BACKGROUND:Continuous glucose monitoring (CGM) accuracy in critically ill patients may be influenced by altered physiology and concurrent therapies. We assessed independent associations between sensor wear time, arterial blood glucose (ABG), noradrenaline-equivalent (NE) dose, erythrocyte volume fraction, pH, lactate, body-mass index and dialysis to CGM performance (Dexcom G6®) in this setting. METHODS:Secondary analysis of a prospective observational study including 40 critically ill adults receiving intravenous insulin, mechanical ventilation and vasopressor therapy. Paired ABG and CGM values (n = 2946) were analyzed. The primary outcome was percentage absolute relative difference (ARD). Secondary outcomes were the proportions of CGM readings meeting ISO 15197:2013 and CLSI POCT12-A3 criteria. Multivariable generalized linear mixed models with patient-level random intercepts were fitted, applying B-splines for continuous covariates. RESULTS:Median (IQR) ARD was 10.8% (5.2-18.8) (mean ARD 12.7 [95% CI 10.7-15.3] %); 64.5% and 56.0% of readings met ISO and CLSI criteria, respectively. Sensor wear time (P < 0.001) and pH (P ≤ 0.02) were independently associated with ARD and both categorical accuracy metrics. Predicted ARD decreased, and the probability of meeting ISO/CLSI criteria increased, during the first 50 h after sensor insertion and then stabilized. The pH-accuracy relationships were approximately linear; in linear-term sensitivity analyses, each 0.1-unit increase in pH was associated with a 1.5 percentage-point higher ARD (P = 0.009) and 32% lower odds of meeting CLSI criteria (P = 0.001). NE-dose (P = 0.006) and ABG (P < 0.001) were independently associated with ISO-defined accuracy. Spline analyses suggested reduced accuracy at higher NE-doses (>0.6 µg/kg/min) and lower ABG (<5 mmol/L [<90 mg/dL]), although observations were limited in these ranges. CONCLUSIONS:In critically ill patients receiving mechanical ventilation and vasopressor therapy, CGM accuracy improves substantially with increasing sensor wear time and is independently associated with arterial pH. Early postinsertion sensor instability and acid-base disturbances appear to be important determinants of CGM performance in critical illness.

Abstract Background Heparin-binding protein (HBP) is an inflammatory protein released by activated polymorphonuclear white cells. It has been suggested as a predictor of sepsis progression and organ dysfunction and plays a role in the pathophysiology of endothelial dysfunction. Endothelin-1 (ET-1) is a potent endothelium-derived vasoconstrictor with pro-inflammatory effects, and high levels are found in patients with sepsis and acute respiratory distress syndrome. We investigated HBP and ET-1 plasma levels in critical COVID-19 disease with the aim of evaluating whether they were associated with 60-day mortality or the need for invasive mechanical ventilation (IMV). These levels were compared with those of a cohort of post-trauma intensive care unit (ICU) patients. Methods We included 96 patients with critical COVID-19 disease in 2020 and ten post-trauma ICU patients. Blood samples were collected at ICU admission, and plasma levels of HBP and ET-1 were measured. Clinical and laboratory data were collected until ICU discharge or death. Results In COVID-19 patients, plasma levels of HBP were markedly increased, with a median level of 150 ng/ml (IQR 47–299), compared to 13.3 ng/ml (IQR 8.8–62.1), p < 0.0001 in the trauma ICU patients. There was no association between HBP levels and 60-day mortality or need for IMV. The levels of ET-1 were 1.6 pg/ml (IQR 1.2–1.9) in the COVID-19 cohort and 2.0 pg/ml (IQR 1.2–2.8), p = 0.25 in the trauma ICU cohort. COVID-19 patients requiring IMV hade higher ET-1 levels than those who did not require such treatment; however, no association was found in a logistic regression model when adjusted for age, sex and body mass index. There was no correlation between plasma HBP and ET-1 levels. Inflammatory parameters such as C-reactive protein, procalcitonin, ferritin, and interleukin-6, were elevated but did not distinguish survivors from non-survivors. Conclusion While HBP levels are markedly elevated in critical COVID-19, they do not predict outcomes at ICU admission. ET-1 levels were also not linked to mortality or the need for IMV.

