Journal Article Annotations
2020, 3rd Quarter

Critical Care

Annotations by O.Joseph Bienvenu, MD, PhD
July, 2020

Association between anxiety and new organ failure, independently of critical illness severity and respiratory status: a prospective multicentric cohort study

PUBLICATION #1 — Critical Care

Association between anxiety and new organ failure, independently of critical illness severity and respiratory status: a prospective multicentric cohort study

Aurélien Mazeraud, Andrea Polito, Sivanthiny Sivanandamoorthy, Raphaël Porcher, Nicholas Heming, Annabelle Stoclin, Tarik Hissem, Marion Antona, François Blot, Raphaël Gaillard, Fabrice Chrétien, Djillali Annane, Fernando A B Bozza, Shidasp Siami, Tarek Sharshar, Groupe d’Explorations Neurologiques en Réanimation (GENER)

Abstract: Crit Care Med. 2020 Oct;48(10):1471-1479. doi: 10.1097/CCM.0000000000004495.

Objectives:
Anxiety results from the anticipation of a threat and might be associated with poor outcome in the critically ill. This study aims at showing that anxiety at admission in critically ill patients is associated with new organ failure over the first 7 days of ICU hospitalization independently of baseline organ failure at admission.

Design:
Prospective multicenter cohort study.

Setting:
Three mixed ICU from April 2014 to December 2017.

Patients:
Coma-, delirium-, and invasive mechanical ventilation-free patients admitted to the ICU were included.

Interventions:
None.

Measurements and main results:
"State anxiety" was assessed using the state component of the State-Trait Anxiety Inventory State. Severity of illness was measured using Simplified Acute Physiology Score II and Sequential Organ Failure Assessment scores. Primary endpoint was a composite of occurrence of death or new organ failure in the first 7 days after admission. Three hundred ninety-one patients were included; 159 of 391 women (40.7%); median age 63 years (49-74 yr); median Simplified Acute Physiology Score II 28 (19-37). Two hundred three out of 391 patients (51.9%) reported moderate to severe anxiety (State-Trait Anxiety Inventory State ≥ 40). One hundred two out of 391 patients (26.1%) developed a new organ failure. After adjustment to Simplified Acute Physiology Score II and Sequential Organ Failure Assessment, State-Trait Anxiety Inventory State greater than or equal to 40 was associated with the primary endpoint (odds ratio, 1.94; 95% CI, 1.18-3.18; p = 0.009) and respiratory failure. In post hoc analysis, State-Trait Anxiety Inventory State greater than or equal to 40 was associated with new organ failure independently and notably of respiratory status at admission (dyspnea-Visual Analogic Scale and PaCO2 ≥ 45 mm Hg).

Conclusions:
Moderate to severe anxiety at ICU admission is associated with early occurrence of new organ failure in critically ill patients, independently of respiratory status and severity of critical illness. The causality link could be addressed in an interventional trial.

Annotation

The finding:
In a previous pilot study involving patients with Guillain-Barré syndrome, the authors noted that anxiety was the earliest predictor of respiratory deterioration. In the current study, the authors found that high state anxiety predicted subsequent new organ failure, even when adjusting for illness severity and respiratory status. Notably, as one might guess, high anxiety was particularly strongly associated with subsequent respiratory failure. It was also associated with longer length of stay in the ICU and hospital.

Strength and weaknesses:
This was a large, multi-site study, and the authors did a nice job accounting for potential confounding variables. However, it was an observational study, and the physiologic mechanisms relating anxiety and subsequent clinical deterioration are unclear.

Relevance:
This study illustrates the prognostic importance of anxiety early in the course of critical illness. I think of anxiety in this case as a marker of risk for clinical deterioration (as delirium can be), though as the authors note, the mechanisms relating anxiety and subsequent organ failure are unclear.

Type of study(EBM guide):
Cohort study