3. ARDS患者の死亡率
cohort (16%, 14%, 19%, and 13%, respectively).
Even though ARDS was the direct cause of death in
only a few patients, it was present in the majority of
patients at the time of death (88%, 86%, 88%, and
96% in 1981–1982, 1990, 1994, and 1998, respec-
tively).
Timing of death in ARDS, divided into early and
late deaths and then further categorized as due to
presenting injury/illness, respiratory failure, or a
complication occurring after ARDS onset, has also
commonly occurred secondary to the presenting
injury or illness.
There has, however, been a significant change in
the case fatality of ARDS patients when stratified by
risk factor (Fig 3), such that the case fatality
of ARDS patients who present with trauma
(p ϭ 0.0002 for trend) or other risk factors
(p ϭ 0.043 for trend) has decreased, but the case
fatality of patients whose risk factor is sepsis
(p ϭ 0.255 for trend) has not changed. Additionally,
Figure 1. Case fatality of ARDS patients at Harborview Medical Center, 1991–1998. Case fatality was
near 60% in the early 1980s and decreased to near 30% by the mid-1900s (p ϭ 0.001 for trend,
Wilcoxon rank-sum test for trend).
528 Clinical Investigations in Critical Care
Downloaded From: http://journal.publications.chestnet.org/ by a Koseiren Hiroshima Sohgoh Byoin User on 09/04/2013
• 死亡率は減少し, 1990年代半ばからはプラトーになっている.
•多臓器不全を伴う敗血症が主な死因（30-50%）であり, 呼吸不全は13-19%程度.
Stapleton RD, Wang BM, Hudson LD, et al. Causes and Timing of Death in Patients With ARDS. CHEST 2005; 128: 525-532.
重症ほど予後が悪い
せん妄期間と認知機能障害
• 重症患者のICU退室 3ヶ月後の時点で認知機能障害は認められ40%程度に認められ,
12ヶ月後の時点においても, 年齢に関係なく改善はみられない.
• せん妄期間と認知機能障害は相関し, せん妄期間が増えれば認知機能も低下した.
The new engl and jour nal of medicine
tients in the ICU,38-40 and it is not known whether
any preventive or treatment strategies can reduce
the risk of long-term cognitive impairment after
critical illness.
These results complement those of earlier
cohort studies that exposed the problem of cog-
nitive deficits in survivors of critical illness.1-4
Some important differences, however, exist be-
tween previous investigations and the BRAIN-ICU
study. First, we enrolled a large sample of pa-
tients with a diverse set of admission diagnoses
and a broad age range. Second, we collected and
analyzed detailed data about delirium and seda-
tive exposure as risk factors for long-term cogni-
tive impairment. Two longitudinal studies3,4 have
advanced the field, but one was limited to patients
with severe sepsis,4 and neither study collected de-
tailed data on in-hospital exposures, such as
delirium and psychoactive medications. In addi-
tion, the previous studies assessed cognitive
outcomes with the use of abbreviated screening
tools, which do not allow comparisons with
other populations, such as patients with trau-
matic brain injury or Alzheimer’s disease.
An important limitation of the BRAIN-ICU
study was our inability to test patients’ cognition
before their emergent illness. We addressed this
limitation in three ways. First, we excluded pa-
tients who were found to have severe dementia
with the use of a rigorous and well-validated ap-
proach that relied on two validated surrogate as-
AdjustedRBANSGlobalCognitionScore
at12Mo
80
90
70
60
0
0 5 10
Days of Delirium
N=382
P=0.04
Figure 2. Duration of Delirium and Global Cognition Score at 12 Months.
Longer durations of delirium were independently associated with worse
RBANS global cognition scores at 12 months. Point estimates and the 95%
confidence interval for these relationships are shown by the blue line and the
gray band, respectively. RBANS global cognition scores have age-adjusted
population norms, with a mean (±SD) score of 100±15. Rug plots show the
distribution of the durations of delirium. Although delirium could be assessed
for up to 30 days in the study, the x axis is truncated at 10 days because 90%
of the patients had delirium for 10 days or less; all available data were used in
the multivariable modeling. As one example, in a comparison of patients with
no delirium and those with 5 days of delirium (the 25th and 75th percentile
values of delirium duration in our cohort), with all other covariates held con-
stant (at the median or mode of the covariate), patients with 5 days of delir-
ium had RBANS global cognition scores at 12 months that were an average
Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive
impairment after critical illness. N Engl J Med. 2013 Oct 3;369(14):1306-16.
The new engl and jour nal o f medicine
an altered level of consciousness and surgical
versus medical ICU did not qualitatively change
our findings.
DISCUSSION
In this multicenter, prospective cohort study involv-
ing a diverse population of patients in general med-
ical and surgical ICUs, we found that one out of
four patients had cognitive impairment 12 months
after critical illness that was similar in severity to
that of patients with mild Alzheimer’s disease,
and one out of three had impairment typically
associated with moderate traumatic brain injury.
Impairments affected a broader array of neuro-
psychological domains than is characteristically
seen in Alzheimer’s disease, but the impairments
were very similar to those observed after moder-
ate traumatic brain injury. A validated instrument
that assessed baseline cognitive status showed
that only 6% of patients had evidence of mild-to-
moderate cognitive impairment before ICU ad-
mission, indicating that these profound cognitive
deficits were new in the majority of patients.
Long-term cognitive impairment affected both
old and young patients, regardless of the burden
of coexisting conditions at baseline.
A longer duration of delirium was associated
with worse long-term global cognition and ex-
Normal
MCI
TBI
Alzheimer’s
disease
RBANSGlobalCognitionScore
120
80
100
60
40
0
3 Mo
(N=97)
12 Mo
(N=89)
≤49 Yr
3 Mo
(N=147)
12 Mo
(N=138)
50–64 Yr
3 Mo
(N=130)
12 Mo
(N=98)
≥65 Yr
Figure 1. Global Cognition Scores in Survivors of Critical Illness.
The box-and-whisker plots show the age-adjusted global cognition scores on
the Repeatable Battery for the Assessment of Neuropsychological Status
(RBANS; with a population age-adjusted mean [±SD] of 100±15, and lower
scores indicating worse global cognition) at 3 months (light-gray boxes) and
12 months (dark-gray boxes), according to age. For each box-and-whisker
plot, the horizontal bar indicates the median, the upper and lower limits of
the boxes the interquartile range, and the ends of the whiskers 1.5 times the
interquartile range. Outliers are shown as black dots. The green dashed line
indicates the age-adjusted population mean (100) for healthy adults, and the
green band indicates the standard deviation (15). Also shown are the expected
population means for mild cognitive impairment (MCI), moderate traumatic
brain injury (TBI), and mild Alzheimer’s disease on the basis of other cohort
studies. Expected population means for MCI and Alzheimer’s disease are
重症なせん妄とは??
4. 亜症候性せん妄
• 2004年（1月から12月まで）のICU入室患者を対象に, ICDSCで8時間ごとにcheck.
• 0ポイントと比べ1-3ポイントでも, 死亡率は上昇, ICU入室日数は増加した.
ifested an ICDSC score
ere performed with SAS
, N.C., USA); differences
e considered statistically
bsyndromal delirium the
1 on the ICDSC were 67
(32.4%), respectively. Of
ed among subsyndromal
re scored 1, 368 (29.7%)
nts with clinical delirium
1.3%), with higher scores
le 2).
r post-ICU mortality analysis:
of patient first exited first ICU;
elirium 4, subsyndromal delir-
e therefore not included in the
nce interval)
95% CI p
0.84–2.08 0.2346
0.61–1.55 0.9098
1.63–3.73 < 0.0001
1.07–2.60 0.0252
, and coma
Fig. 1 Post-ICU mortality. Kaplan–Meier curves depicting time to
death in the no delirium, subsyndromal delirium, and clinical delir-
ium groups
Fig. 2 Distribution of highest checklist scores over time. All pa-
tients were considered nondelirious prior to admission. In patients
with clinical delirium or subsyndromal delirium the maximal scores
occurred early in the ICU admission, with almost one-half occurring
within 24–48 h (i.e., within the first day) of admission, and over 90%
occurring by ICU day 6. See Table 3
using survival analysis. Time to death was computed
from the date of patient exited the ICU for the first time.
Fifty-three patients died during their first ICU stay (4
with no delirium, 19 with subsyndromal delirium, and
30 with delirium) and were not included in the survival
analysis. Survival curves were computed using the Kap-
lan–Meier formulas and compared between the three
groups by the log rank test. In the case of significant
findings 2 × 2 survival curves were also compared using
the log rank test. Cox regression analysis was used to
analyze the effect of group on mortality adjusted for age,
severity of illness (APACHE II) and medication-induced
coma [14]. Cox regression model was also performed
on the clinical delirium group only to determine whether
the initial score (4–8 ICDSC items) is a predictor of
mortality. In this analysis time to death was computed
from the date of patient manifested an ICDSC score
of 4 or higher. All analyses were performed with SAS
version 8.2 (SAS Institute, Cary, N.C., USA); differences
at the level of p ≤ 0.05 were considered statistically
significant.