The long-term consequences of sepsis, including mortality and morbidity among survivors, are insufficiently understood. This nationwide matched cohort study investigated the association between presumed community-acquired critical sepsis (PCACS)and long-term mortality, the morbidity of burden before and after ICU admission, and causes of death. Patients admitted to Swedish ICUs for PCACS over a ten-year period (n = 10,072) were matched 1:5 with population controls (n = 50,180). Data on demographics, comorbidities, education, income, and causes of death were collected. Conditional Cox regression was used to assess long-term mortality. Patients with sepsis exhibited a progressive increase in morbidity during the five years preceding ICU admission, which further escalated in the year following discharge. Sepsis was associated with excess mortality up to three years post-admission. Among one-year survivors, sepsis remained independently associated with increased mortality between years one and three, even after adjusting for prior morbidity, indicating persistent long-term effects not fully explained by diagnosed conditions. Early deaths were primarily due to infections and cancer, while later deaths were dominated by cancer and circulatory diseases. These findings highlight the sustained impact of sepsis on survivors, underscoring the need for long-term follow-up and targeted interventions to mitigate post-septic morbidity and mortality.

Background Trauma is a leading cause of death and disability, both in Sweden and globally. Timely surgical intervention and level of care have been identified as important determinants of outcome, yet it is not known whether time to surgery differs between trauma centers and non-trauma centers in Sweden, or whether previously observed survival differences also apply to patients undergoing early operative management. Methods This retrospective national cohort study included adult trauma patients (≥18 years) who underwent surgery within six hours of hospital arrival between 1 January 2019 and 21 March 2023. Data were obtained from Swedish national quality registries and administrative registers held by the National Board of Health and Welfare (Socialstyrelsen). The primary outcome was time from hospital arrival to initiation of surgery. Secondary outcomes were time to urgent surgery and 30-day mortality. Associations between trauma center status and outcomes were examined using regression models adjusted for demographic and injury-related factors. Results A total of 1,129 adult trauma patients who underwent surgery within six hours of hospital arrival were included, the majority presenting with moderate to severe injuries; of whom 659 (58.4%) were treated at trauma centers and 470 (41.6%) at non-trauma centers. Patients treated at trauma centers had higher injury severity and greater physiological compromise. Trauma center care was associated with shorter time to surgery; the fully adjusted mean difference was 0.68hours compared with non-trauma centers. Crude 30-day mortality was higher at trauma centers, but after full adjustment for case-mix, trauma center care was associated with lower mortality. Conclusion Among trauma patients undergoing early surgery, treatment at trauma centers was associated with shorter time to surgery and improved adjusted survival. Further research is needed to identify which patient groups may benefit most from direct transport to trauma centers.

Mood disorders after aneurysmal subarachnoid haemorrhage (aSAH) are common. Meanwhile, mood disorders are also common after intensive care for any reason, and whether aSAH confers an excess risk remains unknown. In this retrospective study, patients with cases of aSAH admitted to intensive care in 2012–2023 were identified in nationwide registers and antidepressant (AD) prescriptions used as a proxy for mood disorders. The primary outcome was incidence of AD therapy in patients who were previously AD-naïve, along with attributable risk factors and impact on sick leave and disability pensions. To investigate the risk of AD treatment in aSAH exceeding what would be expected after intensive care, a control cohort of all patients in the intensive care unit (ICU) nationwide between 2012 and 2018 was identified. Using machine-learning-driven nearest-neighbour propensity score (PS) matching, the relative risk of AD treatment in ICU-treated aSAH cases vs. non-neurovascular ICU cases was calculated. In all, 3149 patients with aSAH who were AD-naïve were identified, with a cumulative incidence of AD treatment within 1 year of 25.5

