Ely E W, Margolin R, Francis J, May L, Truman B, Dittus R, Speroff T, Gautam S, Bernard G R, Inouye S K
Department of Internal Medicine, Divisions of General Internal Medicine and Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA.
Crit Care Med. 2001 Jul;29(7):1370-9. doi: 10.1097/00003246-200107000-00012.
To develop and validate an instrument for use in the intensive care unit to accurately diagnose delirium in critically ill patients who are often nonverbal because of mechanical ventilation.
Prospective cohort study.
The adult medical and coronary intensive care units of a tertiary care, university-based medical center.
Thirty-eight patients admitted to the intensive care units.
We designed and tested a modified version of the Confusion Assessment Method for use in intensive care unit patients and called it the CAM-ICU. Daily ratings from intensive care unit admission to hospital discharge by two study nurses and an intensivist who used the CAM-ICU were compared against the reference standard, a delirium expert who used delirium criteria from the Diagnostic and Statistical Manual of Mental Disorders (fourth edition). A total of 293 daily, paired evaluations were completed, with reference standard diagnoses of delirium in 42% and coma in 27% of all observations. To include only interactive patient evaluations and avoid repeat-observer bias for patients studied on multiple days, we used only the first-alert or lethargic comparison evaluation in each patient. Thirty-three of 38 patients (87%) developed delirium during their intensive care unit stay, mean duration of 4.2 +/- 1.7 days. Excluding evaluations of comatose patients because of lack of characteristic delirium features, the two critical care study nurses and intensivist demonstrated high interrater reliability for their CAM-ICU ratings with kappa statistics of 0.84, 0.79, and 0.95, respectively (p <.001). The two nurses' and intensivist's sensitivities when using the CAM-ICU compared with the reference standard were 95%, 96%, and 100%, respectively, whereas their specificities were 93%, 93%, and 89%, respectively.
The CAM-ICU demonstrated excellent reliability and validity when used by nurses and physicians to identify delirium in intensive care unit patients. The CAM-ICU may be a useful instrument for both clinical and research purposes to monitor delirium in this challenging patient population.
研发并验证一种用于重症监护病房的工具，以准确诊断因机械通气而常无法言语的重症患者的谵妄。
前瞻性队列研究。
一所基于大学的三级医疗中心的成人内科和冠心病重症监护病房。
38名入住重症监护病房的患者。
我们设计并测试了一种用于重症监护病房患者的改良版谵妄评估方法，并将其称为CAM-ICU。两名研究护士和一名使用CAM-ICU的重症监护医生从患者入住重症监护病房到出院的每日评分，与参考标准进行比较，该参考标准是一名使用《精神疾病诊断与统计手册》（第四版）中谵妄标准的谵妄专家。总共完成了293次每日配对评估，所有观察结果中谵妄的参考标准诊断率为42%，昏迷诊断率为27%。为仅纳入有互动的患者评估，并避免对多天研究的患者产生重复观察者偏倚，我们仅使用每位患者的首次警觉或嗜睡比较评估。38名患者中有33名（87%）在重症监护病房住院期间出现谵妄，平均持续时间为4.2±1.7天。由于缺乏典型的谵妄特征而排除对昏迷患者的评估后，两名重症监护研究护士和重症监护医生对其CAM-ICU评分表现出较高的评分者间信度，kappa统计值分别为0.84、0.79和0.95（p<.001）。与参考标准相比，两名护士和重症监护医生使用CAM-ICU时的敏感性分别为95%、96%和100%，而特异性分别为93%、93%和89%。
护士和医生使用CAM-ICU识别重症监护病房患者的谵妄时，其表现出了出色的信度和效度。CAM-ICU可能是一种在临床和研究中监测这一具有挑战性患者群体谵妄的有用工具。
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