Results
Diagnostic categories
Among the patients with subsyndromal delirium the
number with scores of 3, 2, and 1 on the ICDSC were 67
(37.4%), 54 (30.2%), and 58 (32.4%), respectively. Of
the 1,239 assessments completed among subsyndromal
delirium patients 482 (39%) were scored 1, 368 (29.7%)
2, and 389 (31.3%) 3. In patients with clinical delirium
the most frequent score was 4 (51.3%), with higher scores
progressively less common (Table 2).
Table 2 Results of Cox regression for post-ICU mortality analysis:
time to death, computed from the date of patient first exited first ICU;
53 patients died in their first ICU (no delirium 4, subsyndromal delir-
ium 19, clinical delirium 30) and were therefore not included in the
analysis (HR hazard ratio, CI confidence interval)
HRa 95% CI p
Subsyndromal delirium
Unadjusted model 1.32 0.84–2.08 0.2346
Adjusted modelb 0.97 0.61–1.55 0.9098
Clinical delirium
Unadjusted model 2.46 1.63–3.73 < 0.0001
Adjusted modelb 1.67 1.07–2.60 0.0252
a Reference group is no delirium
b Adjusted for age, APACHE II score, and coma
There were 53 ICU deaths: 2.4%, 10.6%, and 15.9% in
the no delirium, subsyndromal delirium, and clinical delir-
ium groups, respectively (no delirium vs. subsyndromal
delirium, p = 0.0020; no delirium vs. clinical delirium,
p < 0.0001; subsyndromal delirium vs. clinical delirium,
p = 0.1378; Fig. 1). On the 484 surviving patients post-
ICU mortality was higher in the clinical delirium than in
the subsyndromal delirium and no delirium groups (clin-
ical delirium vs. no delirium, log-rank test, p < 0.0001;
clinical delirium vs. subsyndromal delirium, log-rank test,
p = 0.0016 and subsyndromal delirium vs. no delirium,
log-rank test, p = 0.2309; Fig. 2, Table 3). The results of
the Cox regression analysis showed that only the clinical
delirium group had a higher risk of mortality than the no
Fig. 1 Post-ICU mortality. Kaplan–Meier curves depicting time to
death in the no delirium, subsyndromal delirium, and clinical delir-
ium groups
Fig. 2 Distribution of highest checklist scores over time. All pa-
tients were considered nondelirious prior to admission. In patients
with clinical delirium or subsyndromal delirium the maximal scores
occurred early in the ICU admission, with almost one-half occurring
within 24–48 h (i.e., within the first day) of admission, and over 90%
occurring by ICU day 6. See Table 3
ICDSCと死亡率ICDSCの最大スコアの発生日
Ouimet S, Riker R, Bergeron N, et al. Subsyndromal delirium in the ICU:
evidence for a disease spectrum.Intensive Care Med 2007 Jun;33(6):1007-13.
せん妄期間が長いと予後が悪い
• 市中病院ICU（14床）での前向
きコホート研究.
• 60歳以上の入室患者（n=304）
を追跡し, せん妄期間の中央値は
3日間, せん妄期間が長いと1年
死亡が増加した（HR, 1.10: 95%
CI, 1.03-1.18 ）.
Missing values on predictor and control variables were minimal
(Table 1), so a complete case analysis was conducted. A P value of 0.05
was considered to be significant for all two-sided statistical tests. SAS
statistical software, version 9.2 (SAS Institute Inc, Cary, NC), was used.
and mortality was statistically significant (ha
1.10; 95% confidence interval [CI], 1.02–1.18) a
covariates. Multivariable model results remain
the model is pruned of nonsignificant (P
covariates (HR, 1.10; 95% CI, 1.03–1.18). A
reproducibility, bootstrapping confirmed the m
parameter estimate for the model’s main pred
Other factors significantly associated with m
age, impairment in IADL, Charlson Comorb
severity of illness on ICU admission.
DISCUSSION
This study provides new evidence for the im
number of days of ICU delirium as a risk fac
Previous ICU studies have found an asso
presence of delirium and mortality (6) but not
of days of delirium in ICU and mortality. T
Figure 2. Kaplan-Meier s
year mortality post–inten
admission (ICU delirium
Log-rank chi-square statis
of freedom 5 3; P , 001
Receipt of opiods or benzodiazepines in the ICU, n (%) 248 (82)
Receipt of propofol in the ICU, n (%) 22 (7)
Receipt of haloperidol in the ICU, n (%) 99 (33)
ICU length of stay, median (IQR) 5.0 (6)
Total length hospital stay, median (IQR) 11.0 (12)
ICU delirium days, median (IQR) 3.0 (6)
ICU and floor/ward delirium days, median (IQR) 4.0 (9)
Post-ICU discharge, floor/ward delirium days, median (IQR) 1.0 (3)
Death in the ICU, n (%) 48 (16)
Death within 1 yr of ICU admission, n (%) 153 (50)
Definition of abbreviations: APACHE 5 Acute Physiology and Chronic Health
Evaluation; ICU 5 Intensive Care Unit; IQR 5 interquartile range.
* There are missing data for four subjects (dementia, n 5 3; Charlson, n 5 1).
Kaplan-Meier 曲線（せん妄期間と1年死亡率）
Pisani MA, Kong SY, Kasal SV, et al. Days of delirium are associated with 1-year mortality in an
older intensive care unit population. Am J Respir Crit Care Med 2009 Dec 1; 180(11): 1092-7.
hypoatciveに注意
• 予定手術後の50歳以上の患者
（n=172）の前向きコホート研究.
• 74人（43%）の患者でせん妄が発生し,
67.6%がhypoactive, 31.1%がmixed,
1.4%がhyperactiveであった.
• mixedと比較して, hypoactiveの方が
6ヶ月死亡率が高かった（32.0% vs.
8.7%, p=0.04）. せん妄なしは2.1%.
• 仙骨部の褥瘡hypoactiveで多く, デバ
イス抜去はmixedの方で多かった.
Robinson TN, Raebum CD, Tran ZV, et al. Motor subtypes of postoperative
delirium in older adults. Arch Surg 2011 Mar;146(3):295-300.
cluded from statistical comparisons because of the small
group size (n=1). The mean age of study patients was
64 (8) years; 96.5% (166 of 172) were male. The mean
time to initial presentation of delirium in patients was
2.3 (1.8) days. The time to initial onset of delirium did
not differ between the hypoactive (2.4 [1.7] days) vs mixed
(2.2 [1.8] days) groups (P=.66). The mean duration of
delirium among patients in the hypoactive and mixed
groups was 3.5 (4.5) days. The mean duration of de-
lirium did not differ between the hypoactive (2.8 [1.4]
days) vs mixed (3.9 [5.4] days) groups (P=.34).
An overview of operations performed included 44.8%
(77 of 172) abdominal, 37.2% (65 of 172) cardiac, 9.3%
(16 of 172) noncardiac thoracic, and 8.1% (14 of 172)
vascular. Among patients with delirium, the operations
performed did not differ between the hypoactive vs mixed
groups (Table 1).
Preoperative variables were compared among pa-
tients in the hypoactive vs mixed groups (Table 1). Com-
pared with those having mixed delirium, patients hav-
ing hypoactive delirium were older (mean age, 71 [9] vs
65 [9] years) and more anemic (mean hematocrit, 36%
[8%] vs 41% [6%]) (P=.002 for both) (to convert he-
matocrit to a proportion of 1.0, multiply by 0.01).
Intraoperative variables of blood transfusion, operat-
ing room time, and type of anesthesia were compared be-
tween the hypoactive (n=50) vs mixed (n=23) groups.
9) of patients in the hypoactive group vs 0 of 10 patients
in the mixed group (P=.002), and inadvertent tube or
line removals occurred in 90.0% (9 of 10) of patients in
the mixed group vs 22.2% (2 of 9) of patients in the hy-
poactive group (P=.006). The one patient who devel-
oped purely hyperactive postoperative delirium had 3 de-
0
10
20
30
40
50
60
70
HyperactiveMixedHypoactive
Incidence,%
Motor Subtype of Postoperative Delirium
n=50
n=23
n=1
Figure 2. Incidence of motor subtypes of postoperative delirium among 74
patients.
cluded from statistical comparisons because of the small
group size (n=1). The mean age of study patients was
64 (8) years; 96.5% (166 of 172) were male. The mean
time to initial presentation of delirium in patients was
2.3 (1.8) days. The time to initial onset of delirium did
not differ between the hypoactive (2.4 [1.7] days) vs mixed
(2.2 [1.8] days) groups (P=.66). The mean duration of
delirium among patients in the hypoactive and mixed
groups was 3.5 (4.5) days. The mean duration of de-
lirium did not differ between the hypoactive (2.8 [1.4]
days) vs mixed (3.9 [5.4] days) groups (P=.34).
An overview of operations performed included 44.8%
(77 of 172) abdominal, 37.2% (65 of 172) cardiac, 9.3%
(16 of 172) noncardiac thoracic, and 8.1% (14 of 172)
vascular. Among patients with delirium, the operations
performed did not differ between the hypoactive vs mixed
groups (Table 1).
Preoperative variables were compared among pa-
tients in the hypoactive vs mixed groups (Table 1). Com-
pared with those having mixed delirium, patients hav-
ing hypoactive delirium were older (mean age, 71 [9] vs
65 [9] years) and more anemic (mean hematocrit, 36%
[8%] vs 41% [6%]) (P=.002 for both) (to convert he-
matocrit to a proportion of 1.0, multiply by 0.01).