BACKGROUND:Trauma is a major public health concern that often leads to long-term psychological distress and chronic pain. Benzodiazepines (BZDs) are sometimes prescribed for anxiety, insomnia, or acute stress-related symptoms, but long-term use is associated with dependence and adverse outcomes. The extent to which BZDs are initiated after trauma, and their implications for long-term health, remain poorly understood. This study aimed to assess the association between trauma exposure and initiation of high-potency BZDs, identify risk factors within the trauma cohort and examine the association between new BZD use and long-term mortality. METHODS:We conducted a population-based cohort study using data from a regional trauma registry linked to Swedish national health registers. New initiation of BZD prescriptions was defined as filling at least one prescription within 6 months after trauma. Multivariable logistic regression was used to assess associations between trauma exposure and BZD initiation and to identify risk factors within the trauma cohort. Cox proportional hazards regression evaluated the association between new BZD use and 6-18-month mortality. RESULTS:The study included 12,206 BZD-naive trauma patients and 66,801 matched controls. Trauma exposure was independently associated with new high-potency BZD use. Within the trauma cohort, risk factors included older age, psychiatric comorbidity, substance abuse, pre-traumatic opioid or sedative-hypnotic drug use, penetrating trauma, and higher injury severity. New BZD use was associated with markedly elevated 6-18-month mortality (adjusted HR 2.9, 95% CI 2.0-4.2, p < 0.001), a finding that reflects the complex clinical and psychosocial vulnerability of this group. CONCLUSIONS:Trauma exposure independently predicted initiation of high-potency BZDs among previously BZD-naive patients. Psychiatric comorbidity, substance use, and greater injury severity were important risk factors. The association between new BZD use and increased long-term mortality underscores the need for cautious prescribing and structured follow-up after trauma. EDITORIAL COMMENT:This study examines initiation of high-potency benzodiazepines among previously naive survivors of severe trauma using linked registry data. It shows that trauma exposure is strongly associated with new benzodiazepine use, particularly in older, comorbid, and vulnerable patients. Initiation is also associated with higher subsequent mortality, likely reflecting underlying clinical and psychosocial risk rather than a causal drug effect.

Background: Survival after cardiothoracic intensive care has improved, yet long-term psychological and physical morbidities remain common. Depression is frequent after intensive care, and initiation of antidepressant therapy may serve as a proxy for clinically significant psychological distress. We investigated the incidence, associated factors, and outcomes related to new-onset antidepressant use among cardiothoracic ICU survivors in Sweden. Methods: Nationwide, population-based cohort study using linked Swedish registers. We included 27,006 patients who survived ≥ 90 days after their first cardiothoracic ICU admission (2010–2017) and were naïve to antidepressants during the preceding 6 months. The primary outcome was new-onset SSRI use within 12 months after discharge. Multivariable logistic regression identified associated factors, and Cox models assessed long-term mortality. Results: Overall, 2,051 patients (7.6%) initiated SSRI therapy within one year. Factors associated with new-onset antidepressant use included psychiatric comorbidity, substance abuse, higher somatic comorbidity (CCI > 1), and ICU length of stay > 7 days, while male sex was associated with lower odds. New-onset SSRI use was independently associated with higher long-term mortality (adjusted HR 1.9; 95% CI 1.4–2.6). Patients prescribed SSRIs also had fewer care days alive and at home within 90 days after ICU discharge (DAH90), indicating delayed recovery or greater post-ICU morbidity. Conclusions: New-onset SSRI use after cardiothoracic critical illness was associated with markers of higher mortality and fewer early days at home. These findings underscore the importance of addressing mental health in post-ICU care.

