title: The confusion assessment method for the intensive care unit in patients with cirrhosis.
abstract: In the intensive care unit (ICU), delirium is routinely measured with the widely-used, validated Confusion Assessment Method for the ICU (CAM-ICU), but CAM-ICU has not been studied in patients with cirrhosis. We studied a group of patients with cirrhosis to determine the relationship between delirium measured by CAM-ICU and clinical outcomes. Consecutive patients with cirrhosis admitted to the ICU from 2009 to 2012 were included in a retrospective cohort study. Patients were screened twice daily for coma and delirium during their ICU stay using the Richmond Agitation Sedation Scale (RASS) and CAM-ICU. The association between delirium/coma and mortality was determined using multiple logistic regression. RASS and CAM-ICU were also compared to a retrospective assessment of hepatic encephalopathy (HE). Of 91 patients with cirrhosis, 26 (28.6 %) developed delirium/coma. RASS/CAM-ICU had fair agreement with the HE assessment (κ 0.38). Patients with delirium/coma had numerically greater mortality in-hospital (23.1 vs. 7.7 %, p = 0.07) and at 90 days (30.8 vs. 18.5 %, p = 0.26), and they also had longer hospital length of stay (median 19.5 vs. 6 days, p < 0.001). Delirium/coma was associated with increased inpatient mortality, independent of disease severity (unadjusted OR 3.6; 95 % CI, 0.99-13.1; MELD-adjusted OR 5.4; 95 % CI, 1.3-23.8; acute physiology score-adjusted OR 2.2; 95 % CI, 0.53-8.9). Delirium/coma was also associated with longer length of stay after adjusting for disease severity. In critically ill patients with cirrhosis, delirium/coma as measured by the RASS and CAM-ICU is associated with increased mortality and hospital length of stay. For these patients, these measures provide valuable information and may be useful tools for clinical care. RASS and CAM-ICU need to be compared to HE-specific measures in future studies.
authors.affiliation: Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle Suite 225, Indianapolis, IN, 46202, USA, esorman@iu.edu.
authors.forename: Eric S
authors.initials: ES
authors.lastname: Orman
authors.forename: Anthony
authors.initials: A
authors.lastname: Perkins
authors.forename: Marwan
authors.initials: M
authors.lastname: Ghabril
authors.forename: Babar A
authors.initials: BA
authors.lastname: Khan
authors.forename: Naga
authors.initials: N
authors.lastname: Chalasani
authors.forename: Malaz A
authors.initials: MA
authors.lastname: Boustani
mesh_terms: D000368:Aged; D015331:Cohort Studies; D003221:Confusion / Q000175:diagnosis* / Q000401:mortality / Q000523:psychology*; D016638:Critical Illness / Q000401:mortality / Q000523:psychology*; D005260:Female; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007362:Intensive Care Units / Q000639:trends*; D008103:Liver Cirrhosis / Q000175:diagnosis* / Q000401:mortality / Q000523:psychology*; D008297:Male; D008875:Middle Aged; D010343:Patient Admission / Q000639:trends; D012189:Retrospective Studies