Intraoperative variables of blood transfusion, operat-
ing room time, and type of anesthesia were compared be-
tween the hypoactive (n=50) vs mixed (n=23) groups.
Type of anesthesia is described as the percentage of pa-
9) of patients in the hypoactive group vs 0 of 10 patients
in the mixed group (P=.002), and inadvertent tube or
line removals occurred in 90.0% (9 of 10) of patients in
the mixed group vs 22.2% (2 of 9) of patients in the hy-
poactive group (P=.006). The one patient who devel-
oped purely hyperactive postoperative delirium had 3 de-
lirium-related adverse events (2 peripheral intravenous
pulls and 1 self-extubation).
0
10
20
30
40
50
60
70
HyperactiveMixedHypoactive
Incidence,%
Motor Subtype of Postoperative Delirium
n=50
n=23
n=1
Figure 2. Incidence of motor subtypes of postoperative delirium among 74
patients.
hypoactiveが多く, 予後も悪い.
重症ほど医療費がかかる
• せん妄をポイント化して, 毎日ポイントを加算していく.
that there were no differences in cost per
ICU day between delirious and nondeliri-
ous patient groups. A more plausible
mechanism to explain the delirium-cost
relationship is found in length of stay,
which is known to be a major cost driver
(12) and which was greater in delirious
patients in our study. Because of the ob-
servational nature of this study, we can-
not determine whether delirium caused
longer lengths of stay or if longer lengths
of stay simply resulted in greater time at
risk for developing delirium. However,
delirium could easily lead to increased
length of stay and cost if it resulted in the
administration of excess sedation or if it
otherwise interfered with liberation from
mechanical ventilation. The salient ques-
tion is whether reducing the incidence
and/or severity of delirium will alter clin-
ical outcomes and improve cost. To ad-
dress this question, future work should
include trials of delirium prevention and
treatment interventions that target mod-
ifiable risk factors such as sedation and
analgesia practices (40) and early patient
mobilization.
The associated annual cost of ICU
delirium could be enormous. In our
study, delirium occurred in 82% of me-
chanically ventilated patients and was
associated with an incremental increase
in ICU cost of $9,014 per patient. In the
United States, there are approximately
880,000–2,760,000 ICU admissions an-
nually for respiratory failure requiring
mechanical ventilation (41–45). At the
rate of delirium detected in our cohort,
the estimated number of cases of ICU
delirium could range from 721,600 to
2,263,200 per year with an associated in-
crease in healthcare costs ranging be-
tween $6.5 and $20.4 billion. If we use
Table 4. Patient costs for major subcategories of ICU care
Characteristic
Never Delirium
(n ϭ 41)
Ever Delirium
(n ϭ 183) p Value
Bed expenses 6,278 (3,791–8,804) 10,061 (6,312–16,016) Ͻ.001
Pharmacy 1,641 (918–3,319) 3,293 (1,993–5,106) Ͻ.001
Laboratory 1,303 (665–2,369) 2,262 (1,011–4,260) .003
Diagnostic radiology 1,106 (451–1,946) 1,732 (885–2,834) .002
Respiratory therapya
897 (650–1,467) 1,466 (1,019–2,441) Ͻ.001
Central supply 760 (411–1,301) 1,234 (586–2,245) .001
Biomedical monitoring 105 (53–330) 178 (53–390) .32
PT/OT/speech therapy 0 (0–141) 175 (0–429) .001
Dialysisb
0 (0–0) 0 (0–0) .61
ICU, intensive care unit; PT, physical therapy; OT, occupational therapy. Values are median patient
costs (US$) with interquartile ranges given in parentheses. Subcategories of ICU cost were based on
the general ledger category assigned to each cost item in the hospital billing system.
a
Includes costs of mechanical ventilation; b
27 of 183 (14.8%) delirious patients and 4 of 41 (12.2%)
nondelirious patients required dialysis. Because so few required dialysis, the median (interquartile
range) cost of dialysis for both patient groups was $0 ($0–$0).
Figure 1. Median intensive care unit (ICU) and hospital cost per patient. This histogram shows cost
according to clinical categorization of “ever delirium” vs. “never delirium.” Delirium was significantly
associated with increased ICU and hospital cost.
Figure 2. Median intensive care unit (ICU) and hospital cost per patient. This histogram shows cost
according to cumulative delirium severity indexes. Increasing delirium severity was significantly
associated with incrementally greater ICU and hospital cost.
D
elirium is a com-
mon clinical
event in me-
chanically ventilated medi-
cal intensive care unit pa-
tients and is associated with
significantly higher inten-
sive care unit and hospital
costs.
959Crit Care Med 2004 Vol. 32, No. 4
Table 2. Delirium severity index determinationa
CAM-ICU RASS
Delirium
Severity
Index
— 0
ϩ ϩ4 5
ϩ ϩ3 4
ϩ ϩ2 3
ϩ ϩ1 2
ϩ 0 1
ϩ Ϫ1 2
ϩ Ϫ2 3
ϩ Ϫ3 4
ϩ Ϫ4 5
ϩ Ϫ5 6
CAM-ICU, Confusion Assessment Method for
the Intensive Care Unit; RASS, Richmond Agita-
tion-Sedation Scale.
a
Delirium severity index determination: Non-
delirious (i.e., CAM-ICU negative) patients re-
ceived zero delirium severity index points for a
given day whereas delirious (i.e., CAM-ICU posi-
tive) patients received between 1 and 6 points on
that day as determined by the absolute RASS
score plus 1. In this way, patients with greater
degrees of hyperactive or hypoactive delirium
Table 3. Baseline ch
Cha
Age, mean (SD), yrs
Men, %
Race
White, %
Black, %
Charlson Comorbidi
Vision deficits, %
Hearing deficits, %
Blessed Dementia Ra
Activities of daily liv
APACHE II score, m
SOFA score, mean (
ICU admission diagn
Sepsis/acute respi
Pneumonia
Myocardial infarct
Hepatic or renal f
Chronic obstructi
Gastrointestinal b
Malignancy
Drug overdose
Other
APACHE, Acute
Assessment; ICU, int
Milbrandt EB, Deppen S, Harrison PL, et al. Costs associated with delirium
in mechanically ventilated patients. Crit Care Med 2004 Apr;32(4):955-62.
6. 浅い鎮静深度を維持する
臨床的に禁忌がない限りは, 深い鎮静深度よりは
浅い鎮静深度に調整することを推奨する（+1B）.
Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation,
and delirium in adult patients in the intensive care unit. Crit Care Med. 2013 Jan;41(1):263-306.
鎮静薬を使用する前に...
• 患者の快適性を維持する.
• 適切な鎮痛を行う.
• 頻回にオリエンテーションを行う.
• 正常な睡眠が得られるように環境を調整する.
鎮静薬以外に不安や興奮を和らげる介入を...
痛みの評価方法
• 全てのICU患者に対して, 常時痛みの評価を行うことを推奨する（+1B）.
• 患者本人によるself-reportが“Gold Standard” である.
• 重症患者は, 自分で訴えることが出来ないこともあり, その場合は客観的
な評価方法を用いる.
• Behavioral Pain Scale（BPS）
• Critical care Pain Observation Tool（CPOT）
• 神経因性 痛以外の痛みに対しては, 麻薬を第一選択で用いる（+1C）.
Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation,
and delirium in adult patients in the intensive care unit. Crit Care Med. 2013 Jan;41(1):263-306.
深い鎮静はやめましょう
8. RASS -3∼0 vs. 1日1回中断
（SAS 3 or 4）
麻薬で鎮痛, ミダゾラムなどのベンゾジアゼピンで持続鎮静.
Mehta S, Burry L, Cook D, et al. Daily sedation interruption in mechanically ventilated critically ill patients
cared for with a sedation protocol: a randomized controlled trial. JAMA. 2012 Nov 21;308(19):1985-92.
nt characteristics were similar
groups (TABLE 1). Eighty-
cent received medical diagno-
enrollment, 359 (84.9%) pa-
were receiving midazolam
s; 334 (79.0%), fentanyl; 71
, morphine; and 41 (9.5%),
l. Propofol infusions were dis-
ed at enrollment according to
y protocol.
mes
dian time to successful extuba-
7 days in both groups (hazard
08; 95% CI, 0.86-1.35; P=.52)
2). Adjustment for age, body
dex, Acute Physiology and
Health Evaluation II score, and
on type gave consistent results
d hazard ratio, 1.04; 95% CI,
31). Similarly, in a per-
analysis of patients who had
tions on more than 75% of eli-
udy days, there was no differ-
ence in time to successful extubation
between groups. There were no be-
tween-group differences in ICU or hos-
pital lengths of stay, hospital mortal-
ity, rates of unintentional device
removal, delirium, ICU neuroimag-
ing, barotrauma, tracheostomy, or or-
gan dysfunction (TABLE 2).
