PC3098: Use of Valproic Acid to Treat Refractory Delirium in a Pediatric Patient

Introduction: Intensive care unit (ICU) delirium is a common diagnosis characterized by acute, fluctuating alteration of cognition, consciousness, and baseline mental status. Critically ill patients are at high risk for developing delirium due to multiple risk factors including polypharmacy and alterations in day-night cycles. Occasionally standard environmental and pharmacologic delirium prevention strategies of are unsuccessful, and it becomes necessary to explore alternative agents. Valproic acid (VPA) has been shown to be a promising adjunct agent in the treatment of refractory ICU delirium in adult patients3–5. However, it has not been studied in critically ill pediatric patients with delirium. We present a case of a 21-month-old girl experiencing refractory ICU delirium who was successfully treated with VPA.

Case Description: A 21-month-old female presented to the pediatric intensive care unit after sustaining a burn injury involving 25% of her body surface area. She developed severe acute respiratory distress syndrome requiring initiation of veno-venous extracorporeal membrane oxygenation (VV-ECMO) for 18 days. During this time, she was sedated with continuous infusions of opiates, benzodiazepines, dexmedetomidine, and propofol. Due to severe agitation, she required high doses of sedating medications throughout her course of VV-ECMO and following decannulation. She was extubated 5 days after VV-ECMO decannulation. Delirium was identified and symptoms were tracked using the Cornell Assessment of Pediatric Delirium (CAPD) scoring system. Day-night cycling was encouraged and weaning of sedation was attempted, however she continued to have significant agitation and required maintenance of continuous infusions of dexmedetomidine, hydromorphone, and midazolam as well as scheduled risperidone, lorazepam, methadone, and clonidine. At this time she was also receiving a significant number of as-needed (PRN) doses of the multiple medications for agitation. VPA was initiated at a starting dose of 5mg/kg every 8 hours. Within 12 hours of initiation CAPD scores dramatically improved. The continuous infusion of dexmedetomidine was successfully discontinued within 60 hours of therapy with VPA. The hydromorphone PCA was weaned and was successfully discontinued by day 5. She required no further PRN doses of sedatives. Enteral clonidine, methadone, and lorazepam were successfully weaned via a protocol designed to reduce the risk of withdrawal. VPA was discontinued after 5 days of treatment, and she transitioned to inpatient rehabilitation the following week.

Discussion: The acute deterioration of consciousness in a critically-ill pediatric patient may represent delirium, which carries an increased risk of longer hospital stays and death within 6 months. Occasionally patients develop delirium refractory to standard treatment modalities. Studies in adult patients have demonstrated that VPA is a promising alternative agent for treatment of these patients due to its effects on multiple neurotransmitters

Conclusion: Our experience indicates that that VPA is a promising agent for patients with protracted delirium and may provide an alternative strategy for successfully managing these patients.