Out of the Fire, Into the Fog: Association Between Early Mechanical Ventilation and Delirium in Hospitalized Burn Patients.

Introduction Delirium is a common and clinically significant complication among hospitalized burn patients, associated with increased morbidity, mortality, and healthcare utilization. While multiple factors contribute to delirium risk, mechanical ventilation has been associated with delirium, although this relationship may reflect underlying illness severity and ICU-level treatment exposure. However, large-scale, multicenter administrative analyses comparing coded outcomes between mechanically ventilated and non-ventilated burn patients remain limited. Methods A retrospective cohort study was conducted using the TriNetX (TriNetX, LLC, Cambridge, Massachusetts, United States) database to identify adult hospitalized burn patients with International Classification of Diseases (ICD)-coded burns involving ≥20% total body surface area. Patients were stratified into two cohorts based on receipt of mechanical ventilation within five days of the index burn event. Exclusion criteria included age <18 years and diagnoses of dementia, Alzheimer's disease, substance use disorders, or other conditions associated with baseline cognitive impairment. Cohorts were propensity score matched for age, sex, race, ethnicity, ICD-coded burn extent history, hypertension, diabetes, ischemic heart disease, sepsis, inhalation injury, and respiratory disorders. Outcomes assessed within 30 days included administratively documented delirium, disorientation, mortality, anxiety disorders, depressive disorders, and acute stress-related disorders. Results There were 1,541 patients in each cohort after matching. Ventilated patients had higher rates of administratively documented delirium (risk ratio (RR): 2.16, 95% CI: 1.51-3.09, p<0.0001), mortality (RR: 5.06, 95% CI: 4.23-6.05, p<0.0001), anxiety disorders (RR: 1.88, 95% CI: 1.58-2.21, p<0.0001), disorientation (RR: 3.39, 95% CI: 2.27-5.06, p<0.0001), and acute stress-related disorders (RR: 1.77, 95% CI: 1.40-2.22, p<0.0001). Depressive disorders were not significantly different between cohorts (RR: 1.42, 95% CI: 0.85-2.39, p=0.19). Discussion Early mechanical ventilation was associated with higher rates of administratively documented delirium, mortality, anxiety disorders, disorientation, and acute stress-related disorders among adult hospitalized burn patients. However, these findings likely reflect both ICU-level treatment exposure and substantial residual confounding by underlying illness severity. Early mechanical ventilation may identify a high-risk subgroup that warrants structured neurocognitive monitoring, psychological screening, sedation-conscious care, and post-extubation support. Given the observational design and reliance on administrative coding, these findings should be interpreted as hypothesis-generating.