TABLE 3 summarizes data related to
sedative and opioid administration. Pa-
Figure 2. Kaplan-Meier Curves for Time to Successful Extubation
1.0
0.8
0.6
0.4
0.2
P =.52
0
No. at risk
Protocolized sedation only
Protocolized sedation only
Protocolized sedation and
daily interruption
Protocolized sedation and
daily interruption
0
209
214
5
146
140
10
72
81
15
49
42
20
34
28
25
23
16
30
Time, d
ProportionExtubated
P value calculated from log-rank statistic.
Patient Outcomes
Protocolized Sedation
and Interruption
(n = 214)
Protocolized Sedation
(n = 209) Measure of Effect (95% CI)
P
Value
ccessful extubation, median (IQR)a 7 (4 to 13) 7 (3 to 12) HR, 1.08 (0.86 to 1.35) .52
U,b median (IQR)a 10 (5 to 17) 10 (6 to 20) Mean difference, −3.17 (−6.89 to 0.55) .36
spital, median (IQR)a 20 (10 to 36) 20 (10 to 48) Mean difference, −8.2 (−17.64 to 1.19) .42
ty, No. (%) 50 (23.4) 52 (24.9) RR, 0.94 (0.67 to 1.32) .72
ortality, No. (%) 63 (29.6) 63 (30.1) RR, 0.98 (0.73 to 1.31) .89
ed organ failure and supportive
es, No. (%)
DS 89 (41.8) 78 (37.3) RR, 1.12 (0.88 to 1.42) .35
sopressors/inotropes 121 (56.8) 130 (62.2) RR, 0.91 (0.78 to 1.07) .26
nal replacement 50 (23.5) 37 (17.7) RR, 1.33 (0.91 to 1.94) .14
uromuscular blockade 20 (9.7) 21 (10.2) RR, 0.94 (0.53 to 1.69) .84
nal device removal, No. (%)
tube 18 (8.5) 29 (13.9) RR, 0.61 (0.35 to 1.07) .08
acheal tube 10 (4.7) 12 (5.8) RR, 0.82 (0.36 to 1.84) .64
catheter 6 (2.8) 13 (6.2) RR, 0.45 (0.17 to 1.17) .09
venous or arterial catheter 17 (8.0) 10 (4.8) RR, 1.68 (0.79 to 3.57) .18
ing in ICU, No. (%)
uted tomography 29 (13.6) 33 (15.9) RR, 0.85 (0.54 to 1.35) .53
tic resonance imaging 9 (4.2) 7 (3.4) RR, 1.25 (0.47 to 3.29) .64
straint
s, No. (%) 166 (76.4) 166 (79.4) RR, 0.96 (0.87 to 1.07) .46
days, mean (SD) 4.71 (5.67) 5.36 (6.14) Mean difference, −0.70 (−1.84 to 0.43)
o (%)b 113 (53.3) 113 (54.1) RR, 0.98 (0.82 to 1.17) .83
on within 48 h, No. (%) 12 (5.6) 16 (7.7) RR, 0.73 (0.35 to 1.50) .39
omy, No (%) 49 (23.2) 54 (26.3) RR, 0.88 (0.63 to 1.23) .46
s: ARDS, acute respiratory distress syndrome; HR, hazard ratio; ICU, intensive care unit; IQR, interquartile range; RR, relative risk.
e measured from enrollment.
ho ever had a score of 4 or more on the Intensive Care Screening Delirium Checklist.19
DAILY SEDATION INTERRUPTION IN MECHANICALLY VENTILATED CRITICALLY ILL PATIENTS
merican Medical Association. All rights reserved. JAMA, Published online October 17, 2012 E5
抜管成功までの時間は差がなかった.
看護師の仕事量は, 1日1回中断群で増加した.
浅い鎮静深度（ガイドラインの例）
• 落ち着いて覚醒している: RASS 0, SAS 4
• 浅い鎮静深度: RASS -1 or -2, SAS 3
• 深い鎮静深度: RASS -3 ∼ -5, SAS 1 or 2
Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation,
and delirium in adult patients in the intensive care unit. Crit Care Med. 2013 Jan;41(1):263-306.
身体刺激でなく, 呼びかけで反応
アイコンタクトやコミュニケーション可能
Early Goal-Directed Sedation
• EGDS vs. 標準治療.
• EGDS（Early Goal-Directed Sedation）: ミダゾラム使用しない.
• デクスメデトミジンをベースとした浅い鎮静（RASS -2から1）に, 必要
ならプロポフォールを使用.
• 標準治療: デクスメデトミジンは使用できず, ミダゾラムやプロポ
フォールなどを使用.
• 浅い鎮静（RASS -2から1）の達成時間と, せん妄や血管収
縮薬, 身体拘束, デバイス抜去などの安全性を評価した.
Shehabi Y, Bellomo R, Reade MC, et al. Early goal-directed sedation versus standard sedation in
mechanically ventilated critically ill patients: a pilot study. Crit Care Med. 2013 Aug;41(8):1983-91.
主な結果
• 最初48時間以内の浅い鎮静の時間: 増加（66% vs. 38%, p=0.01）.
• せん妄なしの日数: 差はなかった（58% vs. 47%, p=0.27）.
• 身体拘束: 有意に少なかった（5% vs. 31%, p=0.03）.
• 血管収縮薬の使用や自己抜管, ICU滞在日数などは差がなかった.
!
患者のケアへの協力はプロポフォールやミダゾラムと比べ,
デクスメデトミジンで良かった.
Jakob SM, Ruokonen E, Grounds RM, wt al. Dexmedetomidine vs midazolam or propofol for sedation during
prolonged mechanical ventilation: two randomized controlled trials. JAMA. 2012 Mar 21;307(11):1151-60.
9. 鎮静薬の選択
• ベンゾジアゼピン（ミダゾラム）を避ける.
!
• デクスメデトミジン ≧ .
• デクスメデトミジンの方が, 浅い鎮静向きかもしれない.
せん妄の評価スケール
hypoactiveは見逃されやすい
• オランダの大学病院で, 3ヶ月間, 48時間以上ICU入室した患者（認知症や中枢
神経系の疾患がある場合は除外）. n=46（425 patients days）.
• スケールを用いずに, 看護師と医師の印象でせん妄かどうか1日1回質問した.
Spronk PE, Riekerk B, Hofhuis J, et al. Occurrence of delirium is severely
underestimated in the ICU during daily care. Intensive Care Med 2009; 35: 1276-80.
RASS -3 ∼ -1 0 ∼ +1 +2 ∼ +5
せん妄の印象 Yes No Yes No Yes No
看護師
CAM+ 21 28 9 29 1 1
CAM- 1 14 2 153 0 0
医師
CAM+ 14 35 9 29 2 0
CAM- 0 15 0 155 0 0
hypoactiveでは, CAM-ICU+でも半数以上がNoと回答.
CAM-ICU
Confusion Assessment Method for the Intensive Care Unit
• 日本語版のトレーニングマニュアルが簡単にダウンロードできる.
意識評価の 2 ステップ・アプローチ
ステップ 1：鎮静評価
The Richmond Agitation and Sedation Scale: The RASS
スコア 用 語 説 明
+4 好戦的な 明らかに好戦的な、暴力的な、スタッフに対す
る差し迫った危険
+3 非常に興奮した チューブ類またはカテーテル類を自己抜去；攻
撃的な
+2 興奮した 頻繁な非意図的な運動、人工呼吸器ファイティ
ング
+1 落ち着きのない 不安で絶えずそわそわしている、しかし動きは
攻撃的でも活発でもない
0 意識清明な
落ち着いている
-1 傾眠状態 完全に清明ではないが、呼びかけに 10 秒以上の
開眼及びアイ・コンタクトで応答する
-2 軽い鎮静状態 呼びかけに 10 秒以下のアイ・コンタクトで応答 呼びかけ
刺激
-3 中等度鎮静状態 呼びかけに動きまたは開眼で応答するがアイ・
コンタクトなし
-4 深い鎮静状態 呼びかけに無反応、しかし、身体刺激で動きま
たは開眼 身体刺激
-5 昏睡 呼びかけにも身体刺激にも無反応
もし RASS が-4 または-5 の場合、評価を中止し、後で再評価しなさい。
もし RASS が-4 より上（-3∼+4）の場合、ステップ 2 に進みなさい。）
*Sessler, et al. AJRCCM 2002; 166:1338-1344.
*Ely, et al. JAMA 2003; 289:2983-2991.
ステップ 2：せん妄評価
所見 1：精神状態変化の急性発症または変動性の経過
＋
所見 2：注意力欠如
＋
所見 3：無秩序な思考 または 所見 4：意識レベルの変化
＝せん妄
5
Ely EW, Inouye SK, Bernard GR, et al. Delirium in Mechanically Ventilated Patients Validity and Reliability of
the Confusion Assesment Method for the Intensive Care Unit（CAM-ICU）. JAMA 2001;286:2703-2710.
RASS -4 or -5ではせん妄評価できない.
10. ICDSC
Intensive Care Delirium Screening Checklist
• 各勤務帯（8時間のシフ
ト）や24時間で得られ
た情報をもとに, 点数を
つける.
• 4点以上をせん妄とする.
