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Preadmission Oral Corticosteroids Are Associated With Reduced Risk of Acute Respiratory Distress Syndrome in Critically Ill Adults With Sepsis*

McKown, Andrew C. MD1; McGuinn, Erin M. MD2; Ware, Lorraine B. MD1,3; Wang, Li MS4; Janz, David R. MD, MSc5; Rice, Todd W. MD, MSc1; Semler, Matthew W. MD, MSc1

doi: 10.1097/CCM.0000000000002286
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Objectives: To determine the association between preadmission oral corticosteroid receipt and the development of acute respiratory distress syndrome in critically ill patients with sepsis.

Design: Retrospective observational study.

Setting: Medical, surgical, trauma, and cardiovascular ICUs of an academic medical center.

Patients: A total of 1,080 critically ill patients with sepsis.

Interventions: None.

Measurements and Main Results: The unadjusted occurrence rate of acute respiratory distress syndrome within 96 hours of ICU admission was 35% among patients who had received oral corticosteroids compared with 42% among those who had not (p = 0.107). In a multivariable analysis controlling for prespecified confounders, preadmission oral corticosteroids were associated with a lower incidence of acute respiratory distress syndrome in the 96 hours after ICU admission (odds ratio, 0.53; 95% CI, 0.33–0.84; p = 0.008), a finding that persisted in multiple sensitivity analyses. The median daily dose of oral corticosteroids among the 165 patients receiving oral corticosteroids, in prednisone equivalents, was 10 mg (interquartile range, 5–30 mg). Higher doses of preadmission oral corticosteroids were associated with a lower incidence of acute respiratory distress syndrome (odds ratio for 30 mg of prednisone compared with 5 mg 0.53; 95% CI, 0.32–0.86). In multivariable analyses, preadmission oral corticosteroids were not associated with in-hospital mortality (odds ratio, 1.41; 95% CI, 0.87–2.28; p = 0.164), ICU length of stay (odds ratio, 0.90; 95% CI, 0.63–1.30; p = 0.585), or ventilator-free days (odds ratio, 1.06; 95% CI, 0.71–1.57; p = 0.783).

Conclusions: Among ICU patients with sepsis, preadmission oral corticosteroids were independently associated with a lower incidence of early acute respiratory distress syndrome.

1Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN.

2Division of Cardiology, University of Colorado Medical Center, Denver, CO.

3Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN.

4Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN.

5Section of Pulmonary/Critical Care & Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, LA.

*See also p. 910.

Some of the results of this study have been previously reported in the form of an abstract: McGuinn E, Semler MW, Janz D, et al: Pre-admission oral steroids are associated with a decreased risk of ARDS in ICU patients with sepsis. Crit Care Med 2014; 42:A61.

Drs. McKown, McGuinn, Wang, and Semler had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Drs. McGuinn, Ware, Rice, and Semler contributed in study concept and design; Drs. McGuinn, Ware, Janz, and Semler contributed in acquisition of data; Drs. McKown, McGuinn, Wang, Rice, and Semler contributed in analysis and interpretation of data; Drs. McKown and Semler contributed in drafting of the article; Drs. McKown, McGuinn, Ware, Wang, Janz, Rice, and Semler contributed in critical revision of the article for important intellectual content; Drs. McKown, Wang, and Semler contributed in statistical analysis.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Supported, in part, by National Institutes of Health (NIH) HL103836 (Dr. Ware), NIH T32 HL087738 09 (Drs. Janz and Semler), and NIH R34 HL105869 (Dr. Rice). Biostatistical support was provided by Vanderbilt Institute for Clinical and Translational Research grant support—NIH CTSA UL1TR000445.

Dr. Ware received support for article research from the National Institutes of Health (NIH) National Heart, Lung, and Blood Institute (NHLBI) through grant HL103836. She disclosed past consulting with Boehringer, Ingelheim, and Abbot. Her institution received funding from Boehringer Ingelheim (research grant), Global Blood Therapeutics (research grant), and the NIH through NHLBI grant HL103836. She received funding from Hemocue (consulting). Drs. Janz and Semler received funding from the NIH through the NHLBI T32 award HL087738 09. Dr. Rice received salary support from the NIH through the NHLBI grant HL105869. He received funding from GlaxoSmithKline, Avisa Pharma, LLC, and Cumberland Pharmaceutical. Biostatistical support was provided by Vanderbilt Institute for Clinical and Translational Research grant support through the NIH National Center for Advancing Translational Sciences UL1TR000445 grant. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: andrew.c.mckown@vanderbilt.edu

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