Swedish Intensive Care Units Research Articles

Unpredictable supplementation of vitamin D to infants in the neonatal intensive care unit: An experimental study.

Extremely premature infants receive nutrition and medication through nasogastric tubes. Breastmilk given accordingly is subject to fat loss. This study aimed to investigate whether this could also apply to vitamin D. A questionnaire investigated vitamin D administration at a level III neonatal intensive care unit in Sweden in 2021. Feeding simulations with breastmilk and various vitamin D mixtures were done accordingly. After administration, vitamin D3 concentration was analysed using chromatography with mass spectrometry, followed by repeated simulations with vitamin D mixtures without breastmilk in 2023. The questionnaire was completed by 10 persons. Vitamin D was administered as drops using an enteral syringe and a nasogastric tube in conjunction with a breastmilk meal. In the feeding simulations, vitamin D3 concentration after administration was significantly higher using a syringe alone compared to standard administration. When vitamins were administered according to standard but without breastmilk, 100% of the vitamin D and 40% of the multivitamins were lost. The vitamins adhered to the material, mainly in the nasogastric tube. Our findings indicate that standard vitamin D supplementation in the neonatal intensive care unit may be unpredictable when administered by enteral syringe and nasogastric tube. We suggest using direct oral administration whenever possible.

Mortality following admission to the paediatric intensive care unit: A Swedish longitudinal cohort study.

This study aimed to compare outcomes post-admission to a Swedish paediatric intensive care unit (PICU) in children with complex chronic conditions (CCC) and without CCC. In this observational registry-based study, consecutive admissions to the Astrid Lindgren Children's Hospital PICU from 1 January 2008 to 31 December 2016 were analysed. Data on demographics, predicted death rates (PDR), admission diagnoses and causes of death were collected. Mortality was recorded up to 15 years after admission and compared between groups. Patients with CCC constituted 64.6% (n = 3026) of PICU admissions and 83.5% (n = 111) of PICU deaths. The crude mortality rate in PICU was 2.84% overall. CCC-patients were 2.83 times more likely to die in PICU compared to non-CCC (OR 2.83; 95% CI: 1.78-4.49). Mortality increased in the CCC-cohort up to 5 years after PICU discharge, while non-CCC patients generally survived if they survived in PICU. Of the patients who died in PICU, the median PDR was 22.9% for CCC-patients and 66.5% in the non-CCC cohort. Children with CCC accounted for most admissions and deaths in PICU. Despite lower severity of illness scores upon admission, CCC patients were nearly three times more likely to die in PICU compared to non-CCC patients.

What would have made work in the COVID-19 ICU less demanding? A qualitative study from 13 Swedish COVID-19 ICUs.

The COVID-19 pandemic stretched Swedish intensive care unit (ICU) resources to an extent never experienced before, but even before the pandemic staffing was difficult and the number of staffed ICU beds was low. Studies have revealed high levels of COVID-19 ICU staff burn-out and fatigue, and as similar situations with high demands are likely to occur in the future a better understanding of resources that improve staff resilience is important. Using the job-demand resource theory as a framework, we explored ICU professionals' views on demands and resources when working in COVID-19 ICUs with the aim to highlight factors that increased the job resources. Data were collected via a web survey distributed to COVID-19 ICU professionals, including both regular and temporary roles, working in 13 COVID-19 ICU wards in Stockholm and Sörmland counties during the spring 2021. A total of 251 written responses to the question "What would have made work in the COVID-19 ICU less demanding?" were analyzed using thematic analysis. One year later a member-checking focus group interview was conducted to validate and further explore staff experiences. The main themes were work strategy, fairness and support, continuity, accessible leadership, introduction/information, and crisis preparedness. The analysis of the focus group conducted confirmed the main results and the extreme demands on ICU staff during the initial stages of the pandemic. To increase staff health and performance in a long-term crisis our results suggest; maintaining workplace leadership, scheduling work in advance and, when possible, schedule for recovery.

Comorbid burden at ICU admission in COVID-19 compared to sepsis and acute respiratory distress syndrome.

