**5. You need to know the enemy by sight, or how not to pass by delirium**

Aggression, sometimes with self-damaging actions (attempts to remove drainage tubes, venous catheters, etc.), agitation, insomnia, disturbance of circadian rhythms, depression, disorientation, uncontrolled speech, short-term memory disturbances, hallucinations, impaired perception, decreased attention level, disturbances consciousness [66]. All this is a description of various manifestations of POD in children. Of course, there is nothing new in it, and almost every doctor who works with children in the postoperative period has encountered such manifestations. The question is: how to distinguish such a clinical picture from the normal behavior of a child who is simply experiencing a feeling of fear and anxiety and wants to be close to his parents as soon as possible? Special scales come to the rescue. There are not so many of them in pediatric practice, but they all have a high diagnostic value. And this value rises sharply in the field of cardiac surgery. First of all, this is due to the fact that most children after cardiac surgery are in the intensive care unit and intensive care, and contact with them is often difficult due to prolonged mechanical ventilation and the presence of an endotracheal tube or tracheostomy cannula. However, in modern scales, such difficulties are taken into account, as are the characteristics of children of all ages [67]. Let us consider a few of them.

As described earlier, POD in children is most often found in a hyperactive form with severe symptoms [8]. Such delirium is commonly referred to in international guidelines as emergence delirium [68]. In this case, it is necessary to carry out a differential diagnosis between the child's agitation after surgery and this type of delirium. Agitation is characterized by anxiety and discomfort in the child. Emergence delirium includes a wider range of symptoms: disorders of the child's consciousness, in particular, disorientation in the outside world, changes in perception, including hypersensitivity to stimuli, and the appearance of hyperactive motor skills during awakening from anesthesia with no success in trying to calm the child [69, 70]. It is easier to carry out such differential diagnosis using The Pediatric Anesthesia Emergence Delirium (PAED) scale. The assessment is carried out quickly, in 5 blocks: the child's

eye contact with others, the purposefulness of his actions, his ability to become aware of his surroundings, the general level of anxiety, and the child's reaction to attempts to calm him down. Points are assigned from 0 to 4 for each block [8]. The maximum total score is 20. The result of 10 points or more indicates the presence of emergence delirium with a sensitivity level of 64% and a specificity of 86%, 12 points or more— 100% and 94.5%, respectively [71]. Such a high level of sensitivity can be explained by the specialization of the scale specifically from the emergence of delirium with severe symptoms. If we are talking about using it to diagnose all types of delirium, then its sensitivity is not yet clear enough and, according to some researchers, does not exceed 50% [72].

PAED, as already noted, has a very low sensitivity to hypoactive forms of delirium, and a different scale is required for their detection. This role can be played by The Cornell Assessment for Pediatric Delirium (CAPD), which is, in fact, a modified PAED scale (see **Table 1**). The changes consist of the addition of three new assessment units to those already existing in PAED, and they are aimed precisely at the detection of the hypoactive form of delirium [73]. The following areas of assessment have emerged: the need for communication, inadequate level of activity while awake, and delayed response when interacting with the child. Similarly, a score for each block is given from 0 to 4 points, and a result of 9 points or more indicates the presence of POD. Studies showing different levels of sensitivity and specificity depending on the age of the patient cannot be ignored. So, for example, for children over 13 years of age, the specificity is 98%, but the sensitivity reaches only 50%. The situation is mirrored in the group of children under 2 years of age, in which the specificity will already be only 68%, but the sensitivity will be 100% [74, 75]. As for the age at which to start using the PAED and CAPD scales, most studies agree at the age of 1.5 years. The presented scales are a good example of the fact that the assessment of AML in the


### **Table 1.**

*Cornell assessment of pediatric delirium scale [73].*


### **Table 2.**

*Prevention and relief of systemic inflammatory response [43, 78–89].*

conditions of the intensive care unit does not take much time and effort, but it can bring a lot of new information about the patient. It is only important to do it regularly and, of course, only after assessing the child on a pain scale convenient for a doctor, for example, FLACC, NIPS, or Wong-Baker [76].

There are many works on the effect of POD on clinical outcomes and on the undoubted increase in the duration of hospitalization and even mortality [24]. The question of the impact of POD on the cognitive development of a child in the long term is also important. How much is it possible to compensate for the resulting damage to the brain and further return to normal indicators of its performance? Such questions are just beginning to be investigated and do not yet have a sufficient evidence base [77].

As mentioned above, SIR and neuroinflammation play an important role in the formation of cerebral damage. In the conditions of modern anesthetic technology and perfusion, a considerable amount of information has accumulated on various methods of preventing SIR, which are effective to a greater or lesser extent. We offer an overview of the most commonly used methods for the prevention of SIR (see **Table 2**) [43, 78–89].
