Intensive Care Med (2014) 40:137–138

DOI 10.1007/s00134-013-3120-8 CO RRESPONDENCE

Dimitri Gusmao-Flores the ICU for [48 h. We observed an profound sedation determines the
Juliana C. S. Martins overall prevalence of delirium of convergence of the findings using the
Daniele Amorin 34 % (37 patients). However, when various tools to diagnose delirium,
Lucas C. Quarantini only patients with RASS -2 (19 including the gold standard [Diag-
patients) were considered, the inci- nostic and Statistical Manual of
dence of delirium was 89.5 % (17 Mental Disorders (DSM) 4th edn].
Tools for diagnosing delirium patients). When the CAM-ICU was The opposite trend seem to be true.
performed in these patients the first The sensitivity of the CAM-ICU and
in the critically ill: is calibration time they evolved to RASS -1 or ICDSC, for example, in non-critically
needed for the less sedated higher, only six patients were asses- ill patients is\50 % [5] and therefore
patient? sed as being in delirium. Figure 1 not useful for diagnosis.
shows the 1,873 evaluations per- Hence, we agree with Haenggi
Received: 6 September 2013 formed during this period. The result et al. [1] that a delirium assessment of
Accepted: 17 September 2013 of applying the CAM-ICU was strat- patients receiving some form of
Published online: 3 October 2013 ified by the level of sedation; patients sedation (RASS -2 or deeper) will
Ó Springer-Verlag Berlin Heidelberg and
ESICM 2013 with RASS ?1 to ?4 were excluded likely not provide a proper measure-
from this analysis because they ment of delirium and that to insist on
accounted for only 1 % of all applying any of the current delirium
assessments. screening tools (CAM-ICU or IC-
We also observed that a higher DSC) or even the newest version of
Dear Editor, level of RASS is accompanied by a the DSM (5th edn) to this population
The recent study performed by Hae- lower frequency of delirium when the will almost always result in a diag-
nggi et al. [1] adds important evaluation is done with the CAM- nosis of delirium. However, we
information relating to the diagnosis ICU. This observation may explain question whether the frequency of
of delirium in critically ill patients: the lower frequency of delirium in delirium in less sedated patients is in
the effect of sedation. The authors non-sedated critically ill patients [2] fact lower or whether these tools have
suggest that the prevalence of delir- compared with those on mechanical a low sensitivity to detect delirium in
ium as assessed using the Confusion ventilation and thus under the influ- this population? We believe that the
Assessment Method for the ICU ence of some kind of sedative [3]. current tools, especially CAM-ICU
(CAM-ICU) and the Intensive Care Despite the validation of the CAM- and ICDSC, require better calibration
Delirium Screening Checklist (IC- ICU and ICDSC in several languages to properly evaluate patients under
DSC) depends on the level of for their good performance in terms light sedation (RASS [ -1).
consciousness of the patient at the of diagnosis, in the recent meta-ana-
time of evaluation. These authors lysis conducted by our group we Conflicts of interest On behalf of all
found that the proportion of CAM- observed that the lower the RASS, the authors, the corresponding author states that
there is no conflict of interest.
ICU- and ICDSC-positive evaluations higher the sensitivity of the CAM-
decreased significantly if assessments ICU [4]. It would appear that more
from patients at Richmond Agitation
Sedation Scale (RASS) -2/-3 were
excluded.
Interestingly, these findings are in
line with what we observe at our
medical institution. In our ICU,
delirium assessments are performed
twice daily using the CAM-ICU.
However, we do not evaluate patients
at RASS -3 because we believe it is
not possible to obtain a reliable result
in this group of patients using any of
the validated diagnostic tools. This
year, we have evaluated 108 consec- Fig. 1 Frequency of diagnosis of delirium among 1,873 evaluations, stratified by the
utive patients admitted to our hospital Richmond Agitation Sedation Scale (RASS), determined with the Confusion Assessment
who were predicted to be admitted to Method for the ICU (CAM-ICU)
138
References
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(2007) Delirium assessment in the
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Chalhub RA et al (2012) The confusion
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(2011) Evaluation of two intensive care
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Psychosomatics 52:133–140
D. Gusmao-Flores
Intensive Care Unit, University Hospital
Prof. Edgard Santos, Universidade Federal
da Bahia, Salvador, BA, Brazil
D. Gusmao-Flores
Programa de Pós-graduação em Processos
Interativos dos Órgãos e Sistemas, Instituto
de Ciências da Saúde (ICS), Universidade
Federal da Bahia, Salvador, BA, Brazil
D. Gusmao-Flores ())
Rua Sabino Silva, 273, Ap. 801, Salvador,
BA 40155-250, Brazil
e-mail: dimitrigusmao@gmail.com
Tel.: ?55-71-99968535
J. C. S. Martins
D. Amorin
Faculty of Medicine, Universidade Federal
da Bahia, Salvador, BA, Brazil
L. C. Quarantini
Department of Psychiatry, University
Hospital Prof. Edgard Santos, Universidade
Federal da Bahia, Salvador, BA, Brazil
L. C. Quarantini
Programa de Pós-graduação em Medicina e
Saúde, Faculdade de Medicina da Bahia,
Universidade Federal da Bahia (UFBA),
Salvador, BA, Brazil