Comorbidities are similarly associated with short-term mortality for COVID-19, acute respiratory distress syndrome (ARDS) and sepsis in intensive care unit (ICU) patients, but their adjusted frequencies at admission are unknown. Thus, we aimed to evaluate the adjusted distribution, reported as odds ratios, of known risk factors (i.e., age, sex and comorbidities) for ICU admission between COVID-19, sepsis and ARDS patients in this nationwide registry-based study. In this cohort study, we included adult patients admitted to Swedish ICUs with COVID-19 (n = 7382) during the pandemic and compared them to patients admitted to ICU with sepsis (n = 22,354) or ARDS (n = 2776) during a pre-COVID-19 period. The main outcomes were the adjusted odds for comorbidities, sex, and age in multivariable logistic regression on diagnostic categories in patients admitted to ICU, COVID-19 or sepsis and COVID-19 or ARDS. We found that most comorbidities, as well as age, had a stronger association with sepsis admission than COVID-19 admission with the exception of male sex, type 2 diabetes mellitus, and asthma that were more strongly associated with COVID-19 admission, while no difference was seen for chronic renal failure and obesity. For COVID-19 and ARDS admission most risk factors were more strongly associated with ARDS admission except for male sex, type 2 diabetes mellitus, chronic renal failure, and obesity which were more strongly associated with COVID-19 admission, whereas hypertension, chronic obstructive pulmonary disease and asthma were not different. Patients admitted to ICU with sepsis or ARDS carry a heavier burden of comorbidity and high age than patients admitted with COVID-19. This is likely caused by a combination of: (1) respiratory failure in COVID-19 being less dependent on comorbidities than in other forms of ARDS, and the cause of critical illness in other infections causing sepsis and (2) COVID-19 patients being deferred admission in situations where patients with the other syndromes were admitted.

ICURE: Intensive care unit (ICU) risk evaluation for 30-day mortality. Developing and evaluating a multivariable machine learning prediction model for patients admitted to the general ICU in Sweden.

A prediction model that estimates mortality at admission to the intensive care unit (ICU) is of potential benefit to both patients and society. Logistic regression models like Simplified Acute Physiology Score 3 (SAPS 3) and APACHE are the traditional ICU mortality prediction models. With the emergence of machine learning (machine learning) and artificial intelligence, new possibilities arise to create prediction models that have the potential to sharpen predictive accuracy and reduce the likelihood of misclassification in the prediction of 30-day mortality. We used the Swedish Intensive Care Registry (SIR) to identify and include all patients ≥18 years of age admitted to general ICUs in Sweden from 2008 to 2022 with SAPS 3 score registered. Only data collected within 1 h of ICU admission was used. We had 153 candidate predictors including baseline characteristics, previous medical conditions, blood works, physiological parameters, cause of admission, and initial treatment. We stratified the data randomly on the outcome variable 30-day mortality and created a training set (80% of data) and a test set (20% of data). We evaluated several hundred prediction models using multiple ML frameworks including random forest, gradient boosting, neural networks, and logistic regression models. Model performance was evaluated by comparing the receiver operator characteristic area under the curve (AUC-ROC). The best performing model was fine-tuned by optimizing hyperparameters. The model's calibration was evaluated by a calibration belt. Ultimately, we simplified the best performing model with the top 1-20 predictors. We included 296,344 first-time ICU admissions. We found age, Glasgow Coma Scale, creatinine, systolic blood pressure, and pH being the most important predictors. The AUC-ROC was 0.884 in test data using all predictors, specificity 95.2%, sensitivity 47.0%, negative predictive value of 87.9% and positive predictive value of 70.7%. The final model showed excellent calibration. The ICU risk evaluation for 30-day mortality (ICURE) prediction model performed equally well to the SAPS 3 score with only eight variables and improved further with the addition of more variables. The ICURE prediction model predicts 30-day mortality rate at first-time ICU admission superiorly compared to the established SAPS 3 score.

