportune interdisciplinary care&#46; Although the evaluated patients presented a broad range of health problems&#44; the different types of PICUs require the conduction of studies in Units with other operating protocols&#44; of a monographic nature or with a greater prevalence of concrete disease conditions&#44; with more patients receiving deep sedation and subjected to mechanical ventilation&#44; as well as with groups presenting an increased mortality risk&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">It should be underscored that although our sample of patients with delirium was small&#44; a detailed account of the individual neuropsychiatric characteristics was provided&#44; evaluated with the pCAM-ICU according to the motor types of the DRS-R98&#46; This allowed us to contribute to the clinical understanding of the syndrome&#44; which has been little studied in the PICU setting to date&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">In conclusion&#44; delirium is very prevalent in pediatric intensive care&#44; and because of its health consequences needs to be dealt with on a routine basis&#46; The characteristics of the syndrome are similar in all motor types of the disease&#44; and hypoactive delirium is the most common presentation&#46; As a result&#44; clinical suspicion needs to be emphasized&#44; since hypoactive forms of the disease are often overlooked&#46; Different factors related to the physiopathology of delirium are related to the diagnosis in children admitted to the PICU&#46; Some factors may be preventable through the rationalization of medical care&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Financial support</span><p id="par0200" class="elsevierStylePara elsevierViewall">This study was financed by the <span class="elsevierStyleItalic">Direcci&#243;n de Investigaci&#243;n e Innovaci&#243;n</span> &#40;CIDI&#41; of the Universidad Pontificia Bolivariana &#40;project&#58; 434B-08&#47;15-45&#41;&#46; The CIDI did not participate in the design of the study or in data compilation&#44; analysis or interpretation&#46; Likewise&#44; it did not intervene in the drafting of the article or in the decision to submit it for publication&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Authorship</span><p id="par0205" class="elsevierStylePara elsevierViewall">Carmenza Ricardo-Ramirez and Matilde Ligia &#193;lvarez-G&#243;mez participated in conception of the study&#44; project design&#44; patient evaluation&#44; data compilation&#44; data analysis and drafting of the manuscript&#46; Camilo Andr&#233;s Agudelo-V&#233;lez and Jos&#233; Gabriel Franco-V&#225;squez participated in critical review of the project&#44; patient evaluation&#44; data compilation&#44; data processing and analysis and drafting of the manuscript&#46; Susana Zuluaga-Penagos&#44; Ricardo Antonio Consuegra-Pe&#241;a&#44; Katerine Uribe-Hern&#225;ndez&#44; Isabel Cristina Mej&#237;a-Gil and Eliana Mar&#237;a Cano-Londo&#241;o participated in critical review of the project&#44; patient evaluation&#44; data compilation and critical review of the article&#46; Mussatye Elorza-Parra participated in patient evaluation&#44; data compilation and critical review of the article&#46; All the authors reviewed and approved submission for publication of the final manuscript&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Conflicts of interest</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors declare that they have no financial or personal conflicts of interest in relation to the contents of this article&#46;</p></span></span>"
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                  "titulo" => "Items of the Delirium Rating Scale &#8211; Revised-98 &#40;DRS-R98&#41; for the evaluation of motor function"
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    "fechaRecibido" => "2017-09-26"
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            1 => "Intellectual disability"
            2 => "Artificial respiration"
            3 => "Liver failure"
            4 => "Nervous system diseases"
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            1 => "Discapacidad intelectual"
            2 => "Respiraci&#243;n artificial"
            3 => "Fallo hep&#225;tico"
            4 => "Enfermedades del sistema nervioso"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate the clinical characteristics&#44; prevalence and factors associated with delirium in critical patients from 5 to 14 years of age&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">An analytical&#44; cross-sectional observational study was made&#46; Delirium was assessed with the Pediatric-Confusion Assessment Method for the Intensive Care Unit &#40;pCAM-ICU&#41; and motor classification was established with the Delirium Rating Scale Revised-98&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A pediatric Intensive Care Unit&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">All those admitted over a one-year period were assessed during the first 24&#8211;72<span class="elsevierStyleHsp" style=""></span>h&#44; or when possible in deeply sedated patients&#46; Exclusion criteria&#58; Patients in stupor or coma&#44; with severe communication difficulty&#44; subjected to deep sedation throughout admission&#44; and those with denied consent&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Results</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Twenty-nine