Orman Eric S, Perkins Anthony, Ghabril Marwan, Khan Babar A, Chalasani Naga, Boustani Malaz A
Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle Suite 225, Indianapolis, IN, 46202, USA,
Metab Brain Dis. 2015 Aug;30(4):1063-71. doi: 10.1007/s11011-015-9679-8. Epub 2015 May 7.
In the intensive care unit (ICU), delirium is routinely measured with the widely-used, validated Confusion Assessment Method for the ICU (CAM-ICU), but CAM-ICU has not been studied in patients with cirrhosis. We studied a group of patients with cirrhosis to determine the relationship between delirium measured by CAM-ICU and clinical outcomes. Consecutive patients with cirrhosis admitted to the ICU from 2009 to 2012 were included in a retrospective cohort study. Patients were screened twice daily for coma and delirium during their ICU stay using the Richmond Agitation Sedation Scale (RASS) and CAM-ICU. The association between delirium/coma and mortality was determined using multiple logistic regression. RASS and CAM-ICU were also compared to a retrospective assessment of hepatic encephalopathy (HE). Of 91 patients with cirrhosis, 26 (28.6 %) developed delirium/coma. RASS/CAM-ICU had fair agreement with the HE assessment (κ 0.38). Patients with delirium/coma had numerically greater mortality in-hospital (23.1 vs. 7.7 %, p = 0.07) and at 90 days (30.8 vs. 18.5 %, p = 0.26), and they also had longer hospital length of stay (median 19.5 vs. 6 days, p < 0.001). Delirium/coma was associated with increased inpatient mortality, independent of disease severity (unadjusted OR 3.6; 95 % CI, 0.99-13.1; MELD-adjusted OR 5.4; 95 % CI, 1.3-23.8; acute physiology score-adjusted OR 2.2; 95 % CI, 0.53-8.9). Delirium/coma was also associated with longer length of stay after adjusting for disease severity. In critically ill patients with cirrhosis, delirium/coma as measured by the RASS and CAM-ICU is associated with increased mortality and hospital length of stay. For these patients, these measures provide valuable information and may be useful tools for clinical care. RASS and CAM-ICU need to be compared to HE-specific measures in future studies.
在重症监护病房（ICU），谵妄通常采用广泛应用且经过验证的ICU意识模糊评估法（CAM-ICU）进行测量，但尚未在肝硬化患者中对CAM-ICU进行研究。我们对一组肝硬化患者进行研究，以确定通过CAM-ICU测量的谵妄与临床结局之间的关系。2009年至2012年入住ICU的连续性肝硬化患者被纳入一项回顾性队列研究。在患者入住ICU期间，每天使用里士满躁动镇静量表（RASS）和CAM-ICU对其进行两次昏迷和谵妄筛查。使用多因素逻辑回归确定谵妄/昏迷与死亡率之间的关联。还将RASS和CAM-ICU与肝性脑病（HE）的回顾性评估进行比较。91例肝硬化患者中，26例（28.6%）出现谵妄/昏迷。RASS/CAM-ICU与HE评估有中等程度的一致性（κ=0.38）。出现谵妄/昏迷的患者住院期间（23.1%对7.7%，p=0.07）和90天时（30.8%对18.5%，p=0.26）的死亡率在数值上更高，并且住院时间也更长（中位数19.5天对6天，p<0.001）。谵妄/昏迷与住院死亡率增加相关，与疾病严重程度无关（未调整的比值比为3.6；95%置信区间，0.99-13.1；终末期肝病模型（MELD）调整后的比值比为5.4；95%置信区间，1.3-23.8；急性生理学评分调整后的比值比为2.2；95%置信区间，0.53-8.9）。在调整疾病严重程度后，谵妄/昏迷也与更长的住院时间相关。在重症肝硬化患者中，通过RASS和CAM-ICU测量的谵妄/昏迷与死亡率增加和住院时间延长相关。对于这些患者，这些测量方法提供了有价值的信息，可能是临床护理的有用工具。在未来的研究中，需要将RASS和CAM-ICU与针对HE的测量方法进行比较。
