Letter to the Editor
In reply to: «The diagnosis of delirium in pediatric intensive care: A burdensome yet essential task»
En respuesta a: «Diagnóstico del delirium en pediatría: una tarea ardua pero imprescindible»
a Grupo de Investigación en Psiquiatría de Enlace, Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
b Grupo de Investigación en Cuidado, Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
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Ricardo Ramírez, M. Álvarez Gómez, J.G. Franco Vásquez" "autores" => array:3 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Ricardo Ramírez" "email" => array:1 [ 0 => "carmenza.ricardo@upb.edu.co" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Álvarez Gómez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J.G." "apellidos" => "Franco Vásquez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Grupo de Investigación en Psiquiatría de Enlace, Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Grupo de Investigación en Cuidado, Escuela de Ciencias de la Salud, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "En respuesta a: «Diagnóstico del <span class="elsevierStyleItalic">delirium</span> en pediatría: una tarea ardua pero imprescindible»" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We truly appreciate the interest shown by Rodríguez-Rubio et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> to our article on the characteristics of delirium in 5-to-14-year-old critically ill children published on M<span class="elsevierStyleSmallCaps">edicina</span> I<span class="elsevierStyleSmallCaps">ntensiva</span>. Their comments encourage us to discuss fundamental concepts on the phenotype of this disorder, screening, and risk factors often treated superficially in research reports.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Conscience is being able to know self-feelings, thoughts, and acts. Delirium—a mental disorder according to the WHO—is the disturbance of conscience when there is a low level of awareness as a consequence of a medical condition.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Experimental psychopathology has defined the combination of 3 core domains that are characteristic in this disturbance: cognitive, higher-order thinking, and circadian domains (see our article). On the other hand, fluctuating behavioral disorders are suspicious of delirium, but are nonspecific because are not easy to distinguish from the behavioral response to the underlying disease or pain. Also, it is difficult to attribute them to conscience disorders in cases of mental disability or triggering factors like electrolytic disorders or iatrogenic withdrawal syndrome. And vice versa, as it occurs with delirium itself, the precipitating entities of delirium show nonspecific symptoms like a cluster of more characteristic clinical aspects.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Because there is not always a psychiatrist available, delirium screening tools are useful for the treating team, but they need to reflect the core mental disorders of the clinical manifestations as good as possible.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The pCAM-ICU and the CAPD rating scales are useful tools to screen delirium at the PICU setting. They have both been validated opposite to a psychiatrist’s criterion based on the DSM-IV criteria. The first one assesses the fluctuation of mental state in 24 h in one single application while taking into account symptoms of 2 different domains: cognitive domain (awareness) and higher-order-thinking domain (disorganized thinking). The latter assesses repeated observations over a watch of motor fluctuations (circadian domain) and in nonspecific behaviors such as being inconsolable or responding to interactions. The pCAM-ICU Youden’s index is 0.830 and the CAPD Youden’s index is 0.733. Higher pCAM-ICU Youden’s indices equal more validity (fewer false positives and negatives) and more representative of the core characteristics of delirium. In this sense, it is significant to see that in the presence of mental disability the specificity of the CAPD score drops to 0.512.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">These considerations confirm that we are right when choosing the cross-sectional application of the pCAM-ICU rating scale to report the prevalence of delirium.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Rodríguez-Rubio et al. think that our study contradicts the medical literature because it did not find any correlations between the administration of benzodiazepines and a higher risk of delirium in the PICU under study. As confirmatory examples they refer to such a correlation in the studies published by Smith et al. (2017) and Madden et al. (2018).<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">7,8</span></a> We believe there is no consensus among the different researchers on the factors associated with delirium. Without going any deeper on this issue, their examples somehow validate our position on the lack of unanimity: while the former authors refer to a moderate increase in the risk of suffering this disorder based on the dose of benzodiazepines, the latter found no causal relation whatsoever.</p><p id="par0040" class="elsevierStylePara elsevierViewall">We stand by what we say in our article: we need studies in units that work differently, special centers or with many patients on deep sedation. All these characteristics modify the impact exerted by several factors on delirium</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ricardo Ramírez C, Álvarez Gómez M, Franco Vásquez JG. En respuesta a: «Diagnóstico del <span class="elsevierStyleItalic">delirium</span> en pediatría: una tarea ardua pero imprescindible» Med Intensiva. 2020;44:129–130.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnóstico del delirium en cuidados intensivos pediátricos: una tarea ardua pero imprescindible" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Rodríguez-Rubio" 1 => "E. Álvarez-Rojas" 2 => "P. De la Oliva" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Med Intensiva." 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| 2022 December | 36 | 31 | 67 |
| 2022 November | 42 | 31 | 73 |
| 2022 October | 45 | 26 | 71 |
| 2022 September | 26 | 25 | 51 |
| 2022 August | 30 | 38 | 68 |
| 2022 July | 23 | 34 | 57 |
| 2022 June | 18 | 13 | 31 |
| 2022 May | 24 | 32 | 56 |
| 2022 April | 27 | 36 | 63 |
| 2022 March | 29 | 44 | 73 |
| 2022 February | 22 | 27 | 49 |
| 2022 January | 18 | 31 | 49 |
| 2021 December | 25 | 34 | 59 |
| 2021 November | 35 | 36 | 71 |
| 2021 October | 91 | 71 | 162 |
| 2021 September | 35 | 29 | 64 |
| 2021 August | 28 | 40 | 68 |
| 2021 July | 15 | 27 | 42 |
| 2021 June | 25 | 19 | 44 |
| 2021 May | 30 | 46 | 76 |
| 2021 April | 73 | 78 | 151 |
| 2021 March | 56 | 31 | 87 |
| 2021 February | 48 | 31 | 79 |
| 2021 January | 45 | 7 | 52 |
| 2020 December | 48 | 13 | 61 |
| 2020 November | 25 | 17 | 42 |
| 2020 October | 7 | 5 | 12 |
| 2020 July | 22 | 6 | 28 |
| 2020 June | 13 | 15 | 28 |
| 2020 May | 15 | 4 | 19 |
| 2020 April | 19 | 11 | 30 |
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