Log in | Register

Effect of sedation level on the prevalence of delirium when assessed with CAM-ICU and ICDSC

Matthias Haenggi| Sina Blum| Ruth Brechbuehl| Anna Brunello| Stephan M. Jakob| Jukka Takala
Original
Volume 39, Issue 12 / December , 2013

Pages 2171 - 2179

Abstract

Purpose

We hypothesized that reduced arousability (Richmond Agitation Sedation Scale, RASS, scores −2 to −3) for any reason during delirium assessment increases the apparent prevalence of delirium in intensive care patients. To test this hypothesis, we assessed delirium using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) in intensive care patients during sedation stops, and related the findings to the level of sedation, as assessed with RASS score.

Methods

We assessed delirium in 80 patients with ICU stay longer than 48 h using CAM-ICU and ICDSC during daily sedation stops. Sedation was assessed using RASS. The effect of including patients with a RASS of −2 and −3 during sedation stop (“light to moderate sedation”, eye contact less than 10 s or not at all, respectively) on prevalence of delirium was analyzed.

Results

A total of 467 patient days were assessed. The proportion of CAM-ICU-positive evaluations decreased from 53 to 31 % (p < 0.001) if assessments from patients at RASS −2/−3 (22 % of all assessments) were excluded. Similarly, the number of positive ICDSC results decreased from 51 to 29 % (p < 0.001).

Conclusions

Sedation per se can result in positive items of both CAM-ICU and ICDSC, and therefore in a diagnosis of delirium. Consequently, apparent prevalence of delirium is dependent on how a depressed level of consciousness after sedation stop is interpreted (delirium vs persisting sedation). We suggest that any reports on delirium using these assessment tools should be stratified for a sedation score during the assessment.

Keywords

References

  1. Girard TD, Pandharipande PP, Ely EW (2008) Delirium in the intensive care unit. Crit Care 12(Suppl 3):S3. doi:10.1186/cc6149
    • View reference on publisher's website
  2. Pisani MA, Kong SY, Kasl SV, Murphy TE, Araujo KL, Van Ness PH (2009) Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med 180:1092–1097. doi:10.1164/rccm.200904-0537OC
    • View reference on PubMed
    • View reference on publisher's website
  3. Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y (2007) Incidence, risk factors and consequences of ICU delirium. Intensive Care Med 33:66–73. doi:10.1007/s00134-006-0399-8
  4. Ely EW, Gautam S, Margolin R, Francis J, May L, Speroff T, Truman B, Dittus R, Bernard R, Inouye SK (2001) The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med 27:1892–1900. doi:10.1007/s00134-001-1132-2
  5. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE Jr, Inouye SK, Bernard GR, Dittus RS (2004) Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 291:1753–1762
    • View reference on PubMed
    • View reference on publisher's website
  6. Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, Speroff T, Gautam S, Bernard GR, Inouye SK (2001) Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 29:1370–1379 (pii 11445689)
    • View reference on PubMed
    • View reference on publisher's website
  7. Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, Truman B, Speroff T, Gautam S, Margolin R, Hart RP, Dittus R (2001) Delirium in mechanically ventilated patients: validity and reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). JAMA 286:2703–2710 (pii 11730446)
    • View reference on PubMed
    • View reference on publisher's website
  8. Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y (2001) Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med 27:859–864 (pii 11430542)
  9. van Eijk MM, van den Boogaard M, van Marum RJ, Benner P, Eikelenboom P, Honing ML, van der Hoven B, Horn J, Izaks GJ, Kalf A, Karakus A, Klijn IA, Kuiper MA, de Leeuw FE, de Man T, van der Mast RC, Osse RJ, de Rooij SE, Spronk PE, van der Voort PH, van Gool WA, Slooter AJ (2011) Routine use of the Confusion Assessment Method for the Intensive Care Unit: a multicenter study. Am J Respir Crit Care Med 184:340–344
    • View reference on PubMed
    • View reference on publisher's website
  10. Pandharipande P, Cotton BA, Shintani A, Thompson J, Costabile S, Truman Pun B, Dittus R, Ely EW (2007) Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care unit patients. Intensive Care Med 33:1726–1731. doi:10.1007/s00134-007-0687-y
  11. Peterson JF, Pun BT, Dittus RS, Thomason JW, Jackson JC, Shintani AK, Ely EW (2006) Delirium and its motoric subtypes: a study of 614 critically ill patients. J Am Geriatr Soc 54:479–484. doi:10.1111/j.1532-5415.2005.00621.x
    • View reference on PubMed
    • View reference on publisher's website
  12. Spronk PE, Riekerk B, Hofhuis J, Rommes JH (2009) Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med 35:1276–1280
  13. Ouimet S, Riker R, Bergeron N, Cossette M, Kavanagh B, Skrobik Y (2007) Subsyndromal delirium in the ICU: evidence for a disease spectrum. Intensive Care Med 33:1007–1013. doi:10.1007/s00134-007-0618-y
  14. Jakob SM, Lubszky S, Friolet R, Rothen HU, Kolarova A, Takala J (2007) Sedation and weaning from mechanical ventilation: effects of process optimization outside a clinical trial. J Crit Care 22:219–228. doi:10.1016/j.jcrc.2007.01.001
    • View reference on PubMed
    • View reference on publisher's website
  15. Pun BT, Gordon SM, Peterson JF, Shintani AK, Jackson JC, Foss J, Harding SD, Bernard GR, Dittus RS, Ely EW (2005) Large-scale implementation of sedation and delirium monitoring in the intensive care unit: a report from two medical centers. Crit Care Med 33:1199–1205 (pii 15942331)
    • View reference on PubMed
    • View reference on publisher's website
  16. Soja SL, Pandharipande PP, Fleming SB, Cotton BA, Miller LR, Weaver SG, Lee BT, Ely EW (2008) Implementation, reliability testing, and compliance monitoring of the Confusion Assessment Method for the Intensive Care Unit in trauma patients. Intensive Care Med 34:1263–1268. doi:10.1007/s00134-008-1031-x
  17. Ely EW (2010) Confusion Assessment Method for the ICU (CAM-ICU) the complete training manual. http://www.mc.vanderbilt.edu/icudelirium/docs/CAM_ICU_training.pdf. Accessed 15 Mar 2013
  18. Association AP (2013) Delirium diagnostic and statistical manual of mental disorders DSM-5. American Psychiatric Publishing, Arlington, pp 596–602
  19. Haenggi M, Ypparila H, Takala J, Korhonen I, Luginbuhl M, Petersen-Felix S, Jakob SM (2004) Measuring depth of sedation with auditory evoked potentials during controlled infusion of propofol and remifentanil in healthy volunteers. Anesth Analg 99:1728–1736. doi:10.1213/01.ANE.0000135634.46493.0A (table of contents)
    • View reference on PubMed
    • View reference on publisher's website
  20. Haenggi M, Ypparila-Wolters H, Buerki S, Schlauri R, Korhonen I, Takala J, Jakob SM (2009) Auditory event-related potentials, bispectral index, and entropy for the discrimination of different levels of sedation in intensive care unit patients. Anesth Analg 109:807–816. doi:10.1213/ane.0b013e3181acc85d
    • View reference on PubMed
    • View reference on publisher's website

Sign In

Connect with ICM

Top 5 Articles Editors Picks Supplement