Parent-infant closeness and care practices during therapeutic hypothermia in Swedish neonatal intensive care units

ObjectivesThe aim of this study was to investigate care practices among Neonatal Intensive Care Units (NICU) providing Therapeutic hypothermia (TH), and more specific to investigate staff’s experiences of parental participation, presence, and possibilities of being close with their infant during TH. MethodsA descriptive, qualitative, and quantitative study. All Swedish NICUs providing TH (n = 10) participated. Data were collected during January–April 2021 via a questionnaire followed by a semi-structured interview with the registered nurse and the neonatologist responsible for TH at each unit. Descriptive statistics were calculated, and a qualitative content analysis was performed. ResultsAll NICUs allowed parents unlimited stay with their infants and were keen to support parental presence, which was a prerequisite for promoting parent-infant closeness. Standardized routines regarding the infants’ care space and course of action were described as time-efficient and staff-saving, which freed up time to focus on the families. ConclusionStandardized routines regarding the care space setup and the medical and caring approach, as well as the NICU environment and practices around the families, can promote or curb the possibilities of parent-infant closeness. Well-established care practices and good environmental conditions with flexibility regarding the family’s needs are therefore required.

#848 Influence of nutrition and other factors on preterm newborns’ kidney development

Abstract Background and Aims According to WHO, in 2020, preterm newborns represented around 10% of all newborns in the world. Premature birth is deeply connected with the risk of developing a chronic kidney disease later in life. This is caused by defects in kidney development (primarily the lower number of nephrons) that are often difficult to identify in the complicated clinical picture of premature babies. Our study aims at providing knowledge on the relationship between preterm infant kidney development and morbidities, nutrition, and blood biomarkers. Method Creatinine was measured in 130 extremely preterm newborns (less than 28 weeks of gestation) enrolled in a randomized controlled trial (Mega Donna Mega) in two Swedish neonatal intensive care units. Creatinine was measured in whole blood or serum with the enzymatic method. Individuals with 4 or more serum creatinine measurements (n = 92) were shortlisted for eGFR calculation. eGFR was calculated with the Wilhelm-Bals weight-based equation due to the lack of length measurements. The patients were divided in 3 groups based upon their kidney development status. This was indirectly assessed using the exponential regression curve describing the eGFR trends as model and the doubling time as discriminating parameter. Data about morbidity, treatment, nutrition, blood lipidomics and proteomics were also collected during the MegaDonnaMega trial and has been used to investigate the differences between the three groups. A linear model adjusted for sex and gestational age was used to analyse lipidomics and proteomics data in relation to eGFR. The omics analysis used average data from the first month of age. Data analysis was performed in R, SPSS, SAS and GraphPad statistical programs. Results Subjects were divided in 3 groups from best to worst kidney function development. The parameter used, doubling time, is inversely correlated to eGFR and kidney development. Subjects in group 1 reached the normal at-term birth eGFR (40 ml/min/1.73 m2) at around 50 days of age, whereas the other two groups were delayed (66 days for group 2, 78 for group 3). Subjects in group 2 and 3 were characterized by longer stay at the NICU, lower weight and length in respect to infants in group 1. Subjects in groups 2 and 3 also showed more co-morbidities in respect to group 1. Regarding nutrition, subjects administered with maternal milk had shorter doubling times when compared to those administered with donor or mixed milk. Six serum fatty acids correlated with the eGFR trends: heptadecanoic (FA 17:0) showed a negative correlation, while palmitoleic (16:1n-7), gamma-linolenic (18:3n-6), erucic (22:1n-9) docosapentaenoic (22:5n-6) and tricosanoic (23:0) acid showed positive correlations. 45 serum proteins correlated with the eGFR trends, in particular, inflammatory and proliferative pathways showed an inverse correlation with eGFR. Conclusion We have detected differences in the eGFR trends of preterm newborns that could be traced back to nutrition and other factors. Moreover, we identified several serum fatty acids and proteins that correlated with eGFR and therefore kidney development. The data indicates that postnatal kidney development may be important to consider in the clinical care of preterm newborns.

Critical care nurses' experiences of ethical challenges in end-of-life care.

In Swedish intensive care units, nine percent of patients do not survive despite receiving advanced life-sustaining treatments. As these patients transition to end-of-life care, ethical considerations may become paramount. To explore the ethical challenges that critical care nurses encounter when caring for patients at the end of life in an intensive care context. The study used a qualitative approach with an interpretive descriptive design. Twenty critical care nurses from eight intensive care units in an urban region in Sweden were interviewed, predominately women with a median age of fifty-one years. This study was approved by The Swedish Ethics Review Authority. Critical care nurses described encountering ethical challenges when life-sustaining treatments persisted to patients with minimal survival prospects and when administering pain-relieving medications that could inadvertently hasten patients' deaths. Challenges also arose when patients expressed a desire to withdraw life-sustaining treatments despite the possibility of recovery, or when family members wanted to shield patients from information about a poor prognosis; these wishes occasionally conflicted with healthcare guidelines. The critical care nurses also encountered ethical challenges when caring for potential organ donors, highlighting the balance between organ preservation and maintaining patient dignity. Critical care nurses encountered ethical challenges when caring for patients at the end of life. They described issues ranging from life-sustaining treatments and administration of pain-relief, to patient preferences and organ donation considerations. Addressing these ethical challenges is essential for delivering compassionate person-centered care, and supporting family members during end-of-life care in an intensive care context.