Haemorrhage is a leading cause of trauma death, yet early coagulation markers are rarely used to predict long-term outcomes. This study assessed whether a single admission rotational thromboelastometry (ROTEM) test could independently predict 30-day all-cause mortality and improve existing trauma scores. We conducted a retrospective cohort study of 1,498 adult trauma patients admitted to a Level 1 trauma centre, with ROTEM (EXTEM, INTEM, FIBTEM) acquired on admission. Machine learning models were developed to predict 30-day mortality using ROTEM alone, using conventional trauma scores (RTS, NISS, GAP, MGAP, TRISS), and their combination. Model performance was assessed through cross validation using AUROC, AUPRC, and specificity at 90

INTRODUCTION:With over 300 million surgical procedures performed worldwide annually and an ageing population with increasing comorbidities, peri-operative risk assessment is more important than ever. Whilst the ASA physical status is used widely to assess surgical risk, its association with age remains underexplored in contemporary, broad surgical populations. This study examines the relationship between ASA physical status, age and postoperative mortality in an adult surgical cohort. METHODS:This nationwide cohort study analysed data from the Swedish Perioperative Register on patients aged ≥ 18 y undergoing major non-cardiac surgery from January 2019 to March 2023. Data on comorbidities, socioeconomic factors and mortality were retrieved from national health registries. The primary outcome was 30-day mortality. Secondary outcomes were 365-day mortality and days at home alive at 30 days. RESULTS:A total of 262,938 elective and 197,108 acute procedures were analysed, with median ages of 66 and 68 y, respectively. Crude mortality rates in elective surgery were 1369 (0.5%) at 30 days and 10,437 (4.0%) at 365 days. For acute surgery, mortality was 10,602 (5.4%) at 30 days and 27,912 (14.2%) at 365 days. Adjusted odds ratios (OR) for 30-day mortality indicated a 14-fold increased risk for ASA physical status 3 compared with ASA physical status 1 in both elective (OR 13.7, 95%CI 7.5-25.0) and acute (OR 14.0, 95%CI 10.2-19.3) surgeries. Correspondingly, ASA physical status ≥ 4 was associated with odds ratios of 62.2 (95%CI 33.5-115.5) for elective and 51.1 (95%CI 37.1-70.3) for acute surgery. DISCUSSION:As populations age and surgical demand increases, continuous evaluation of risk assessment tools like the ASA physical status is essential. This study shows a strong association between ASA physical status and mortality across all ages in a contemporary adult surgical cohort. These findings could enhance our understanding of peri-operative risk stratification in the context of shifting demographic trends.

Summary Introduction As the global population ages, the demand for surgical interventions in older adults is rising. Older patients face increased risks due to age‐related physiological changes and comorbidities, making surgery and postoperative care challenging. This study aimed to assess short‐ and long‐term mortality, as well as patient‐centred outcomes such as days alive and at home 30 and 90 days after surgery, in patients aged ≥ 80 y undergoing surgical procedures. Methods This nationwide cohort study utilised data from the Swedish Perioperative Register, including surgeries in patients aged ≥ 80 y in Sweden from January 2019 to March 2023. We linked peri‐operative data with the National Patient Register for comorbidities and with the National Cause of Death Register. The primary outcome was all‐cause 30‐day mortality, with secondary outcomes of 365‐day mortality and days alive and at home 30 and 90 days after surgery. Results A total of 118,359 patients were included, with 54,320 undergoing elective and 64,039 acute surgeries. Thirty‐day mortality was 1.2% for elective and 9.9% for acute surgeries. Mortality increased significantly with age, particularly for patients aged ≥ 90 y compared with those aged 80–84 y. Days alive and at home 30 and 90 days after surgery were significantly lower for acute surgery patients, indicating longer recovery times and more postoperative complications. Discussion Older adults, especially those aged ≥ 90 y, experience high mortality and significant challenges in postoperative recovery after acute surgeries. Elective surgeries are associated with lower short‐term mortality, suggesting that age alone should not preclude surgical interventions. Tailored peri‐operative care and patient‐centred decision‐making are essential to improve outcomes in this vulnerable population.

