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

Abstract

Objective Delirium is common in mechanically ventilated patients in the intensive care unit (ICU) and associated with short- and long-term morbidity and mortality. The use of systemic corticosteroids is also common in the ICU. Outside of 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 (ALI). Design Prospective cohort study Setting Thirteen ICUs in 4 hospitals in Baltimore, MD Patients 520 mechanically ventilated adult patients with ALI Measurements and Main Results Delirium evaluation was performed by trained research staff using the validated CAM-ICU screening tool. A total of 330 (64%) of the 520 patients had at least two consecutive ICU days of observation in which delirium was assessable (e.g., patient was non-comatose), with a total of 2286 days of observation and a median (inter-quartile range [IQR]) of 15 (9, 28) observation days per patient. These 330 patients had 99 transitions into delirium from a prior non-delirious, non-comatose 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% confidence interval) were independently associated with transition to delirium: older age (compared to <40 years old, 40-60 years (1.81, 1.26 to 2.62) and >=60 years (2.52, 1.65 to 3.87)) and administration of any systemic corticosteroid in the prior 24 hours (1.52, 1.05 to 2.21). Conclusions After adjusting for other risk factors, systemic corticosteroid administration is significantly associated with transitioning to delirium from a non-delirious state. The risk of delirium should be considered when deciding about the use of systemic corticosteroids in critically ill patients with ALI.

The Association between Acute Respiratory Distress Syndrome, Delirium, and In-Hospital Mortality in Intensive Care Unit Patients

“…Sedative-induced coma and prolonged immobility have both been identified as risk factors for ICU delirium (7,34). Third, systemic corticosteroid use has been identified as a risk factor for delirium in ARDS patients in a recent study (11). Although steroid use was greater in our cohort's ARDS patients, it was not significantly associated with delirium in our model.…”

“…Several of the physiologic derangements experienced by ARDS patients (e.g., hypoxemia, metabolic abnormalities), concomitant sepsis, and the treatments that they receive (e.g., invasive mechanical ventilation, sedation-induced coma, neuromuscular blockade, steroids) have been identified as risk factors for ICU delirium (7)(8)(9)(10)(11)(12). Likewise, survivors of ICU delirium and ARDS share similar poor long-term neuropsychiatric and functional outcomes (13)(14)(15)(16).…”

Update of Sepsis in the Intensive Care Unit

“…Neither septic shock progression nor mortality rates (at 28 and 90 days, at ICU, and in hospital) differed between the two groups. An unexpected finding was that the hydrocortisone group had a lower frequency of delirium compared with the placebo group, which contradicts prior studies [60,61] , raising questions concerning the concept of cortisone-induced delirium in critically ill patients.…”

Corticosteroids in Delirium

“…It is perhaps worth reflecting what would have happened if the results had been the other way. Agreeing with findings by Schreiber et al (7). Corticosteroids are a very important therapy and can be considered life saving in some conditions (e.g., severe asthma, flares of autoimmune conditions).…”