Protocolized reduction of non-resuscitation fluids versus usual care in septic shock patients (REDUSE): a randomized multicentre feasibility trial

Background/purposeNon-resuscitation fluids constitute the majority of fluid administered for septic shock patients in the intensive care unit (ICU). This multicentre, randomized, feasibility trial was conducted to test the hypothesis that a restrictive protocol targeting non-resuscitation fluids reduces the overall volume administered compared with usual care.MethodsAdults with septic shock in six Swedish ICUs were randomized within 12 h of ICU admission to receive either protocolized reduction of non-resuscitation fluids or usual care. The primary outcome was the total volume of fluid administered within three days of inclusion.ResultsMedian (IQR) total volume of fluid in the first three days, was 6008 ml (interquartile range [IQR] 3960–8123) in the restrictive fluid group (n = 44), and 9765 ml (IQR 6804–12,401) in the control group (n = 48); corresponding to a Hodges–Lehmann median difference of 3560 ml [95% confidence interval 1614–5302]; p < 0.001). Outcome data on all-cause mortality, days alive and free of mechanical ventilation and acute kidney injury or ischemic events in the ICU within 90 days of inclusion were recorded in 98/98 (100%), 95/98 (98%) and 95/98 (98%) of participants respectively. Cognition and health-related quality of life at six months were recorded in 39/52 (75%) and 41/52 (79%) of surviving participants, respectively. Ninety out of 134 patients (67%) of eligible patients were randomized, and 15/98 (15%) of the participants experienced at least one protocol violation.ConclusionProtocolized reduction of non-resuscitation fluids in patients with septic shock resulted in a large decrease in fluid administration compared with usual care. A trial using this design to test if reducing non-resuscitation fluids improves outcomes is feasible.Trial registrationClinicaltrials.gov, NCT05249088, 18 February 2022. https://clinicaltrials.gov/ct2/show/NCT05249088

The circulatory death that saves lives-Intensive care nurses' conceptions of participating during 'donation after circulatory death': A phenomenographic study.

To describe intensive care nurses' conceptions of participating during the donation after circulatory death (DCD) process in intensive care units in Sweden. A qualitative design with a phenomenographic approach. In total, 12 semi-structured interviews were conducted in April 2022 with intensive care nurses from three hospitals. Data were analysed using a phenomenographic approach. Conceptions of participating during the DCD process varied. Four main themes emerged: DCD as a system; Intensive care nurses' role in the situation; Life to death to life; The essence of DCD. Variations emerged regarding what the informants talked about and how they talked about the what. Variations were based on informants' perspective of their role in relation to the structure and the team, and their conceptions of care for patients and their relatives. The findings illustrated success factors and challenges. Knowledge, experience, distinct structure, and relationship with relatives, among other factors, were described as success factors, while a lack of experience, difficulty in prognosing death, and organisational obstacles emerged as challenges. Furthermore, the findings showed that intensive care nurses play an important role in optimising the outcome of the DCD process. Their work related to DCD was conceived as being meaningful to fulfil more peoples' wishes to donate organs. People on the waiting list for organ transplantation are dying due to a shortage of organs. The implementation of DCD, as a complement to Donation after Brain Death (DBD), contributed to an increase in the number of organ donors, and intensive care nurses play an important role during the DCD process. Previous research manifests the complexity concerning their role. There is a lack of nursing research regarding intensive care nurses' conceptions of what it means to participate in the DCD process, which emphasises the significance of this study. This study is reported using consolidated criteria for reporting qualitative research (SRQR). No patient or public contribution.