BACKGROUND:Continuous glucose monitoring (CGM) has the potential to improve glucose control in critically ill patients, provided that its trend accuracy is reliable. We evaluated the trend accuracy of a subcutaneous CGM system (Dexcom G6) compared with intermittent arterial blood gas (ABG) measurements in intensive care unit (ICU) patients receiving insulin. METHODS:We enrolled 40 adult ICU patients receiving insulin and organ-supportive therapies. We assessed trend accuracy using the Rate Error Grid Analysis (R-EGA) and the Diabetes Technology Society Trend Accuracy Matrix (DTS-TAM), overall, across different ABG levels, and over time from CGM initiation. RESULTS:A total of 2701 paired CGM-ABG trends were analyzed, with a median (IQR) time difference between readings of 83 (65-125) minutes. Overall, 99.7% of trends were classified in R-EGA Zone A and 0.3% in Zone B. On DTS-TAM analysis, 98.6% of trends fell in the No Risk category, while 1.7% were in the adjacent Mild-to-Moderate Risk categories. Trends were more frequently categorized as Mild-to-Moderate Risk when ABG values were <100 mg/dL (5.56 mmol/L) (3.6%) compared with 100 to 180 mg/dL (5.56 to 10 mmol/L) (1.3%) or >180 mg/dL (10 mmol/L) (1.6%). During the first 24 hours of CGM use, 2.9% of trends fell into the Mild-to-Moderate Risk categories, compared with 0.9% beyond 24 hours. CONCLUSIONS:In critically ill patients receiving insulin, CGM demonstrated high overall trend accuracy relative to ABG. Trend accuracy was reduced at lower glucose ranges and during the initial 24 hours of CGM use.

Background: Neutrophil-derived heparin-binding protein (HBP) plays a role in the pathophysiology of impaired endothelial dysfunction during inflammation. HBP has been suggested as a predictor of organ dysfunction and disease progression in sepsis. We investigated the effects of heparins on plasma concentrations of HBP in patients undergoing surgery. Methods: We studied three groups of patients receiving heparins during or after surgery. The vascular surgery group received 3000-7500 U, whereas the cardiac surgery group received 27 500-40 000 U. After major general surgery, the third group received 5000 U of low-molecular-weight heparin (LMWH) subcutaneously. Serial plasma HBP concentrations were measured after these treatments with two different methods: Axis-Shield ELISA and Joinstar FIC-Q100. In addition, plasma myeloperoxidase and syndecan-1 were measured in the cardiac surgery group. Results: During vascular surgery, heparin induced a six-fold increase in HBP within 2 min, from 3.6 (2.4-5.4) to 21.4 (9.0-35.4) ng ml-1 (P<0.001). During cardiac surgery, the higher dose of heparin elevated HBP concentrations from 5.3 (2.7-6.1) to 48.7 (38.4-70.1) ng ml-1 (P<0.0001) within 3 min. Patients receiving LMWH showed an increase from a baseline of 5.7 (3.7-12.1) ng ml-1 to a peak HBP concentration of 14.8 (9.5-18.1) ng ml-1 (P<0.0001) after 3 h. Plasma concentrations of myeloperoxidase, but not syndecan-1, also responded with a rapid increase after heparin. There was a strong correlation between the two methods for HBP analysis (r=0.94). Conclusions: Plasma concentrations of HBP increased rapidly and dose-dependently after heparin administration. Subcutaneous administration of LMWH increases plasma HBP, but to a lesser degree. Clinical trial registration: ClinicalTrials.gov identifier: NCT04146493.

