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ImportanceIntensive care unit (ICU)–acquired delirium and/or coma have consequences for patient outcomes. However, contradictory findings exist, especially when considering short-term (ie, in-hospital) mortality and length of stay (LOS).ObjectiveTo assess whether incident delirium, days of delirium, days of coma, and delirium- and coma-free days (DCFDs) are associated with 14-day mortality, in-hospital mortality, and hospital LOS among patients with critical illness receiving mechanical ventilation.Design, Setting, and ParticipantsThis single-center prospective cohort study was conducted in 6 ICUs of a university-affiliated tertiary hospital in Taiwan. A total of 267 delirium-free patients (aged ≥20 years) with critical illness receiving mechanical ventilation were consecutively enrolled from August 14, 2018, to October 1, 2020.ExposuresParticipants were assessed daily for the development of delirium and coma status over 14 days (or until death or ICU discharge) using the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale, respectively.Main Outcomes and MeasuresMortality rates (14-day and in-hospital) and hospital LOS using electronic health records.ResultsOf 267 participants (median [IQR] age, 65.9 [57.4-75.1] years; 171 men [64.0%]; all of Taiwanese ethnicity), 149 patients (55.8%) developed delirium for a median (IQR) of 3.0 (1.0-5.0) days at some point during their first 14 days of ICU stay, and 105 patients (39.3%) had coma episodes also lasting for a median (IQR) of 3.0 (1.0-5.0) days. The 14-day and in-hospital mortality rates were 18.0% (48 patients) and 42.1% (112 of 266 patients [1 patient withdrew from the study]), respectively. The incidence and days of delirium were not associated with either 14-day mortality (incident delirium: adjusted hazard ratio [aHR], 1.37; 95% CI, 0.69-2.72; delirium by day: aHR, 1.00; 95% CI, 0.91-1.10) or in-hospital mortality (incident delirium: aHR, 1.00; 95% CI, 0.64-1.55; delirium by day: aHR, 1.02; 95% CI, 0.97-1.07), whereas days spent in coma were associated with an increased hazard of dying during a given 14-day period (aHR, 1.16; 95% CI, 1.10-1.22) and during hospitalization (aHR, 1.10; 95% CI, 1.06-1.14). The number of DCFDs was a protective factor; for each additional DCFD, the risk of dying during the 14-day period was reduced by 11% (aHR, 0.89; 95% CI, 0.84-0.94), and the risk of dying during hospitalization was reduced by 7% (aHR, 0.93; 95% CI, 0.90-0.97). Incident delirium was associated with longer hospital stays (adjusted β = 10.80; 95% CI, 0.53-21.08) when compared with no incident delirium.Conclusions and RelevanceIn this study, despite prolonged LOS, ICU delirium was not associated with short-term mortality. However, DCFDs were associated with a lower risk of dying, suggesting that future research and intervention implementation should refocus on maximizing DCFDs to potentially improve the survival of patients receiving mechanical ventilation.

In 2010, following the publication of two large trials of corticosteroids in septic shock, an international survey of corticosteroid use in the management of septic shock reported marked variability in practice. Two large randomised controlled trials of corticosteroids in septic shock (ie, the ADRENAL trial comparing hydrocortisone v placebo 4 and the APROCCHSS trial comparing hydrocortisone plus fludrocortisone v placebo) published in 2018 reported divergent effects of steroids on mortality at day 90, although important secondary outcomes such as duration of shock and mechanical ventilation were improved in both trials.

Background: Both the intensive care delirium screening checklist (ICDSC) and confusion assessment method for ICU (CAM-ICU) are valid tools for identification of delirium, however their relative predictive validity for important delirium outcomes, such as hospital mortality and LOS have not been well-established. We aim to compare the two tools for their predictive validity for outcomes related to delirium, hospital mortality and length of stay (LOS).Methods: The prospective cohort study conducted in six medical ICUs at a tertiary care hospital in Taiwan. The study enrolled consecutive adult patients (≥20 years) who were delirium free at ICU admission. Delirium was screened daily by trained research nurses using the ICDSC and CAM-ICU in random order. Arousal was assessed by the Richmond Agitation-Sedation Scale (RASS). Participants with any one positive result were classified as ICDSC- or CAM-ICU-delirium groups, respectively.Results: Delirium incidence evaluated by the ICDSC and CAM-ICU were 69.1% (67/97) and 50.5% (49/97), respectively. Although the ICDSC identified 18 more cases as delirious, substantial concordance (κ =0.63; p < 0.001) was found between tools. Independent of age, APACHE II score, and Charlson comorbidity index, both ICDSC- and CAM-ICU-rated delirium significantly predicted hospital mortality (adjusted odds ratio [aOR] 4.93; 95% confidence interval [CI]:1.56 to 15.63 vs. 2.79; 95% CI, 1.12 to 6.97, respectively), and only the ICDSC significantly predicted hospital LOS with a mean of 17.59 additional days compared to the no-delirium group. Irrespective of delirium status, a sensitivity analysis of normal-to-increased arousal (RASS≥0) test results did not alter the predictive ability of ICDSC- or CAM-ICU-delirium for hospital mortality (aOR 2.97; 95% CI, 1.06 to 8.37 vs. 3.82; 95% CI, 1.35 to 10.82, respectively). With reduced arousal (RASS<0), neither tool significantly predicted mortality or LOS.Conclusions: The ICDSC identified more delirium cases and may have higher predictive validity for mortality and LOS than the CAM-ICU. However, arousal substantially affected performance. Future studies may want to consider patients’ arousal when deciding which tool to use to maximize the effects of delirium identification on patient mortality.Trial registration: NCT 04206306