of the 156 assessed patients suffered delirium &#40;18&#46;6&#37;&#41; and 55&#46;2&#37; were hypoactive&#46; The neurocognitive alterations evaluated by the pCAM-ICU were similar in the three motor groups&#46; Intellectual disability &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>17&#46;54&#59; 95&#37;CI&#58; 3&#46;23&#8211;95&#46;19&#41;&#44; mechanical ventilation &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>18&#46;80&#59; 95&#37;CI&#58; 4&#46;29&#8211;82&#46;28&#41;&#44; liver failure &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>54&#46;88&#59; 95&#37;CI&#58; 4&#46;27&#8211;705&#46;33&#41;&#44; neurological disease &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;41&#59; 95&#37;CI&#58; 1&#46;23&#8211;15&#46;83&#41;&#44; anticholinergic drug use &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;23&#59; 95&#37;CI&#58; 1&#46;02&#8211;10&#46;26&#41;&#44; different psychotropic agents &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;88&#59; 95&#37;CI&#58; 1&#46;42&#8211;16&#46;73&#41; and tachycardia &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;74&#59; 95&#37;CI&#58; 1&#46;21&#8211;18&#46;51&#41; were associated to delirium according to the logistic regression analysis&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusion</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The frequency of delirium and hypoactivity was high&#46; It is therefore necessary to routinely evaluate patients with standardized instruments&#46; All patients presented with important neurocognitive alterations&#46; Several factors related with the physiopathology of delirium were associated to the diagnosis&#59; some of them are modifiable through the rationalization of medical care&#46;</p></span>"
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        "resumen" => "<span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Evaluar las caracter&#237;sticas cl&#237;nicas&#44; la prevalencia y los factores asociados al delirium en pacientes de entre 5 y 14 a&#241;os de edad y en estado cr&#237;tico&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Dise&#241;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional anal&#237;tico transversal&#46; El delirium se eval&#250;o con el Pediatric-Confusion Assessment Method for the Intensive Care Unit &#40;pCAM-ICU&#41; y la clasificaci&#243;n motora con la Delirium Rating Scale Revised-98&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">&#193;mbito</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Unidad de cuidados intensivos pedi&#225;tricos&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Pacientes</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Todos los que ingresaron durante un a&#241;o fueron evaluados durante las primeras 24&#8211;72<span class="elsevierStyleHsp" style=""></span>h o cuando fue posible si estaban en sedaci&#243;n profunda&#46; Excluidos&#58; pacientes en estupor o coma&#44; con dificultad grave para la comunicaci&#243;n&#44; en sedaci&#243;n profunda durante todo el ingreso y los que no contaban con consentimiento&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Resultados</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Veintinueve &#40;18&#44;6&#37;&#41; de los 156 pacientes evaluados ten&#237;an delirium y el 55&#44;2&#37; eran hipoactivos&#46; Las alteraciones neurocognitivas evaluadas por el pCAM-ICU fueron similares en los 3 grupos motores&#46; La discapacidad intelectual &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>17&#44;54&#59; IC95&#37;&#58; 3&#44;23-95&#44;19&#41;&#44; la ventilaci&#243;n mec&#225;nica &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>18&#44;80&#59; IC95&#37;&#58; 4&#44;29-82&#44;28&#41;&#44; el fallo hep&#225;tico &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>54&#44;88&#59; IC95&#37;&#58; 4&#44;27-705&#44;33&#41;&#44; las enfermedades neurol&#243;gicas &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#44;41&#59; IC95&#37;&#58; 1&#44;23-15&#44;83&#41;&#44; el uso de anticolin&#233;rgicos &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#44;23&#59; IC95&#37;&#58; 1&#44;02-10&#44;26&#41;&#44; diversos tipos de psicotr&#243;picos &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#44;88&#59; IC95&#37;&#58; 1&#44;42-16&#44;73&#41; y la taquicardia &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#44;74&#59; IC95&#37;&#58; 1&#44;21-18&#44;51&#41; se asociaron al delirium seg&#250;n el an&#225;lisis log&#237;stico&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusi&#243;n</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La frecuencia de delirium y del tipo hipoactivo es alta&#44; por lo que es necesario evaluar rutinariamente los pacientes con instrumentos estandarizados&#46; Todos los pacientes presentan alteraci&#243;n neurocognitiva importante&#46; Varios factores relacionados con la fisiopatolog&#237;a del delirium se asocian al diagn&#243;stico&#44; algunos de los cuales son modificables mediante la racionalizaci&#243;n de la atenci&#243;n m&#233;dica&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Ricardo Ramirez C&#44; &#193;lvarez G&#243;mez ML&#44; Agudelo V&#233;lez CA&#44; Zuluaga Penagos S&#44; Consuegra Pe&#241;a RA&#44; Uribe Hern&#225;ndez K&#44; et al&#46; Caracter&#237;sticas cl&#237;nicas&#44; prevalencia y factores asociados al delirium en ni&#241;os de 5 a 14 a&#241;os de edad ingresados en cuidados intensivos&#46; Med