ICDSC（Intensive Care Delirium Screening Checklist）
このスケールはそれぞれ 8 時間のシフトすべて、あるいは 24 時間以内の情報に基づき完成され
る明らかな徴候がある＝ 1 ポイント：アセスメント不能、あるいは徴候がない＝ 0 ポイントで評
価する、それぞれの項目のスコアを対応する空欄に 0または 1 で入力する。
ICDSC（Intensive Care Delirium Screening Checklist）
このスケールはそれぞれ 8 時間のシフトすべて、あるいは 24 時間以内の情報に基づき完成され
る明らかな徴候がある＝ 1 ポイント：アセスメント不能、あるいは徴候がない＝ 0 ポイントで評
価する、それぞれの項目のスコアを対応する空欄に 0または 1 で入力する。
ICDSC（Intensive Care Delirium Screening Checklist）
このスケールはそれぞれ 8 時間のシフトすべて、あるいは 24 時間以内の情報に基づき完成され
る明らかな徴候がある＝ 1 ポイント：アセスメント不能、あるいは徴候がない＝ 0 ポイントで評
価する、それぞれの項目のスコアを対応する空欄に 0または 1 で入力する。
ICDSC（Intensive Care Delirium Screening Checklist）
このスケールはそれぞれ 8 時間のシフトすべて、あるいは 24 時間以内の情報に基づき完成され
る明らかな徴候がある＝ 1 ポイント：アセスメント不能、あるいは徴候がない＝ 0 ポイントで評
価する、それぞれの項目のスコアを対応する空欄に 0または 1 で入力する。
1．意識レベルの変化
（A）反応がないか、（B）何らかの反応を得るために強い刺激を必要とする場合は
評価を妨げる重篤な意識障害を示す。もしほとんどの時間（A）昏睡あるいは
（B）昏迷状態である場合、ダッシュ（−）を入力し、それ以上評価を行わない。
（C）傾眠あるいは、反応までに軽度ないし中等度の刺激が必要な場合は意識レベ
ルの変化を示し、1 点である。
（D）覚醒、あるいは容易に覚醒する睡眠状態は正常を意味し、0 点である。
（E）過覚醒は意識レベルの異常と捉え、1 点である。
2. 注意力欠如
会話の理解や指示に従うことが困難。外からの刺激で容易に注意がそらされる。話題
を変えることが困難。これらのうちいずれかがあれば 1 点。
3. 失見当識
時間、場所、人物の明らかな誤認、これらのうちいずれかがあれば 1 点。
4. 幻覚、妄想、精神障害
臨床症状として、幻覚あるいは幻覚から引き起こされていると思われる行動（例えば、
空を掴むような動作）が明らかにある、現実検討能力の総合的な悪化、これらのう
ちいずれかがあれば 1 点。
5. 精神運動的な興奮あるいは遅滞
患者自身あるいはスタッフへの危険を予測するために追加の鎮静薬あるいは身体抑
制が必要となるような過活動（例えば、静脈ラインを抜く、スタッフをたたく）、活動
の低下、あるいは臨床上明らかな精神運動遅滞（遅くなる）、これらのうちいずれ
かがあれば 1 点。
6. 不適切な会話あるいは情緒
不適切な、整理されていない、あるいは一貫性のない会話、出来事や状況にそぐ
わない感情の表出。これらのうちいずれかがあれば 1 点。
7. 睡眠／覚醒サイクルの障害
4 時間以下の睡眠。あるいは頻回な夜間覚醒（医療スタッフや大きな音で起きた場
合の覚醒を含まない）、ほとんど 1 日中眠っている、これらのうちいずれかがあれば
1 点。
8. 症状の変動
上記の徴候あるいは症状が 24 時間のなかで変化する（例えば、その勤務
帯から別の勤務帯で異なる）場合は 1 点。
合計点
1．意識レベルの変化
（A）反応がないか、（B）何らかの反応を得るために強い刺激を必要とする場合は
評価を妨げる重篤な意識障害を示す。もしほとんどの時間（A）昏睡あるいは
（B）昏迷状態である場合、ダッシュ（−）を入力し、それ以上評価を行わない。
（C）傾眠あるいは、反応までに軽度ないし中等度の刺激が必要な場合は意識レベ
ルの変化を示し、1 点である。
（D）覚醒、あるいは容易に覚醒する睡眠状態は正常を意味し、0 点である。
（E）過覚醒は意識レベルの異常と捉え、1 点である。
2. 注意力欠如
会話の理解や指示に従うことが困難。外からの刺激で容易に注意がそらされる。話題
を変えることが困難。これらのうちいずれかがあれば 1 点。
3. 失見当識
時間、場所、人物の明らかな誤認、これらのうちいずれかがあれば 1 点。
4. 幻覚、妄想、精神障害
臨床症状として、幻覚あるいは幻覚から引き起こされていると思われる行動（例えば、
空を掴むような動作）が明らかにある、現実検討能力の総合的な悪化、これらのう
ちいずれかがあれば 1 点。
5. 精神運動的な興奮あるいは遅滞
患者自身あるいはスタッフへの危険を予測するために追加の鎮静薬あるいは身体抑
制が必要となるような過活動（例えば、静脈ラインを抜く、スタッフをたたく）、活動
の低下、あるいは臨床上明らかな精神運動遅滞（遅くなる）、これらのうちいずれ
かがあれば 1 点。
6. 不適切な会話あるいは情緒
不適切な、整理されていない、あるいは一貫性のない会話、出来事や状況にそぐ
わない感情の表出。これらのうちいずれかがあれば 1 点。
7. 睡眠／覚醒サイクルの障害
4 時間以下の睡眠。あるいは頻回な夜間覚醒（医療スタッフや大きな音で起きた場
合の覚醒を含まない）、ほとんど 1 日中眠っている、これらのうちいずれかがあれば
1 点。
8. 症状の変動
上記の徴候あるいは症状が 24 時間のなかで変化する（例えば、その勤務
帯から別の勤務帯で異なる）場合は 1 点。
合計点
1．意識レベルの変化
（A）反応がないか、（B）何らかの反応を得るために強い刺激を必要とする場合は
評価を妨げる重篤な意識障害を示す。もしほとんどの時間（A）昏睡あるいは
（B）昏迷状態である場合、ダッシュ（−）を入力し、それ以上評価を行わない。
（C）傾眠あるいは、反応までに軽度ないし中等度の刺激が必要な場合は意識レベ
ルの変化を示し、1 点である。
（D）覚醒、あるいは容易に覚醒する睡眠状態は正常を意味し、0 点である。
（E）過覚醒は意識レベルの異常と捉え、1 点である。
2. 注意力欠如
会話の理解や指示に従うことが困難。外からの刺激で容易に注意がそらされる。話題
を変えることが困難。これらのうちいずれかがあれば 1 点。
3. 失見当識
時間、場所、人物の明らかな誤認、これらのうちいずれかがあれば 1 点。
4. 幻覚、妄想、精神障害
臨床症状として、幻覚あるいは幻覚から引き起こされていると思われる行動（例えば、
空を掴むような動作）が明らかにある、現実検討能力の総合的な悪化、これらのう
ちいずれかがあれば 1 点。
5. 精神運動的な興奮あるいは遅滞
患者自身あるいはスタッフへの危険を予測するために追加の鎮静薬あるいは身体抑
制が必要となるような過活動（例えば、静脈ラインを抜く、スタッフをたたく）、活動
の低下、あるいは臨床上明らかな精神運動遅滞（遅くなる）、これらのうちいずれ
かがあれば 1 点。
6. 不適切な会話あるいは情緒
不適切な、整理されていない、あるいは一貫性のない会話、出来事や状況にそぐ
わない感情の表出。これらのうちいずれかがあれば 1 点。
7. 睡眠／覚醒サイクルの障害
4 時間以下の睡眠。あるいは頻回な夜間覚醒（医療スタッフや大きな音で起きた場
合の覚醒を含まない）、ほとんど 1 日中眠っている、これらのうちいずれかがあれば
1 点。
8. 症状の変動
上記の徴候あるいは症状が 24 時間のなかで変化する（例えば、その勤務
帯から別の勤務帯で異なる）場合は 1 点。
合計点
1．意識レベルの変化
（A）反応がないか、（B）何らかの反応を得るために強い刺激を必要とする場合は
評価を妨げる重篤な意識障害を示す。もしほとんどの時間（A）昏睡あるいは
（B）昏迷状態である場合、ダッシュ（−）を入力し、それ以上評価を行わない。
（C）傾眠あるいは、反応までに軽度ないし中等度の刺激が必要な場合は意識レベ
ルの変化を示し、1 点である。
（D）覚醒、あるいは容易に覚醒する睡眠状態は正常を意味し、0 点である。
（E）過覚醒は意識レベルの異常と捉え、1 点である。
2. 注意力欠如
会話の理解や指示に従うことが困難。外からの刺激で容易に注意がそらされる。話題
を変えることが困難。これらのうちいずれかがあれば 1 点。
3. 失見当識
時間、場所、人物の明らかな誤認、これらのうちいずれかがあれば 1 点。
4. 幻覚、妄想、精神障害
臨床症状として、幻覚あるいは幻覚から引き起こされていると思われる行動（例えば、
空を掴むような動作）が明らかにある、現実検討能力の総合的な悪化、これらのう
ちいずれかがあれば 1 点。
5. 精神運動的な興奮あるいは遅滞
患者自身あるいはスタッフへの危険を予測するために追加の鎮静薬あるいは身体抑
制が必要となるような過活動（例えば、静脈ラインを抜く、スタッフをたたく）、活動
の低下、あるいは臨床上明らかな精神運動遅滞（遅くなる）、これらのうちいずれ
かがあれば 1 点。
6. 不適切な会話あるいは情緒
不適切な、整理されていない、あるいは一貫性のない会話、出来事や状況にそぐ
わない感情の表出。これらのうちいずれかがあれば 1 点。
7. 睡眠／覚醒サイクルの障害
4 時間以下の睡眠。あるいは頻回な夜間覚醒（医療スタッフや大きな音で起きた場
合の覚醒を含まない）、ほとんど 1 日中眠っている、これらのうちいずれかがあれば
1 点。
8. 症状の変動
上記の徴候あるいは症状が 24 時間のなかで変化する（例えば、その勤務
帯から別の勤務帯で異なる）場合は 1 点。
合計点
〈看護ワンテーマ BOOK〉せん妄であわてない 医学書院
〈看護ワンテーマ BOOK〉せん妄であわてない 医学書院
〈看護ワンテーマ BOOK〉せん妄であわてない 医学書院
〈看護ワンテーマ BOOK〉せん妄であわてない 医学書院
質問項目に対して「0 点」または「1 点」の点数をつけて、その合計点が 4 点以上の場合、せん妄と評価する。
Bergeron N, Dubois MJ, Dumont M, et al.: Intensive Care Delirium Screening checklist :
evaluation of a newscreenig tool. Intensive Care Med 今 ; 27 : 859 - 864,2001. Dr. Nicolas Bergeron の許可を得て逆翻訳法を使用し翻訳．
翻訳と評価：卯野木 健（筑波大学附属病院），水谷太郎（筑波大学 医学医療系 救急・集中治療部），櫻本秀明（筑波大学附属病院）
質問項目に対して「0 点」または「1 点」の点数をつけて、その合計点が 4 点以上の場合、せん妄と評価する。
Bergeron N, Dubois MJ, Dumont M, et al.: Intensive Care Delirium Screening checklist :
evaluation of a newscreenig tool. Intensive Care Med 今 ; 27 : 859 - 864,2001. Dr. Nicolas Bergeron の許可を得て逆翻訳法を使用し翻訳．
翻訳と評価：卯野木 健（筑波大学附属病院），水谷太郎（筑波大学 医学医療系 救急・集中治療部），櫻本秀明（筑波大学附属病院）
質問項目に対して「0 点」または「1 点」の点数をつけて、その合計点が 4 点以上の場合、せん妄と評価する。
Bergeron N, Dubois MJ, Dumont M, et al.: Intensive Care Delirium Screening checklist :
evaluation of a newscreenig tool. Intensive Care Med 今 ; 27 : 859 - 864,2001. Dr. Nicolas Bergeron の許可を得て逆翻訳法を使用し翻訳．
翻訳と評価：卯野木 健（筑波大学附属病院），水谷太郎（筑波大学 医学医療系 救急・集中治療部），櫻本秀明（筑波大学附属病院）
質問項目に対して「0 点」または「1 点」の点数をつけて、その合計点が 4 点以上の場合、せん妄と評価する。
Bergeron N, Dubois MJ, Dumont M, et al.: Intensive Care Delirium Screening checklist :