Unit-to-unit transfer due to shortage of intensive care beds in Sweden 2015–2019 was associated with a lower risk of death but a longer intensive care stay compared to no transfer: a registry study

BackgroundIntensive care unit-to-unit transfer due to temporary shortage of beds is increasing in Sweden. Transportation induces practical hazards, and the change of health care provider may prolong the length of stay in intensive care. We previously showed that the risk of death at 90 days did not differ between patients transferred due to a shortage of beds and non-transferred patients with a similar burden of illness in a tertiary intensive care unit. The aim of this study was to widen the analysis to a nation-wide cohort of critically ill patients transferred to another intensive care unit in Sweden due to shortage of intensive care beds.MethodsRetrospective comparison between capacity transferred and non-transferred patients, based on data from the Swedish Intensive Care Registry during a 5-year period before the COVID-19 pandemic. Patients with insufficient data entries or a recurring capacity transfer within 90 days were excluded. To assess the association between capacity transfer and death as well as intensive care stay within 90 days after ICU admission, logistic regression models with step-wise adjustment for SAPS3 score, primary ICD-10 ICU diagnosis and the number of days in the intensive care unit before transfer were applied.ResultsFrom 161,140 eligible intensive care admissions, 2912 capacity transfers were compared to 135,641 discharges or deaths in the intensive care unit. Ninety days after ICU admission, 28% of transferred and 21% of non-transferred patients were deceased. In the fully adjusted model, capacity transfer was associated with a lower risk of death within 90 days than no transfer; OR (95% CI) 0.71 (0.65–0.69) and the number of days spent in intensive care was longer: 12.4 [95% CI 12.2–12.5] vs 3.3 [3.3–3.3].ConclusionsIntensive care unit-to-unit transfer due to shortage of bed capacity as compared to no transfer during a 5-year period preceding the COVID-19 pandemic in Sweden was associated with lower risk of death within 90 days but with longer stay in intensive care.

Swedish Intensive Care Nurses' Knowledge, Attitudes, and Views on Donation After Circulatory Death Before a National Implementation.

An increasing population and a shortage of identified potential organ donors are causing the waiting list for organ transplants to grow continuously. Donation after circulatory death (DCD) is a method aimed at meeting the demand for transplantable organs. However, it presents new challenges in nursing care, and there is a lack of studies investigating nurses' attitudes and knowledge of DCD. The objective of this study was to determine and describe intensive care nurses' (ICNs') knowledge, attitudes, and views on DCD before a national implementation in Sweden. This study utilized a cross-sectional mixed-method design. A convenience sampling method was employed, targeting ICNs working in four intensive care units in Sweden. A study-specific tool comprising fixed and free-text questions was developed. Fifty-one ICNs participated. Data were analyzed descriptively, and correlation analysis was performed using Spearman's correlation. Free-text answers were qualitatively assessed and analyzed. An integrated analysis was conducted to synthesize the quantitative and qualitative findings. Fifty-three percent reported limited knowledge about DCD. Nurses with previous education on DCD had significantly higher knowledge (r = .380, p = .006), were more engaged with the public debate on organ donation (r = .423, p = .002), and considered the ethical aspects of DCD more thoroughly (r = .386, p = .022). The qualitative analysis identified four key categories: The importance of the team, the need for ethical discussions, increased knowledge of DCD, and unanswered questions and unmet needs. The integrated analysis underscored the need for targeted education, clear guidelines, and ongoing ethical discussions to prepare ICU nurses for DCD. Nurses educated in organ donor care had better knowledge and a more positive attitude toward DCD implementation. The study also highlights the importance of interprofessional teamwork in DCD implementation. The findings suggest that education on DCD could improve the identification and implementation of DCD donors, addressing the global shortage of transplantable organs.

