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Corticosteroids and Transition to Delirium in Patients With Acute Lung Injury*

Schreiber, Matthew P. MD, MHS1; Colantuoni, Elizabeth PhD2,3; Bienvenu, Oscar J. MD, PhD3,4; Neufeld, Karin J. MD, MPH3,4; Chen, Kuan-Fu MD, PhD5; Shanholtz, Carl MD6; Mendez-Tellez, Pedro A. MD3,7; Needham, Dale M. MD, PhD3,8,9

Critical Care Medicine:
doi: 10.1097/CCM.0000000000000247
Clinical Investigations
Abstract

Objective: Delirium is common in mechanically ventilated patients in the ICU and associated with short- and long-term morbidity and mortality. The use of systemic corticosteroids is also common in the ICU. Outside the ICU setting, corticosteroids are a recognized risk factor for delirium, but their relationship with delirium in critically ill patients has not been fully evaluated. We hypothesized that systemic corticosteroid administration would be associated with a transition to delirium in mechanically ventilated patients with acute lung injury.

Design: Prospective cohort study.

Setting: Thirteen ICUs in four hospitals in Baltimore, MD.

Patients: Five hundred twenty mechanically ventilated adult patients with acute lung injury.

Interventions: None.

Measurements and Main Results: Delirium evaluation was performed by trained research staff using the validated Confusion Assessment Method for the ICU screening tool. A total of 330 of the 520 patients (64%) had at least two consecutive ICU days of observation in which delirium was assessable (e.g., patient was noncomatose), with a total of 2,286 days of observation and a median (interquartile range) of 15 (9, 28) observation days per patient. These 330 patients had 99 transitions into delirium from a prior nondelirious, noncomatose state. The probability of transitioning into delirium on any given day was 14%. Using multivariable Markov models with robust variance estimates, the following factors (adjusted odds ratio; 95% CI) were independently associated with transition to delirium: older age (compared to < 40 years old, 40–60 yr [1.81; 1.26–2.62], and ≥ 60 yr [2.52; 1.65–3.87]) and administration of any systemic corticosteroid in the prior 24 hours (1.52; 1.05–2.21).

Conclusions: After adjusting for other risk factors, systemic corticosteroid administration is significantly associated with transitioning to delirium from a nondelirious state. The risk of delirium should be considered when deciding about the use of systemic corticosteroids in critically ill patients with acute lung injury.

Author Information

1Division of Pulmonary and Critical Care, University of Nevada School of Medicine, Las Vegas, NV.

2Department of Biostatistics, Johns Hopkins University, Baltimore, MD.

3Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD.

4Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD.

5Department of Emergency Medicine, Chang Gung University and Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan

6Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore, MD.

7Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, Baltimore, MD.

8Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD.

9Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD.

* See also p. 1565.

Supported, in part, by the National Institutes of Health (Acute Lung Injury Specialized Centers of Clinically Oriented Research Grant # P050 HL 73994). The funding body had no role in the study design, article writing, or decision to submit the article for publication.

Dr. Shanholtz received grant support from the National Heart, Lung, and Blood Institute (NHLBI) and support for article research from the National Institutes of Health (NIH). His institution received grant support from the NHLBI. Dr. Needham received support for article research from the NIH. His institution received grant support from the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: dale.needham@jhmi.edu

© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins