Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada.
Crit Care Med. 2013 Aug;41(8):2002-7. doi: 10.1097/CCM.0b013e31828e96c0.
To assess the feasibility and reliability of systematic evaluations of analgesia, sedation level, and delirium features in the neurologically critically ill and to determine whether delirium features are linked to clinical outcomes in this population.
Multicentered prospective observational study.
Neurological, Neurosurgical, Neurosciences or Surgical Trauma ICUs from three hospitals (two in Canada and one in the United States).
A convenience sample of adult NICU or neurologic, neurosurgical, neurosciences, or surgical trauma ICU patients admitted for greater than 12 hours from November 2011 to April 2012.
Systematic assessments were simultaneously and independently performed by a neurologist, intensivists, or trauma surgeon, and a nurse in three multispecialty ICUs. Pain was evaluated with the numeric rating scale or behavioral pain scale. Sedation was assessed using the Richmond Agitation-Sedation Scale. Patients with Richmond Agitation-Sedation Scale greater than or equal to -4 were screened for features of delirium with the Intensive Care Delirium Screening Checklist. Intraclass correlation coefficient was used to evaluate inter-rater reliability between the nurse and the physician for pain and sedation scales, and the kappa coefficient was calculated for concordance of the Intensive Care Delirium Screening Checklist items.
151 patients had 439 assessments. Pain and sedation were always assessable with excellent inter-rater reliability (numeric rating scale intraclass correlation coefficient, 0.92; behavior pain scale intraclass correlation coefficient, 0.83; and Richmond Agitation-Sedation Scale intraclass correlation coefficient, 0.92). Patients were sufficiently alert for delirium screening 3/4 of the time; Intensive Care Delirium Screening Checklist items had good concordance (kappa coefficients between 0.58 and 0.91 for the eight Intensive Care Delirium Screening Checklist items). Nonevaluable items were most often orientation, hallucinations, and speech or mood content. Furthermore, each additional Intensive Care Delirium Screening Checklist item present in proportion to the total evaluable Intensive Care Delirium Screening Checklist score was associated with a 10% increase in ICU length of stay.
Pain and sedation can be systematically assessed in the neurologically critically ill; the majority can also be screened for delirium features with excellent inter-rater reliability. Increased proportion of Intensive Care Delirium Screening Checklist items is associated with worse outcomes.
评估对神经危重症患者镇痛、镇静水平和谵妄特征进行系统评估的可行性和可靠性，并确定该人群中谵妄特征是否与临床结局相关。
多中心前瞻性观察研究。
三家医院（加拿大两家，美国一家）的神经科、神经外科、神经科学或外科创伤 ICU。
2011 年 11 月至 2012 年 4 月，在神经重症监护病房或神经科、神经外科、神经科学或外科创伤 ICU 接受超过 12 小时住院治疗的成年 ICU 患者的方便样本。
在三个多学科 ICU 中，由神经科医生、重症监护医生或创伤外科医生以及护士同时独立进行系统评估。疼痛采用数字评分量表或行为疼痛量表进行评估。镇静采用 Richmond 躁动-镇静量表进行评估。Richmond 躁动-镇静量表评分≥-4 的患者使用重症监护谵妄筛查检查表筛查谵妄特征。采用组内相关系数评估护士和医生之间对疼痛和镇静量表的评估者间信度，采用 Kappa 系数计算重症监护谵妄筛查检查表项目的一致性。
151 例患者共进行了 439 次评估。疼痛和镇静始终可以进行评估，并且评估者间信度极好（数字评分量表组内相关系数为 0.92；行为疼痛量表组内相关系数为 0.83；Richmond 躁动-镇静量表组内相关系数为 0.92）。患者有足够的警觉进行谵妄筛查的时间为 3/4；重症监护谵妄筛查检查表项目的一致性良好（重症监护谵妄筛查检查表八项条目之间的 Kappa 系数在 0.58 至 0.91 之间）。不可评估的项目最常见的是定向力、幻觉和言语或情绪内容。此外，每个附加的重症监护谵妄筛查检查表项目与总可评估的重症监护谵妄筛查检查表评分的比例成正比，与 ICU 住院时间延长 10%相关。
在神经危重症患者中可以系统地评估疼痛和镇静；大多数患者也可以进行具有极好评估者间信度的谵妄特征筛查。重症监护谵妄筛查检查表项目比例的增加与不良结局相关。