evaluation of a newscreenig tool. Intensive Care Med 今 ; 27 : 859 - 864,2001. Dr. Nicolas Bergeron の許可を得て逆翻訳法を使用し翻訳．
翻訳と評価：卯野木 健（筑波大学附属病院），水谷太郎（筑波大学 医学医療系 救急・集中治療部），櫻本秀明（筑波大学附属病院）
Bergeron N, Dubois MJ, Dumont M, et al. Intensive Care
Delirium Screening Checklist: evaluation of a new screening
tool. Intensive Care Med 2001 May;27(5):859-64.
CAM-ICU vs. ICDSC
• CAM-ICU
• その時点で「今, せん妄かどうか」の評価ができる.
• 陽性 or 陰性の判断で, 程度（重症度）が分からない.
• 評価のため, 患者さんに質問する必要がある.
• ICDSC
• 今ではなく, 勤務帯や1日を振り返って, 過去のせん妄評価をする.
• 点数化（8点満点）されており, せん妄ありなしに関わらず, 程度の違いを評価できる.
• 必ずしも患者さんに介入を必要とせず, 観察することで評価が可能.
CAM-ICU: 感度 80.0%（77.1-82.6%）, 特異度 95.9%（94.8-96.8%）.
ICDSC: 感度 74.0%（65.3-81.5%）, 特異度 81.9%（76.7-86.4%）.
Gusmao-Flores D, Salluh JI, Chalhub RA, et al. The Confusion Assessment Method for the Intensive
Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) for the diagnosis of
delirium: a systematic review and meta-analysis of clinical studies. Crit Care. 2012 Jul 3;16(4):R115.
CAM-ICU vs. ICDSC
• 2008年3月から11月まで, 外科系
ICUに入室（ブラジルの大学病院）,
RASS -3から2までの患者.
• CAM-ICU, ICDSCの両方を用いて
評価した.
Tomasi CD, Grandi C, Salluh J, et al. Comparison of CAM-ICU and ICDSC for the detection of delirium
in critically ill patients focusing on relevant clinical outcomes. J Crit Care 2012 Apr;27(2):212-7.
cycle disturbance, symptom fluctuation) can be evaluated in
the course of daily routine by nurses. Thus, while the patients
are involved actively on the CAM-ICU, they are indirectly
involved on the ICDSC [16,18,19].
To date, few studies have compared the performance of
different tools used for the diagnosis of delirium in the ICU
setting [18,19]. However, to the best of our knowledge, this
is the first study comparing the ability of CAM-ICU and
ICDSC to predict clinical relevant outcomes in ICU patients.
Recently, the CAM-ICU and the ICDSC were
compared in 174 surgical ICU patients, and a κ value
of .80 was reported [19]. This was superior as compared
with the findings of the present study (κ = .55). This
difference raises the possibility that these tools performed
differently between surgical and general ICU patients, but
our study was not designed to address this question.
When we analyzed surgical patients separately, we found
a κ value of .79. In the study by van Eijk et al [18], the
CAM-ICU presented a higher sensitivity as compared with
the ICDSC (64% vs 43%) but a lower specificity (88% vs
95%), and this is quite different to the studies that
validate both scales.
In the present cohort, 26.5% of the patients had a
diagnosis of delirium when assessed by the CAM-ICU and
34.6% as confirmed by the ICDSC. In addition, 32.7% of
studied patients presented subsyndromal delirium detected
by the ICDSC. As expected, patients with delirium as
diagnosed by any of the tools were older, more severely ill,
used more sedation and needed further physical restrain, had
longer hospital stay, and increased mortality rates, and this is
in accordance with previous results [21]. The major new
finding of our study is that the delirium diagnosis using
CAM-ICU was predicted more accurately in individuals with
higher mortality rates as compared with ICDSC diagnosis.
Additionally, patients with positive ICDSC but negative
CAM-ICU (Table 5) had mortality rates and LOS compa-
rable with those patients without delirium (negative CAM-
ICU and ICDSC), suggesting that a diagnosis of delirium by
the ICDSC with a negative CAM-ICU does not seem to be
associated with worse outcomes. We can hypothesize that
delirium was not present in these patients since we did not
use the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV) as criterion standard
for the diagnosis of delirium, or despite a correct diagnosis,
these patients presented some particular characteristic such
as disorientation or sleep disorders that may not be associated
to higher mortality.
Our study has some important limitations that should be
mentioned. First, it is a single-center study and relatively low
delirium rates were observed. Therefore, these results must
be confirmed by multicenter studies including larger
populations. In addition, we could not determine the impact
of our findings on long-term outcomes as patients were not
followed beyond hospital discharge. Second, our study was
performed by CAM-ICU and ICDSC scores only; we did not
use a criterion standard, like DSM-IV. However, others
studies had performed without a criterion standard [18,19].
Finally, our study excluded patients whose RASS scores
were −4 and −5 for 3 days to control for possible outcomes
bias, as our research is focused into patients' outcomes.
Excluding these patients, there was also possibly a decreased
incidence of delirium in this specific study.
In conclusion, we demonstrated that delirium patients
diagnosed by CAM-ICU or ICDSC presented similar
clinical profile, but outcomes in patients diagnosed only
by ICDSC were comparable with nondelirium patients. The
findings of our study suggest that CAM-ICU is a better
predictor of outcome.
Fig. 2 Kaplan-Meier survival curves in CAM-ICU and ICDSC
delirium patients.
Table 5 Clinical Outcomes of Delirium Status for ICDSC positive scores in comparison with CAM-ICU scores
ICDSC positive ICDSC negative P
CAM-ICU positive CAM-ICU Negative CAM-ICU negative
Length of hospital stay (d), mean (SD) 15.1 (9.1)⁎ 10.9 (5.9) 9.3 (5.7) 0.04
Hospital mortality, n (%) 8 (80%)⁎ 2 (20%) 6 (5.5) 0.002
Clinical outcomes were analyzed compared CAM-ICU and ICDSC scores.
