Beyer L P, Gathen L von Zur, Rayah B El, Dewald O, Zieschang T, Diers A, Ely E Wesley, Guenther U
Fakultät VI - Medizin und Gesundheitswissenschaften, Carl von Ossietzky Universität, Oldenburg, Germany.
Universitätsklinik für Intensivmedizin, Klinikum Oldenburg AöR, Rahel-Straus-Straße 10, 26133, Oldenburg, Germany.
BMC Anesthesiol. 2024 Dec 13;24(1):451. doi: 10.1186/s12871-024-02849-3.
Disorientation is an early indicator of developing postoperative delirium (POD), which is associated with increased mortality and cognitive decline. The well-established "Confusion-Assessment-Method-for-Intensive-Care-Unit" (CAM-ICU) for diagnosing POD in intubated patients cannot make use of the feature 'disorientation', as this requires verbal communication. Other tools such as the 4AT test for disorientation but are not established in ICU settings. We therefore combined test-variables of the CAM-ICU (level of consciousness, fluctuating mental status and inattention) with verbal testing for disorientation to develop and enhance diagnostic accuracy of the "Confusion Assessment Method for Intermediate Care Unit" (CAM-IMC). In the present study we describe the development and the evaluation of the diagnostic accuracy of the CAM-IMC.
We conducted a prospective cohort-study to develop and evaluate the diagnostic accuracy of the CAM-IMC and disorientation for diagnosing POD in non-intubated patients undergoing elective cardiac surgery. All patients were eligible during data collection period. Exclusion criteria were preexisting brain-organic disease, age < 50 years, preoperative intubation, and insufficient language skills. Patients were assessed for POD using the CAM-IMC as the index-test by two independent examiners over three postoperative days. Reference-testing was conducted by experienced reference-raters. The primary outcome was the diagnostic test-performance.
Among 178 eligible patients, 624 paired observations were completed with 155 patients. Of these, 9% experienced POD. Sensitivity and specificity were 0.96 (CI-95%: 0.87-1.00) and 0.94 (CI-95%: 0.92-0.96), respectively. Area-Under-the-Receiver-Operating-Characteristic-Curve (AUROC; equivalent to c-statistic) for CAM-IMC with a cut-off at three points was 0.95 (CI-95%: 0.93-0.98). The interrater reliability was 0.80 (CI-95%: 0.69-0.91).
The CAM-IMC demonstrates excellent test performance for diagnosing POD in non-intubated patients by combining features of the CAM-ICU with 'disorientation'. Given an aging community with an increasing delirium risk, the CAM-IMC provides a highly structured assessment tool for POD. It enables early and accurate detection of delirium, which is critical for timely intervention and improved patient outcomes. The CAM-IMC appears to be a useful tool to be implemented in units for not-intubated patients and seems to be the perfect match where the CAM-ICU is already in use for monitoring POD.
DRKS00026980 (German registry of clinical studies).
定向障碍是术后谵妄（POD）发展的早期指标，与死亡率增加和认知功能下降相关。用于诊断插管患者POD的成熟的“重症监护病房意识模糊评估方法”（CAM-ICU）无法利用“定向障碍”这一特征，因为这需要言语交流。其他工具如用于评估定向障碍的4AT测试，但在重症监护病房环境中尚未确立。因此，我们将CAM-ICU的测试变量（意识水平、精神状态波动和注意力不集中）与定向障碍的言语测试相结合，以开发和提高“中级护理病房意识模糊评估方法”（CAM-IMC）的诊断准确性。在本研究中，我们描述了CAM-IMC的开发及其诊断准确性评估。
我们进行了一项前瞻性队列研究，以开发和评估CAM-IMC及定向障碍对接受择期心脏手术的非插管患者诊断POD的准确性。在数据收集期间，所有患者均符合条件。排除标准为既往有脑器质性疾病、年龄<50岁、术前插管和语言能力不足。在术后三天内，由两名独立检查者使用CAM-IMC作为指标测试对患者进行POD评估。由经验丰富的参考评估者进行参考测试。主要结果是诊断测试性能。
在178名符合条件的患者中，对155名患者完成了624对观察。其中，9%的患者发生了POD。敏感性和特异性分别为0.96（95%CI：0.87-1.00）和0.94（95%CI：0.92-0.96）。CAM-IMC在三个点处截断的受试者工作特征曲线下面积（AUROC；等同于c统计量）为0.95（95%CI：0.93-0.98）。评分者间信度为0.80（95%CI：0.69-0.91）。
CAM-IMC通过将CAM-ICU的特征与“定向障碍”相结合，在诊断非插管患者的POD方面表现出优异的测试性能。鉴于社区老龄化且谵妄风险增加，CAM-IMC为POD提供了一种高度结构化的评估工具。它能够早期准确地检测谵妄，这对于及时干预和改善患者预后至关重要。CAM-IMC似乎是一种可在非插管患者病房实施的有用工具，并且似乎是在已经使用CAM-ICU监测POD的地方的完美匹配。
DRKS00026980（德国临床研究注册）。
