Influence of Sedation Level and Ventilation Status on the Diagnostic Validity of Delirium Screening Tools in the ICU—An International, Prospective, Bi-Center Observational Study (IDeAS)
Flavio E. Nacul,
Nicolas Paul,
Claudia D. Spies,
Henriette Sechting,
Thomas Hecht,
Jörn S. Dullinger,
Sophie K. Piper,
Alawi Luetz,
Felix S. Balzer,
Klaus-Dieter Wernecke,
Anna Karinina Sa,
Carolina Barros Ferreira da Costa,
Lisa Eymold,
Chokri Chenitir,
Björn Weiss
Affiliations
Flavio E. Nacul
Surgical Critical Care Medicine, Hospital Pro-Cardiaco, Rio de Janeiro, RJ 22280-003, Brazil
Nicolas Paul
Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany
Claudia D. Spies
Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany
Henriette Sechting
Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany
Thomas Hecht
Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany
Jörn S. Dullinger
Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany
Sophie K. Piper
Institute of Biometry and Clinical Epidemiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany
Alawi Luetz
Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany
Felix S. Balzer
Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany
Klaus-Dieter Wernecke
Institute of Biometry and Clinical Epidemiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany
Anna Karinina Sa
Surgical Critical Care Medicine, Hospital Pro-Cardiaco, Rio de Janeiro, RJ 22280-003, Brazil
Carolina Barros Ferreira da Costa
Surgical Critical Care Medicine, Hospital Pro-Cardiaco, Rio de Janeiro, RJ 22280-003, Brazil
Lisa Eymold
Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany
Chokri Chenitir
Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany
Björn Weiss
Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany
Background and objectives: The use of delirium screening instruments (DSIs) is recommended in critical care practice for a timely detection of delirium. We hypothesize that the patient-related factors “level of sedation” and “mechanical ventilation” impact test validity of DSIs. Materials and Methods: This is a prospective, bi-center observational study (clinicaltrials.gov: NCT01720914). Critically ill patients were screened for delirium daily for up to seven days after enrollment using the Nursing Delirium Screening Scale (Nu-DESC), Intensive Care Delirium Screening Checklist (ICDSC), and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Reference standard for delirium diagnosis was the neuropsychiatric examination using the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Immediately before delirium assessment, ventilation status and sedation levels were documented. Results: 160 patients were enrolled and 151 patients went into final analysis. Delirium incidence was 23.2%. Nu-DESC showed a sensitivity and specificity of 88.5%, a positive predictive value (PPV) of 71.9%, and a negative predictive value (NPV) of 95.8%. ICDSC had a sensitivity of 62.5%, a specificity of 92.4%, a PPV of 71.4%, and a NPV of 89.0%. CAM-ICU showed a sensitivity of 75.0%, a specificity of 94.7%, a PPV of 85.7%, and a NPV of 90.0%. For Nu-DESC and ICDSC, test validity was significantly better for non-sedated patients (Richmond Agitation Sedation Scale (RASS) 0/−1), whereas test validity for CAM-ICU in a severity scale version showed no significant differences for different sedation levels. No DSI showed a significant difference in test validity between noninvasively and invasively ventilated patients. Conclusions: Test validities of DSIs were comparable to previous studies. The observational scores ICDSC and Nu-DESC showed a significantly better performance in awake and drowsy patients (RASS 0/−1) when compared with other sedation levels. Physicians should refrain from sedation whenever possible to avoid suboptimal performance of DSIs.