Background: Subcutaneous continuous glucose monitoring (CGM) may facilitate glucose control in the ICU. We aimed to assess the accuracy of CGM (Dexcom G6) against arterial blood glucose (ABG) in adult critically ill patients receiving intravenous insulin infusion and vasopressor therapy. We also aimed to assess feasibility and tolerability of CGM in this setting. Methods: We included ICU patients receiving mechanical ventilation, insulin, and vasopressor therapy. Numerical accuracy was assessed by the mean absolute relative difference (MARD), overall, across arterial glucose strata, over different noradrenaline equivalent infusion rates, and over time since CGM start. MARD <14% was considered acceptable. Clinical accuracy was assessed using Clarke Error Grid (CEG) analysis. Feasibility outcome included number and duration of interrupted sensor readings due to signal loss. Tolerability outcome included skin reactions related to sensor insertion or sensor adhesives. Results: We obtained 2946 paired samples from 40 patients (18 with type 2 diabetes) receiving a median (IQR) maximum noradrenaline equivalent infusion rate of 0.18 (0.08-0.33) µg/kg/min during CGM. Overall, MARD was 12.7% (95% CI 10.7-15.3), and 99.8% of CGM readings were within CEG zones A and B. MARD values ≥14% were observed when ABG was outside target range (6-10 mmol/L [108-180 mg/dL]) and with noradrenaline equivalent infusion rates above 0.10 µg/kg/min. Accuracy improved with time after CGM start, reaching MARD values <14% after 36 h. We observed four episodes of interrupted sensor readings due to signal loss, ranging from 5 to 20 min. We observed no skin reaction related to sensor insertion or sensor adhesives. Conclusions: In our ICU cohort of patients receiving vasopressor infusion, subcutaneous CGM demonstrated acceptable overall numerical and clinical accuracy. However, suboptimal accuracy may occur outside glucose ranges of 6-10 mmol/L (108-180 mg/dL), during higher dose vasopressor infusion, and during the first 36 h after CGM start.

Modern intensive care has improved survival rates, but emerging evidence suggests a high prevalence of post-intensive care unit (ICU) health problems, including post-traumatic stress disorder, depression and anxiety. These symptoms may have a detrimental effect on quality of life and increase mortality. The primary objective of this study is to examine the extent of initiation of antidepressant medication among ICU survivors and identify the factors associated with its usage. The secondary objective is to investigate whether the use of these medications is linked to an increased mortality. The nationwide study cohort included 125,130 ICU survivors admitted between 2010 and 2017. Within the first 3 months after ICU discharge, 7% of patients initiated antidepressant medication, by 1 year 15.5% had started medication. We found no tendency to a decrease during the 2-year follow-up period. Factors associated with antidepressant use included middle age, female sex, psychiatric and somatic comorbid conditions, substance dependence, higher illness severity, and longer ICU stay. Antidepressant users had a higher mortality rate, and deaths due to external causes and suicide were more frequent in this group. This study emphasizes the importance of detecting and addressing depression in ICU survivors to improve their quality of life and reduce mortality rates.

OBJECTIVES: Exposure to critical illness and intensive care may lead to long-term psychologic and physical impairments. To what extent ICU survivors become prolonged users of benzodiazepines after exposure to critical care is not fully explored. This study aimed to describe the extent of onset of prolonged high-potency benzodiazepine use among ICU survivors not using these drugs before admission, identify factors associated with this use, and analyze whether such usage is associated with increased mortality. DESIGN: Retrospective cohort study. SETTING: Sweden, including all registered ICU admissions between 2010 and 2017. PATIENTS: ICU patients surviving for at least 3 months, not using high-potency benzodiazepine before admission, were eligible for inclusion. INTERVENTIONS: Admission to intensive care. MEASUREMENTS AND MAIN RESULTS: A total of 237,904 patients were screened and 137,647 were included. Of these 5338 (3.9%) became prolonged users of high-potency benzodiazepines after ICU discharge. A peak in high-potency benzodiazepine prescriptions was observed during the first 3 months, followed by sustained usage throughout the follow-up period of 18 months. Prolonged usage was associated with older age, female sex, and a history of both somatic and psychiatric comorbidities, including substance abuse. Additionally, a longer ICU stay, a high estimated mortality rate, and prior consumption of low-potency benzodiazepines were associated with prolonged use. The risk of death between 6 and 18 months post-ICU admission was significantly higher among high-potency benzodiazepine users, with an adjusted hazard ratio of 1.8 (95% CI, 1.7-2.0; p < 0.001). No differences were noted in causes of death between users and nonusers. CONCLUSIONS: Despite the lack of evidence supporting long-term treatment, prolonged usage of high-potency benzodiazepines 18 months following ICU care was notable and associated with an increased risk of death. Considering the substantial number of ICU admissions, prevention of benzodiazepine misuse may improve long-term outcomes following critical care.

