Routine use of the confusion assessment method for the intensive care unit: a multicenter study.

RATIONALE: Delirium is often unrecognized in ICU patients and associated with poor outcome. Screening for ICU delirium is recommended by several medical organizations to improve early diagnosis and treatment. The Confusion Assessment Method for the ICU (CAM-ICU) has high sensitivity and specificity for delirium when administered by research nurses. However, test characteristics of the CAM-ICU as performed in routine practice are unclear. OBJECTIVES: To investigate the diagnostic value of the CAM-ICU in daily practice. METHODS: Teams of three delirium experts including psychiatrists, geriatricians, and neurologists visited 10 ICUs twice. Based on cognitive examination, inspection of medical files, and Diagnostic and Statistic Manual of Mental Disorders, 4th edition, Text Revision criteria for delirium, the expert teams classified patients as awake and not delirious, delirious, or comatose. This served as a gold standard to which the CAM-ICU as performed by the bedside ICU-nurses was compared. Assessors were unaware of each other's conclusions. MEASUREMENTS AND MAIN RESULTS: Fifteen delirium experts assessed 282 patients of whom 101 (36%) were comatose and excluded. In the remaining 181 (64%) patients, the CAM-ICU had a sensitivity of 47% (95% confidence interval [CI], 35%-58%); specificity of 98% (95% CI, 93%-100%); positive predictive value of 95% (95% CI, 80%-99%); and negative predictive value of 72% (95% CI, 64%-79%). The positive likelihood ratio was 24.7 (95% CI, 6.1-100) and the negative likelihood ratio was 0.5 (95% CI, 0.4-0.8). CONCLUSIONS: Specificity of the CAM-ICU as performed in routine practice seems to be high but sensitivity is low. This hampers early detection of delirium by the CAM-ICU.

Emergency endovascular repair of an aortoesophageal fistula caused by a foreign body.

PURPOSE: To report stent-graft treatment of an aortoesophageal fistula caused by a foreign body. CASE REPORT: A 32-year-old man was admitted with massive upper gastrointestinal bleeding 10 days after swallowing a fish bone. Computed tomography demonstrated a fistula from the proximal descending thoracic aorta to the mid esophagus. The bleeding was initially controlled by inflating a Sengstaken-Blakemore tube. A 28-mm x 16-cm Talent stent-graft was delivered transfemorally to repair the aortic defect; the esophageal injury was repaired primarily using a pedicled intercostal muscle flap via a right thoracotomy. Chest radiography at 12 months showed no migration of the stent-graft. Blood parameters of infection were normal; the patient remains well 18 months after stent-graft implantation. CONCLUSIONS: This case illustrates stent-graft treatment of a life-threatening hemorrhage from an aortoesophageal fistula.