216 C.D. Tomasi et al.
(unarousable) to +4 (combative). Vital status at ICU,
hospital discharge, and 90 days after internation were
obtained in all patients. Patients with a length of hospital
stay longer than 90 days were censored at this moment.
2.3. Statistical analyses
Standard descriptive statistics were calculated to examine
baseline characteristics of the study population. Continuous
variables with normal distribution were presented as mean ±
SD and compared by Student t test or ANOVA followed by
Bonferroni post hoc analysis, as appropriate. Continuous
variables with a nonnormal distribution were reported as
median (25%-75% interquartile range) and compared using
Mann-Whitney U test or Kruskal-Wallis test, as appropriate.
Categorical variables were presented as absolute numbers
(frequency percentages) and analyzed by χ2 test or Fisher
exact test (with Yates correction where applicable). The
diagnostic value of the CAM-ICU and ICDSC were
described using 2 × 2 tables. The κ coefficient was calculated
Fig. 1 Flowchart of patients in study.
Table 2 Comparison of CAM-ICU and ICDSC for delirium
diagnosis (n = 162)
ICDSC
(n)
CAM-ICU (n)
Negative Positive Total
Negative 105 1 106 (67.3)
Positive 14 42 56 (34.6)
Total 119 (71.6) 43 (26.5) 162 (100)
Data are n (%), P b .01.
214 C.D. Tomasi et al.
CAM-ICU（-）, ICDSC（+）のせん妄患者は,
せん妄なしと比べ, 予後に有意な差はなかった.
せん妄評価の現状
• ICDSCでは後ろ向き, 活動型の症状もcheckできる.
• CAM-ICUではその時点でのせん妄を評価することが出来るが,
「注意力欠如」に重点がおかれている.
• hypoactiveな方が頻度が多く, 予後に関係すると思われる.
• hypoactiveのせん妄の方が見逃しやすく, なんらかのスケール
が必要である.
• せん妄を見つけたら, 続かないように, 悪化しないように.
11. せん妄管理のポイント
• せん妄の予防.
• せん妄の早期発見.
• risk factorを把握.
• モニタリングをする.
• 早期介入.
せん妄のリスク
Page 4 of 12
(page number not for citation purposes)
In the domain of the acute illness, factors were studied relating
to the current diagnosis or treatment. All patients could be
classified as either a surgical or an internal medicine patient.
As patients were included at the time they scored a Glasgow
Coma Scale of 10 or more, the length of stay in the intensive
1.6 to 5.4) describe
tance of psychoact
the use of morphine
studies. A risk of mo
ogy Score (SAPS II)
Health Evaluation (A
versity hospital and
were transformed in
tality' indicating an A
of at least 40. The
28 (TISS 28) was
[19]. A cut-off value
workload of 318 min
Factors from the fou
or the interaction b
Admission characte
presence of a visibl
e.g. an open space
were scored at all lo
of physical restraint
Statistical approa
Continuous or cate
with a binary score.
Figure 1
Four domains of risk factors for intensive care deliriumFour domains of risk factors for intensive care delirium. TISS 28 = The
Therapeutic Intervention Scoring System-28.
変更できない
変更できる
患者背景・性格 慢性疾患
年齢, 男性
飲酒, 喫煙
独居
心不全, 肺疾患
認知症
環境要因 急性疾患
救急入院, 転床
個室, 時計なし
日光が見えない
面会できない, 身体拘束
open ICU
長期入室, 発熱, 重症度, 内科疾患
点滴の種類・数, 経口摂取不可
ベンゾジアゼピン（鎮静）, 麻薬
チューブ, カテーテル
Van Rompaey B, Elseviers MM, Schuurmans MJ, et al. Risk factors for delirium in
intensive care patients: a prospective cohort study. Crit Care 2009;13(3):R77.
せん妄予防
•早期離床はせん妄を減らす（+1B）.
•薬物療法は十分な根拠はなく, 推奨しない（0, C）.
• 定型および非定型の抗精神病薬の投与は推奨しない（-2C）.
• デクスメデトミジンについてもデータはなく推奨しない（0, C）.
とにかく離床・予防, 根拠のある薬剤はない.
Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation,
and delirium in adult patients in the intensive care unit. Crit Care Med. 2013 Jan;41(1):263-306.
せん妄予防について
• 鎮痛・鎮静プロトコール
• 消化管 / 膀胱機能の評価
•早期離床
• 栄養過剰, 不足
• 脱水
• 視覚・聴覚（眼鏡・補聴器）
• 合併症の予防・治療
• 睡眠促進
• スタッフの教育
• 酸素の供給
• 認知機能・見当識の維持
• 使用薬物
Reston JT, Schoelles KM. In-facility delirium prevention programs as a patient safety
strategy: a systematic review. Ann Intern Med. 2013 Mar 5;158(5 Pt 2):375-80.
12. 家族も含めた介入
• 2009年11月から1010年7月まで, チリの急性期病院に入院した内科疾
患で, せん妄のハイリスク患者（年齢 >70, 認知症の既往, アルコール,
電解質異常など）.
• 除外: 入院時にすでにせん妄.
• 家族の非薬物的介入（n=143） vs. 従来の標準的管理（n=144）.
• 家族へ10分程度の簡単な説明, 時計とカレンダーを設置, 必要なら眼
鏡や補聴器, クッション・写真など家族のものを置く, 家族からオリ
エンテーション, 5時間以上の面会.
• Primary outcome: 入院中のせん妄の発生.
Martinez FT, Tobar C, Beddings CI, et al. Preventing delirium in an acute hospital
using a non-pharmacological intervention. Age Ageing. 2012 Sep;41(5):629-34.
せん妄が減少
介入群 5.6% vs. 標準的管理群 13.3%, RR 0.41; 95%CI; p=0.027
outcome, given that the sample size was not conceived to
detect differences in a complication considerably less fre-
quent than delirium. Further studies should be done on the
potential association between reduction in falls and imple-
mented multicomponent interventions, because this is also a
highly relevant complication to the hospitalised patient.
The strengths of this study include: daily assessment of
There are some limitations that must be considered.
Although this is a randomised controlled trial, family
members of the patients in the control group were allowed
to implement certain measures that could influence delir-
ium development (daily visits, provision of orientation
objects, sensory support equipment, etc.). The incidence of
delirium was lower than expected, a fact that is most likely
related to this phenomenon. This could have made our
statistical power insufficient to detect differences between
groups, but the protective effects of the intervention
remained significant. It should also be considered that the
generation of randomisation sequences by means other
than patient inclusion, such as ward location or room
number, would have been an inappropriate way to achieve
true random allocation.
Simple data masking was another major limitation. The
event adjudicants were aware of treatment assignment,
which has obvious implications when analysing conclusions.
Nevertheless, masking adjudicants would have meant
moving patients out of the multicomponent intervention
place, which in turn would have interfered with the appro-
priate interpretation of the study outcomes.
Another factor to be considered is the small number of
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Table 2. Study outcomes
Outcome Control
group
(n = 143)
Intervention
group
(n = 144)
P-value
Incident delirium, no. (%) 19 (13.3) 8 (5.6) 0.027
Mixed delirium, no. (%) 9 (6.3) 2 (1.4)
Hypoactive delirium no. (%) 8 (5.6) 2 (1.4)
Hyperactive delirium, no. (%) 2 (1.4) 4 (2.8)
Median delirium duration (days) (IQR) 3 (1–5) 2 (1–2) 0.37
Falls, no. (%) 4 (2.8) 0 (0) 0.06
Median hospital stay (days) (IQR) 9 (5–12) 9 (6–13) 0.36
Figure 2. Time-to-event curves of the studied patients.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Table 1. Baseline characteristics of the patients
Characteristic Control
group
(n = 143)
Intervention
group
(n = 144)
P-value
Mean age (years) (SD) 78.3 ± 6.1 78.1 ± 6.3 0.74
Male gender, no. (%) 96 (67) 84 (58) 0.16
Barthel index, median (IQR) 95 (85–100) 95 (85–100) 0.88
Comorbiditiesa
Charlson comorbidity index,
median (IQR)
2 (1–3) 2 (1–4) 0.45
Cancer, no. (%) 28 (19.6) 23 (15.9) 0.44
Metastatic Cancer, no. (%) 6 (4.2) 3 (2.1) 0.33
Heart failure, no. (%) 29 (27.3) 44 (30.6) 0.60
Chronic obstructive pulmonary
disease, no. (%)
28 (19.6) 34 (23.6) 0.47
Chronic kidney disease, no. (%) 22 (15.4) 18 (12.5) 0.42
Acute myocardial infarction, no.