Sepsis mimics among presumed sepsis patients at intensive care admission: a retrospective observational study

BackgroundDiagnosing sepsis remains a challenge because of the lack of gold-standard diagnostics. Since there are no simple, broadly accepted criteria for infection, there is a risk of misclassifying sepsis patients (sepsis mimics) among patients with organ failure. The main objective of this study was to investigate the proportion of non-infected patients (sepsis mimics) in ICU patients with presumed sepsis at intensive care unit (ICU) admission.MethodsAdult patients were screened retrospectively during 3.5 years in four ICUs in Sweden for fulfilment of the sepsis-3 criteria at ICU admission (presumed sepsis). Proxy criteria for suspected infection were sampled blood culture(s) and concomitant antibiotic administration. Culture-negative presumed sepsis patients were screened for infection according to the Linder-Mellhammar Criteria of Infection (LMCI). Sepsis mimics were defined as without probable infection according to the LMCI. Confirmed sepsis was defined as presumed sepsis after the exclusion of sepsis mimics.ResultsIn the ICU presumed sepsis cohort (2664 patients), 25% were considered sepsis mimics. The most common reasons for ICU admission among sepsis mimics were acute heart failure and unspecific respiratory failure. Comparing sepsis mimics and confirmed sepsis showed that confirmed sepsis patients were slightly more severely ill but had similar mortality. C-reactive protein had modest discriminatory power (AUROC 0.71) with confirmed sepsis as the outcome.ConclusionsOne-fourth of a presumed ICU sepsis population identified with the sepsis-3 criteria could be considered sepsis mimics. The high proportion of sepsis mimics has a potential dilutional effect on the presumed sepsis population, which threatens the validity of results from sepsis studies using recommended sepsis criteria.

An analysis of central venous catheter-related bloodstream infections in patients treated in a Swedish Covid-19 intensive care unit.

Catheter-related bloodstream infection is a well-known, severe complication of central venous catheter insertion. Studies that have evaluated the coronavirus disease 2019 pandemic's influence on the incidence of catheter-related bloodstream infection in intensive care units are limited. Therefore, we conducted a retrospective study on catheter-related bloodstream infection in coronavirus disease 2019 intensive care unit with previously documented low incidence rates to evaluate the pandemic's impact. To evaluate the impact of the coronavirus disease 2019 pandemic on catheter-related bloodstream infection incidence in the intensive care unit. All central venous catheter-inserted patients aged ⩾18 years admitted to the intensive care unit with coronavirus disease 2019 pneumonia were included. The primary outcome was the incidence of catheter-related bloodstream infection, and the secondary outcome was the detection of catheter-related bloodstream infection-causative microorganisms. During the pandemic's first year, 124 patients were admitted, and 203 central venous catheters were inserted. Two patients developed catheter-related bloodstream infection. The incidence of catheter-related bloodstream infection was 0.79/1000 catheter days. The microorganisms responsible for catheter-related bloodstream infection were Staphylococcus epidermidis and Escherichia coli. This study revealed a low incidence of catheter-related bloodstream infection in the coronavirus disease 2019-intensive care unit, thus suggesting that coronavirus disease 2019 is not a risk factor for catheter-related bloodstream infection and indicating the high resilience of well-established routines aimed at catheter-related bloodstream infection prevention.

Improved oxygenation in prone positioning of mechanically ventilated patients with COVID-19 acute respiratory distress syndrome is associated with decreased pulmonary shunt fraction: a prospective multicenter study

BackgroundProne position is used in acute respiratory distress syndrome and in coronavirus disease 2019 (Covid-19) acute respiratory distress syndrome (ARDS). However, physiological mechanisms remain unclear. The aim of this study was to determine whether improved oxygenation was related to pulmonary shunt fraction (Q’s/Q’t), alveolar dead space (Vd/Vtalv) and ventilation/perfusion mismatch (V’A/Q’).MethodsThis was an international, prospective, observational, multicenter, cohort study, including six intensive care units in Sweden and Poland and 71 mechanically ventilated adult patients.ResultsProne position increased PaO2:FiO2 after 30 min, by 78% (83–148 mm Hg). The effect persisted 120 min after return to supine (p < 0.001). The oxygenation index decreased 30 min after prone positioning by 43% (21–12 units). Q’s/Q’t decreased already after 30 min in the prone position by 17% (0.41–0.34). The effect persisted 120 min after return to supine (p < 0.005). Q’s/Q’t and PaO2:FiO2 were correlated both in prone (Beta -137) (p < 0.001) and in the supine position (Beta -270) (p < 0.001). V’A/Q’ was unaffected and did not correlate to PaO2:FiO2 (p = 0.8). Vd/Vtalv increased at 120 min by 11% (0.55–0.61) (p < 0.05) and did not correlate to PaO2:FiO2 (p = 0.3). The ventilatory ratio increased after 30 min in the prone position by 58% (1.9–3.0) (p < 0.001). PaO2:FiO2 at baseline predicted PaO2:FiO2 at 30 min after proning (Beta 1.3) (p < 0.001).ConclusionsImproved oxygenation by prone positioning in COVID-19 ARDS patients was primarily associated with a decrease in pulmonary shunt fraction. Dead space remained high and the global V’A/Q’ measure could not explain the differences in gas exchange.