Intensiva&#46; 2019&#59;43&#58;147&#8211;155&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Discrete variables compared with the <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> test and continuous variables with the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span>-test&#46;</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">PRISM&#58; Pediatric Risk of Mortality Score&#59; IQR&#58; interquartile range&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">With delirium &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Without delirium &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>127&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;0 &#40;7&#46;0&#8211;12&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;0 &#40;8&#46;0&#8211;13&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Gender&#44; frequency &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;62&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64 &#40;50&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;37&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63 &#40;49&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Educational level&#44; frequency &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;3&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Preschool&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;17&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;7&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Primary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;55&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71 &#40;55&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Secondary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;24&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43 &#40;33&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">History of intellectual disability&#44; frequency &#40;&#37;&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;20&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;3&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Six most frequent diagnostic categories upon admission</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&#44; <span class="elsevierStyleItalic">frequency &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Systemic infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;27&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;21&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Organ insufficiency or failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;10&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25 &#40;19&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Metabolic-endocrine disorder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;6&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;13&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Systemic neoplastic disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;9&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intracranial neoplasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;6&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;7&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Traumatic brain injury&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;10&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;3&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Postsurgery&#44; frequency &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;37&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40 &#40;31&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Mechanical ventilation&#44; frequency</span> &#40;&#37;&#41;<span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;31&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;4&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">PRISM&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;6 &#40;0&#46;95&#8211;6&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;8 &#40;1&#46;0&#8211;4&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The diagnoses are grouped according to the categories of the Delirium Etiology Checklist &#40;DEC&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">No differences among the 3 groups<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&#46;</p><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">pCAM-ICU&#58; Pediatric Confusion Assessment Method for the Intensive Care Unit&#59; RASS&#58; Richmond Agitation Sedation Scale&#59; IQR&#58; interquartile range&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristic&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Fluctuation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;85&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Attention alteration according to pCAM-ICU&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;0 &#40;0&#46;0&#8211;2&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;5 &#40;2&#46;2&#8211;5&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Alteration in RASS&#44; frequency &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;93&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Alteration of the thought process according to pCAM-ICU&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                        "tituloSerie" => "J Neuropsychiatry Clin Neurosci"
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                            0 => "P&#46;T&#46; Trzepacz"
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