意識混濁の評価法に関する臨床的研究（第2報）

A CLINICAL STUDY ON A SYSTEM OF ASSESSMENT OF IMPAIRED CONSCIOUSNESS (THE SECOND REPORT)

I．はじめに

　急性期脳障害の患者を管理していく上で，意識混濁程度の把握は極めて重要である。だが，実地臨床上使いやすく，しかも信頼のおける判定法についての報告は少ない。筆者らは前回，太田らにより提唱されている3-3−9度方式^7）と我々の最大刺激　最良反応方式^11）との対比検討を行ない，①3-3−9度方式の20-30-100のレベル間には有意の差を認め難く，これらを等間隔で同一スケール上に置くことは疑問である，②3-3−9度方式は睡眠という生理的現象を病的変化として把えてしまう危険性を含むことなどを指摘した^10）。今回は更に別の方法によつて，この両者につき二，三の検討を行ない，このような尺度を用いていく上での注意点についても考察した。

Comparative studies have been carried out be-tween Ohta's "3-3-9 formula"and our"best re-sponse to maximum stimuli scale". The latter consists of : 0=alert, 1=answering simple questions, 2=obeying simple commands, 3=localising move-ments of limbs on painful stimuli, 4=flexion of limbs on pain, 5=extension of limbs to pain, and 6=no response to pain.

Both scales were printed up and down in a chart. Singular or plural doctors and plural nurses were asked to examine the same patients one to two minutes apart, and mark on two different scales without talking to each other. Taking a judgement of the most senior doctor as standard, disagreement rate, expectation and its standard deviation, and coefficient of variation were calculated. The follow-ing conclusions were drawn from these data :

Disagreement rate was larger on 3-3-9 formula (40%) in contrast to 32% of the other. Disagree-ment rate of more than one level was about four times larger on 3-3-9 formula.

On "best response to maximum stimuli scale", it was proved that change of more than one level would actually mean some objective alteration oc-curring on the side of patients.

On "3-3-9 formula" on the other hand, apparent changes on the scale could hardly be attributed to any objective alteration of the patients. Ob-servors' error is so great and variable among dif-ferent levels that it is necessary to check the previ-ous level and change the judgement from time to time, in order to say it an objective change.

It is mandatory that this kind of formula should use clear and precise words in describing patients' response. The importance of standardizing the volume and quality of stimuli given by the ex-aminers was also stressed.