AIMS:To study the association between glycated haemoglobin (HbA1c) and sepsis in adults with type 1 diabetes, and to explore the relationship between HbA1c and mortality among individuals who developed sepsis. MATERIALS AND METHODS:We included 33 549 adult individuals with type 1 diabetes recorded in the Swedish National Diabetes Register between January 2005 and December 2015. We used multivariable Cox regression and restricted cubic spline analyses to study the relationship between HbA1c values and sepsis occurrence and association between HbA1c and mortality among those with sepsis. RESULTS:In total, 713 (2.1%) individuals developed sepsis during the study period. Compared with the HbA1c reference interval of 48-52 mmol/mol (6.5-6.9%), the adjusted hazard ratio for sepsis was: 2.50 [95% confidence interval (CI) 1.18-5.29] for HbA1c <43 mmol/mol; 1.88 (95% CI 0.96-3.67) for HbA1c 43-47 mmol/mol; 1.78 (95% CI 1.09-2.89) for HbA1c 53-62 mmol/mol; 1.86 (95% CI 1.14-3.03) for HbA1c 63-72 mmol/mol; 3.15 (95% CI 1.91-5.19) for HbA1c 73-82 mmol/mol; and 4.26 (95% CI 2.53-7.16) for HbA1c >82 mmol/mol. On multivariable restricted cubic spline analysis, we found a J-shaped association between HbA1c and sepsis risk, with the lowest risk observed at HbA1c of approximately 53 mmol/mol. We found no association between HbA1c and mortality among those individuals who developed sepsis. CONCLUSIONS:In our nationwide observational study of adult individuals with type 1 diabetes we found a J-shaped relationship between HbA1c and risk of sepsis, with the lowest risk at HbA1c levels about 53 mmol/mol (7.0%). HbA1c was not associated with mortality in individuals affected by sepsis.

OBJECTIVE:Using 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 explore the association between chronic dysglycaemia and clinical outcomes related to ICU stay. DESIGN:Multicentre retrospective observational study. SETTING:ICUs in three hospitals in Stockholm, Sweden. PARTICIPANTS:COVID-19 patients admitted to the ICU between 5 March 2020 and 13 August 2020 with available HbA1c at admission. Chronic dysglycaemia was determined based on previous diabetes history and HbA1c. PRIMARY AND SECONDARY OUTCOMES:Primary outcome was the actual prevalence of chronic dysglycaemia (pre-diabetes, unknown diabetes or known diabetes) among COVID-19 patients. Secondary outcome was the association of chronic dysglycaemia with 90-day mortality, ICU length of stay, duration of invasive mechanical ventilation (IMV) and renal replacement therapy (RRT), accounting for treatment selection bias. RESULTS:A total of 308 patients with available admission HbA1c were included. Chronic dysglycaemia prevalence assessment was restricted to 206 patients admitted ICUs in which HbA1c was measured on all admitted patients. Chronic dysglycaemia was present in 82.0% (95% CI 76.1% to 87.0%) of patients, with pre-diabetes present in 40.2% (95% CI 33.5% to 47.3%), unknown diabetes in 20.9% (95% CI 15.5% to 27.1%), well-controlled diabetes in 7.8% (95% CI 4.5% to 12.3%) and uncontrolled diabetes in 13.1% (95% CI 8.8% to 18.5%). All patients with available HbA1c were included for the analysis of the relationship between chronic dysglycaemia and secondary outcomes. We found no independent association between chronic dysglycaemia and 90-day mortality, ICU length of stay or duration of IMV. After excluding patients with specific treatment limitations, no association between chronic dysglycaemia and RRT use was observed. CONCLUSIONS:In our cohort of critically ill COVID-19 patients, the prevalence of chronic dysglycaemia was 82%. We found no robust associations between chronic dysglycaemia and clinical outcomes when accounting for treatment limitations.