Surviving critical COVID-19 requiring mechanical ventilation is associated with a high risk of cardiovascular events post discharge

Abstract Background The long-term risk for cardiovascular adverse events after severe COVID-19 requiring intensive care are largely unknown. Purpose The primary aim of this study was to investigate the composite risk of incident atherosclerotic cardiovascular disease (ASCVD) during six months after discharge from an intensive care unit (ICU) for severe COVID-19 requiring mechanical ventilation. Secondary aims were to assess the risk for individual cardiovascular and thrombotic events. Methods We performed a nationwide case-control study on all patients with severe COVID-19 treated with mechanical ventilation and discharged alive from an intensive care unit in Sweden between March 2020 and June 2021. Each case was matched (age, sex, district of residence) with up to 10 population-based controls. The study database was merged with multiple national registries. Patients with pre-existing diagnosis for MI longer than one month ago, CVL or Heart failure were excluded. Also COVID-19 patients receiving the same diagnosis during their ICU-stay as in the follow up period were excluded, making sure all post-covid events were new. The primary outcome was a composite of ASCVD defined as a fatal or non-fatal myocardial infarction, unstable angina pectoris requiring urgent revascularization, fatal and non-fatal ischemic stroke and cardiovascular death. Secondary outcomes were pre-specified as, fatal or nonfatal MI, fatal or nonfatal stroke, myocarditis, pericarditis, PE and DVT. To compare groups, Hazard ratios (HR) with (95% CI) were calculated with adjustments for age, sex, comorbidities (hypertension, hyperlipedemia, diabetes 1&amp;2, obesity, chronic kidney failure, atrial fibrillation, COPD, asthma, malignancy), level of education, marital status, and income quintile. Results In total, included 3 023 patients with severe Covid-19 that were treated with mechanical ventilation at a Swedish ICU and were subsequently discharged alive and compared with 28,463 control subjects. All results in Table 1. The incidence rate for ASCVD was 22.2 (14.9-33.2) per 1,000 person years in patients discharged after severe COVID-19 compared to 2.9 (2.3-3.8) in control subjects. When adjusted for confounders, the risk for ASCVD during the follow-up period was increased compared to control subjects (HR 4.0, 95% CI 2.4-6.7). The incidence rate for pulmonary embolism was 97.4 (80.6-120.0) per 1,000 person years after severe COVID-19 compared to 1.0 (0.6-1.7) in control subjects with a markedly increased risk HR 89.8 (95% CI 48.6-166.1) in patients discharged after severe Covid-19 compared to controls. Conclusions Among patients treated at the intensive care due to severe Covid-19, we found a significant and substantial increased risks for ASCVD and thrombotic events within 6 months from discharge. This finding implies that these patients should be closely monitored after discharge with a low threshold to initiate preventive treatment for ASCVD and thrombotic events during this period.

Influenza-associated invasive aspergillosis in patients admitted to the intensive care unit in Sweden: a prospective multicentre cohort study

Background The purpose of this study was to prospectively investigate the incidence of influenza-associated pulmonary aspergillosis (IAPA) in influenza patients admitted to intensive care units in Sweden. Methods The study included consecutive adult patients with PCR-verified influenza A or B in 12 Swedish intensive care units (ICUs) over four influenza seasons (2019-2023). Patients were screened using serum galactomannan and β-d-glucan tests and fungal culture of a respiratory sample at inclusion and weekly during the ICU stay. Bronchoalveolar lavage was performed if clinically feasible. IAPA was classified according to recently proposed case definitions. Results The cohort included 55 patients; 42% were female, and the median age was 59 (IQR 48-71) years. All patients had at least one galactomannan test, β-d-glucan test and respiratory culture performed. Bronchoalveolar lavage was performed in 24 (44%) of the patients. Five (9%, 95% CI 3.8% − 20.4%) patients were classified as probable IAPA, of which four lacked classical risk factors. The overall ICU mortality was significantly higher among IAPA patients than non-IAPA patients (60% vs 8%, p = 0.01). Conclusions The study represents the first prospective investigation of IAPA incidence. The 9% incidence of IAPA confirms the increased risk of invasive pulmonary aspergillosis among influenza patients admitted to the ICU. Therefore, it appears reasonable to implement a screening protocol for the early diagnosis and treatment of IAPA in influenza patients receiving intensive care. Trial registration ClinicalTrials.gov NCT04172610, registered November 21, 2019