(%)
11 (7.7) 15 (10.4) 0.41
Mild cognitive impairment, no. (%) 14 (9.8) 9 (6.3) 0.28
Dementia, no. (%) 8 (5.6) 9 (6.3) 1
Diabetes mellitus with end-organ
damage, no. (%)
11 (7.6) 13 (9) 0.83
Peripheral vascular disease, no. (%) 7 (4.9) 11 (7.6) 0.34
Previous delirium, no. (%) 3 (2.1) 8 (5.5) 0.22
Mild liver disease, no. (%) 6 (4.2) 4 (2.8) 0.54
Severe liver disease, no. (%) 2 (1.4) 3 (2.1) 1
Mesenchymopathies, no. (%) 3 (2.1) 7 (4.9) 0.34
Peptic ulcer disease, no. (%) 2 (1.4) 8 (5.5) 0.10
Lymphoma, no. (%) 1 (0.7) 1 (0.7) 1
Leukaemia, no. (%) 0 (0) 1 (0.7) 0.5
Hemiplegia, no. (%) 0 (0) 0 (0) –
Acquired immunodeficiency
syndrome, no. (%)
0 (0) 0 (0) –
Laboratory
Serum sodium (mEq/l) (SD) 136 ± 5 137 ± 4 0.34
Hyponatremia, no. (%) 29 (20.3) 26 (18) 0.64
Serum potassium (mEq/l) (SD) 4.2 ± 0.7 4.2 ± 0.6 0.95
Serum creatinine (mEq/l) (SD) 1.4 ± 1.1 1.3 ± 1 0.42
Uremia (mg/dl) (SD) 52 ± 38 48 ± 42 0.45
Haemoglobin (g/dl) (SD) 12 ± 2.2 12.1 ± 0.7 0.61
C reactive protein (mg/l) (SD) 11.7 ± 19.8 15.9 ± 30.7 0.22
White cell count (cells/mm3
) 9.580 ± 4.570 9.820 ± 4.185 0.67
Medications
Patients started on risky
medications, no. (%)
7 (4.9) 8 (5.5) 0.80
Benzodiazepines, no. (%) 4 (2.8) 5 (3.5) 0.75
Antihistamines, no. (%) 0 (0) 2 (1.4) 0.25
Anticholinergics, no. (%) 2 (1.4) 1 (0.7) 1
Opioids, no. (%) 1 (0.7) 0 (0) 1
SD, standard deviation.
a
As defined in the Charlson comorbidity index.
Preventing delirium in an acute hospital
atkouseiren-hiroshima-sohgoh-byoinonMarch16,2014http://ageing.oxfordjournals.org/Downloadedfrom
ARDSから回復した後… ARDSになった後…
• 大学の関連病院, トロント, 1998年3月から2002年3月まで.
• 対象:
• 16歳以上, 少なくともPEEP ≧5cmH2OでP/F ≦200.
• 195人がTrialに登録され, 生存した117人（60%）がFollow upされた.
• 除外:
• ICU入室前に独立した機能なし, 肺切除後, 神経疾患・精神疾患がある.
• ICU退室後, 3・6・12ヶ月後に外来で評価を行った.
• 呼吸機能, 身体機能, 復職など.
Herridge MS, Cheung AM, Tansey CM, et al. One-year outcomes in survivors of the
acute respiratory distress syndrome. N Engl J Med. 2003 Feb 20;348(8):683-93.
13. ARDS 1年後
• 半年後には, 肺活量や1秒率などは正常化.
• 1年後では...
• 酸素投与が必要な患者はいなかったが, 軽度の拡散能障害は残存して
おり, 6%の患者が労作時にSpO2 <88%になった.
• 胸部単純X線写真は, 80%で正常化, 20%で軽度な陰影が残存.
• 6分間歩行やSF-36の全項目の評価で, 同年代の予測値を下回った.
• 49%の患者が働いており, その8割がもとの仕事に復帰できていた.
Herridge MS, Cheung AM, Tansey CM, et al. One-year outcomes in survivors of the
acute respiratory distress syndrome. N Engl J Med. 2003 Feb 20;348(8):683-93.
その後はどうなる??
ARDS 5年後
• 109人中, 9人が死亡, 36人がフォローアップできず.
•呼吸機能は正常もしくは正常に近い状態に.
• 患者の25%で施行されたCTでは, ほとんどで軽度の線維化
が見られた.
• 6分間歩行やSF-36の評価では, 同年代の予測値を下回った.
•51%が身体機能からの抑うつや不安があった.
•77%が復職（そのうち94%がもとの職業）.
Herridge MS, Tansey CM, Matté A, et al. Functional disability 5 years after acute
respiratory distress syndrome. N Engl J Med. 2011 Apr 7;364(14):1293-304.
5年間で...
• 肺の画像所見は軽度異常が残存するが, 呼吸機能は,
正常もしくはほぼ正常まで改善.
•身体機能の改善は不十分で, 5年後では77%で復職.
• そのうちわけは, 外勤 77%, 復学 6%, 非常勤の女性 17%.
• 医療費は年間50-60万円, 再入院はのICU入室中の
合併症や疾患によって増加した.
Herridge MS, Tansey CM, Matté A, et al. Functional disability 5 years after acute
respiratory distress syndrome. N Engl J Med. 2011 Apr 7;364(14):1293-304.
14. うつ症状と身体機能障害の累積発生率
between depressive symptoms at last follow-up and incident im-
paired physical function, we repeated the prior analyses to eval-
uate if depressive symptoms at last follow-up were only associated
with individual nonphysical incident IADL dependencies. The
number of patients with incident IADL dependencies/number
at risk were: using the telephone, 34/175; shopping, 80/133; pre-
paring food, 57/132; housekeeping, 85/121; doing laundry, 67/136;
traveling, 73/143; taking medications, 48/159; and managing
Figure 2. Cumulative incidence of depressive
symptoms or impaired physical function in
the first 2 years after acute lung injury. During
2-year follow-up after acute lung injury, the
cumulative incidence of depressive symptoms
was 40%, and the cumulative incidence of im-
paired physical function was 66%. Incidence
was highest by the 3-month follow-up and de-
clined thereafter.
Figure 3. Recovery from incident depres-
sive symptoms or impaired physical func-
tion in the first 2 years after acute lung
injury. Thin lines and thick lines indicate
individual and mean trajectories, respec-
tively, for patients whose conditions
remitted (A and C) and did not remit
(B and D) during 2-year follow-up after
acute lung injury. Horizontal dashed lines
indicate thresholds for depressive symp-
toms (A and B) and impaired physical
function (C and D). HAD ¼ Hospital
Anxiety and Depression Scale; IADL ¼
instrumental activities of daily living.
520 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 185 2012
うつ症状 身体機能障害
Bienvenu OJ, Colantuoni E, Mendez-Tellez PA, et al. Depressive symptoms and impaired physical function
after acute lung injury: a 2-year longitudinal study. Am J Respir Crit Care Med. 2012 Mar 1;185(5):517-24.
ARDSでICUに入室したら…
• 筋力低下は急性期から始まる.
• 呼吸機能は結構回復する.
• 筋力低下は, ICU入室後も問題になっている.
• ADL, 雇用機会, うつ病, 医療費の増加など.
!
• せん妄になると, 死亡率が上昇し, 退室後も認知機能障
害につながる.
ICU退室
退院
抜管
何が出来るか??
15. 筋力低下
• ICU-Acquired Weakness（ICU-AW）
• 他に原因がなく, 重症患者に起こる神経障害・筋障害のこと.
• 急性期の診断は困難であり, 多くは人工呼吸器からの離脱困難で発見される.
• Schweickert WD, Hall J.ICU-acquired weakness.Chest. 2007 May;131(5):1541-9.
• 頻度やリスクファクター:
• 7日間以上の人工呼吸管理を受けた患者の33%にみられ, 人工呼吸器離脱の
遅れに繋がった.
• De Jonghe B, Bastuji-Garin S, Sharshar T, et al. Does ICU-acquired paresis lengthen weaning from mechanical ventilation?
Intensive Care Med. 2004 Jun;30(6):1117-21.
• 高齢, 高い重症度や高血糖などの全身状態, 筋弛緩薬やステロイド, アミノグ
リコシド系抗菌薬の使用などがリスクになる.
ICU-AWの診断基準
1. 重症疾患罹患後に, 進行性の全身の脱力.
2. 脱力はびまん性（遠位筋・近位筋とも）, 両側性, 弛緩性で, 一般的に
脳神経障害は合併しない.
3. 24時間以上間隔を空けた2回以上の検査でMRC合計スコアが48未満,
もしくは検査可能な全ての筋群の平均MRCスコアが4未満.
4. 人工呼吸に依存した状態.
5. 筋力低下について, 他の原因が排除できている.
* 少なくとも, 1, 2, 3 or 4, 5を満たす.
Stevens RD, Marshall SA, Cornblath DR, et al. A framework for diagnosing and classifying
intensive care unit-acquired weakness. Crit Care Med. 2009 Oct;37(10 Suppl):S299-308.
用語について
• ICU-AW: Intensive Care Unit-Acquired Weakness
• ICUでおこった筋力低下.
!
• CIP: Critical illness polyneuropathy →神経障害
• CIM: Critical illness myopathy →筋障害
• CINM: Critical illness neuromyopathy →CIP + CIM
いつから始まるの?
• 健康なボランティアを安静臥床させたところ, 4時間で
筋萎縮が始まった.
• Kasper CE, Talbot LA, Gaines JM. Skeletal muscle damage and recovery. AACN Clin Issues 2002;13(2):237-247.
• 7人の健康な男性を, 6週間の安静臥床した後の筋力に
ついて調査していったところ, 1週間毎に4-5%程度の
筋力低下を認めた.
• Berg HE, Larsson L, Tesch PA. Lower limb skeletal muscle function after 6 wk of bed rest. J Appl Physiol 1997;82(1):
182-188.
結構早く始まり, 放っておくと, どんどん進む.