IMPORTANCE:. Refined knowledge of risk factors for critical influenza and COVID-19 may lead to improved understanding of pathophysiology and better pandemic preparedness. OBJECTIVES:. To compare risk-factor profiles of patients admitted to intensive care with critical influenza and COVID-19. DESIGN, SETTING, AND PATIENTS:. A nationwide retrospective matched case-control study, including all adults admitted to an ICU in Sweden with influenza or COVID-19 between 2014 and September 2020 and a matched control population (ratio 1:5, patients:controls). MEASUREMENTS AND MAIN RESULTS:. Admission to an ICU. The study included 1,873 influenza and 2,567 COVID-19 ICU patients, and 9,365 and 12,835 controls, respectively, matched on sex, age, and geographical region. Influenza patients were older and less likely male, and carried a larger burden of comorbidity and a higher Simplified Acute Physiology Score III score, whereas short-term mortalities were similar when compared to COVID-19 patients. The risk-factor profiles at ICU admission were largely comparable including socioeconomic, psychiatric, and several somatic variables. Hypertension was a strong risk factor in critical COVID-19 patients compared with influenza. Nonglucocorticoid immunosuppressive therapy was associated with critical influenza but not COVID-19. Premorbid medication with statins and renin-angiotensin-aldosterone system inhibitors reduced the risk for both conditions, the opposite was a seen for glucocorticoid medication. Notably, medication with betablockers, oral anticoagulation, and platelet inhibitors reduced the risk of critical COVID-19 but not influenza. CONCLUSIONS:. The risk-factor profiles for critical influenza and COVID-19 were largely comparable; however, some important differences were noted. Hypertension was a stronger risk factor for developing critical COVID-19, whereas the use of betablockers, oral anticoagulants, and platelet inhibitors all reduced the risk of ICU admission for COVID-19 but not influenza. Findings possibly reflected differences in pathophysiological mechanisms between these conditions.

Background COVID-19 ARDS shares features with non-COVID ARDS but also demonstrates distinct physiological differences. Despite a lack of strong evidence, prone positioning has been advocated as a key therapy for COVID-19 ARDS. The effects of prone position in critically ill patients with COVID-19 are not fully understood, nor is the optimal time of initiation defined. In this nationwide cohort study, we aimed to investigate the association between early initiation of prone position and mortality in mechanically ventilated COVID-19 patients with low oxygenation on ICU admission. Methods Using the Swedish Intensive Care Registry (SIR), all Swedish ICU patients ≥ 18 years of age with COVID-19 admitted between March 2020, and April 2021 were identified. A study-population of patients with PaO 2 /FiO 2 ratio ≤ 20 kPa on ICU admission and receiving invasive mechanical ventilation within 24 h from ICU admission was generated. In this study-population, the association between early use of prone position (within 24 h from intubation) and 30-day mortality was estimated using univariate and multivariable logistic regression models. Results The total study cohort included 6350 ICU patients with COVID-19, of whom 46.4% were treated with prone position ventilation. Overall, 30-day mortality was 24.3%. In the study-population of 1714 patients with lower admission oxygenation (PaO 2 /FiO 2 ratio ≤ 20 kPa), the utilization of early prone increased from 8.5% in March 2020 to 48.1% in April 2021. The crude 30-day mortality was 27.2% compared to 30.2% in patients not receiving early prone positioning. We found no significant association between early use of prone positioning and survival. Conclusions During the first three waves of the COVID-19 pandemic, almost half of the patients in Sweden were treated with prone position ventilation. We found no association between early use of prone positioning and survival in patients on mechanical ventilation with severe hypoxemia on ICU admission. To fully elucidate the effect and timing of prone position ventilation in critically ill patients with COVID-19 further studies are desirable.