Prior physical illness predicts death better than acute physiological derangement on intensive care unit admission in COVID-19: A Swedish registry study.

COVID-19 is associated with prolonged intensive care unit (ICU) stay and considerable mortality. The onset of persistent critical illness, defined as when prior illness predicts death better than acute physiological derangement, has not been studied in COVID-19. This national cohort study based on the Swedish Intensive Care Registry (SIR) included all patients admitted to a Swedish ICU due to COVID-19 from 6 March 2020 to 9 November 2021. Simplified Acute Physiology Score-3 (SAPS3) Box 1 was used as a measure of prior illness and Box 3 as a measure of acute derangement to evaluate the onset and importance of persistent critical illness in COVID-19. To compare predictive capacity, the area under receiver operating characteristic (AUC) of SAPS3 and its constituent Box 1 and 3 was calculated for 30-day mortality. In 7 969 patients, of which 1 878 (23.6%) died within 30 days of ICU admission, the complete SAPS3 score had acceptable discrimination: AUC 0.75 (95% CI 0.74 to 0.76) but showed under prediction in low-risk patients and over prediction in high-risk patients. SAPS3 Box 1 showed markedly better discrimination than Box 3 (AUC 0.74 vs 0.65, P<0,0001). Using custom logistic models, the difference in predictive performance of prior and acute illness was validated, AUC 0.76 vs AUC 0.69, p<0.0001. Prior physical illness predicts death in COVID-19 better than acute physiological derangement during ICU stay, and the whole SAPS3 score is not significantly better than just prior illness. The results suggests that COVID-19 may exhibit similarities to persistent critical illness immediately from ICU admission, potentially because of long median ICU length-of-stay. Alternatively, the variables in the acute physiological derangement model may not adequately capture the severity of illness in COVID-19.

Prevalence and impact of chronic dysglycaemia among patients with COVID-19 in Swedish intensive care units: a multicentre, retrospective cohort study

ObjectiveUsing glycated haemoglobin A1c (HbA1c) screening, we aimed to determine the prevalence of chronic dysglycaemia among patients with COVID-19 admitted to the intensive care unit (ICU). Additionally, we aimed to...

Long-term survival after intensive care for COVID-19: a nationwide cohort study of more than 8000 patients

BackgroundWas it worth it—what is the outcome after the extended ICU (intensive care unit) length of stay for COVID-19 patients? Surprisingly, data on long-term mortality in large cohorts are lacking. We investigate long-term mortality including differences between men and women, as previous studies show that men generally suffer a more severe course of COVID-19 in terms of severity of illness and short-term mortality.MethodsNationwide cohort including all adult COVID-19 patients admitted to Swedish ICUs until August 12, 2022. Primary outcome was 360-day mortality after ICU admission. Logistic regression was used to estimate associations between demographics, comorbidities, clinical characteristics and mortality.ResultsIn total, 8392 patients were included. Median (IQR) age was 63 (52–72) years and the majority (70.1%) were men. Among the 7390 patients with complete 360-day mortality data, 1775 (24.4%) patients died within 30 days, 2125 (28.8%) within 90 days and 2206 (29.8%) within 360 days from ICU admission. 360-day mortality was 27.1% in women and 31.0% in men. Multivariable logistic regression analysis showed increased risk of 360-day mortality in men compared to women (OR: 1.33, 95% CI: 1.17–1.52). Other variables associated with poor 360-day mortality were age, cardiac disease, COPD/asthma, diabetes, immune deficiency, chronic kidney disease, neuromuscular disease, and malignancy.ConclusionThis study confirms the increased severity of disease in critically ill men with COVID-19, even in a long-term perspective. However, mortality beyond 90 days was strikingly low, indicating high probability of survival after the acute phase of illness.