Glycaemic control and sepsis risk in adults with type 1 diabetes.

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.

Risk for Acute Myocardial Infarction After Ophthalmologic Procedures.

BACKGROUND: Preoperative cardiovascular evaluations are frequently done before ambulatory ophthalmologic procedures. However, whether these procedures can trigger an acute myocardial infarction (AMI) is unknown. OBJECTIVE: To assess the short-term risk for AMI associated with ophthalmologic procedures. DESIGN: Case-crossover design. SETTING: Population-based nationwide study from Norway and Sweden. PARTICIPANTS: First-time patients with AMI, aged 40 years and older, identified via inpatient registries and linked to outpatient surgical procedures in Norway (2008 to 2014) and Sweden (2001 to 2014), respectively. MEASUREMENTS: Using self-matching, for each participant, exposure to ophthalmologic procedures in the 0 to 7 days before AMI diagnosis (hazard period) was compared with an 8-day period 30 days earlier, that is, days 29 to 36 before AMI (control period) to estimate the relative risk for an AMI the week after an ophthalmologic procedure. The odds ratios (ORs) with 95% CIs were calculated, using conditional logistic regression. Only patients who had a procedure of interest during either the hazard or control period were included. RESULTS: For the 806 patients with AMI included in this study, there was a lower likelihood of AMI in the week after an ophthalmologic procedure than during the control week (OR, 0.83; 95% CI, 0.75 to 0.91). Furthermore, there was no evidence of increased risk for AMI when analyses were stratified by surgery subtype, anesthesia (local or general), duration, invasiveness (low, intermediate, or high), patient's age (<65 years or ≥65 years), or comorbidity (none vs. any). LIMITATION: Potential bias from time-varying confounders between the hazard and the control periods. CONCLUSION: Ophthalmologic procedures done in an outpatient setting did not seem to be associated with an increased risk for AMI. PRIMARY FUNDING SOURCE: Central Norway Regional Health Authority and the Swedish Research Council.

Population Kinetics of 0.9% Saline Distribution in Hemorrhaged Awake and Isoflurane-anesthetized Volunteers.

BACKGROUND: Population-based, pharmacokinetic modeling can be used to describe variability in fluid distribution and dilution between individuals and across populations. The authors hypothesized that dilution produced by crystalloid infusion after hemorrhage would be larger in anesthetized than in awake subjects and that population kinetic modeling would identify differences in covariates. METHODS: Twelve healthy volunteers, seven females and five males, mean age 28 ± 4.3 yr, underwent a randomized crossover study. Each subject participated in two separate sessions, separated by four weeks, in which they were assigned to an awake or an anesthetized arm. After a baseline period, hemorrhage (7 ml/kg during 20 min) was induced, immediately followed by a 25 ml/kg infusion during 20 min of 0.9% saline. Hemoglobin concentrations, sampled every 5 min for 60 min then every 10 min for an additional 120 min, were used for population kinetic modeling. Covariates, including body weight, sex, and study arm (awake or anesthetized), were tested in the model building. The change in dilution was studied by analyzing area under the curve and maximum plasma dilution. RESULTS: Anesthetized subjects had larger plasma dilution than awake subjects. The analysis showed that females increased area under the curve and maximum plasma dilution by 17% (with 95% CI, 1.08 to 1.38 and 1.07 to 1.39) compared with men, and study arm (anesthetized increased area under the curve by 99% [0.88 to 2.45] and maximum plasma dilution by 35% [0.71 to 1.63]) impacted the plasma dilution whereas a 10-kg increase of body weight resulted in a small change (less than1% [0.93 to 1.20]) in area under the curve and maximum plasma dilution. Mean arterial pressure was lower in subjects while anesthetized (P < 0.001). CONCLUSIONS: In awake and anesthetized subjects subjected to controlled hemorrhage, plasma dilution increased with anesthesia, female sex, and lower body weight. Neither study arm nor body weight impact on area under the curve or maximum plasma dilution were statistically significant and therefore no effect can be established.

Impact of hemodynamic goal-directed resuscitation on mortality in adult critically ill patients: a systematic review and meta-analysis.

The effect of hemodynamic optimization in critically ill patients has been challenged in recent years. The aim of the meta-analysis was to evaluate if a protocolized intervention based on the result of hemodynamic monitoring reduces mortality in critically ill patients. We performed a systematic review and meta-analysis according to the Cochrane Handbook for Systematic Reviews of Interventions. The study was registered in the PROSPERO database (CRD42015019539). Randomized controlled trials published in English, reporting studies on adult patients treated in an intensive care unit, emergency department or equivalent level of care were included. Interventions had to be protocolized and based on results from hemodynamic measurements, defined as cardiac output, stroke volume, stroke volume variation, oxygen delivery, and central venous-or mixed venous oxygenation. The control group had to be treated without any structured intervention based on the parameters mentioned above, however, monitoring by central venous pressure measurements was allowed. Out of 998 screened papers, thirteen met the inclusion criteria. A total of 3323 patients were enrolled in the six trials with low risk of bias (ROB). The mortality was 22.4% (374/1671 patients) in the intervention group and 22.9% (378/1652 patients) in the control group, OR 0.94 with a 95% CI of 0.73-1.22. We found no statistically significant reduction in mortality from hemodynamic optimization using hemodynamic monitoring in combination with a structured algorithm. The number of high quality trials evaluating the effect of protocolized hemodynamic management directed towards a meaningful treatment goal in critically ill patients in comparison to standard of care treatment is too low to prove or exclude a reduction in mortality.

Can noninvasive hemoglobin measurement reduce the need for preoperative venipuncture in pediatric outpatient surgery?

BACKGROUND: Noninvasive measurements of hemoglobin in the pediatric perioperative setting could be helpful to avoid venipunctures in children. The present study aims to evaluate this by using a noninvasive device for hemoglobin determination. We compared noninvasively obtained hemoglobin with laboratory hemoglobin concentrations in children during their preoperative assessment. METHODS: In an observational study, 122 nonanemic children (age 4.2 ± 1.6 years) who were scheduled to undergo different surgical procedures under general anesthesia were included. In their preoperative preparations, single invasive blood samples for laboratory hemoglobin concentrations were routinely taken following hospital policy and compared to simultaneous noninvasive determinations of hemoglobin. A preoperative invasive value ≤9 g/dL would have caused cancelation of surgery and implied further investigations. RESULTS: A Bland-Altman plot showed that the average difference between noninvasively obtained hemoglobin and laboratory hemoglobin concentration was -0.44 g/dL (bias) with a standard deviation of the mean bias of 1.04 g/dL. A hemoglobin error grid showed that the noninvasive device could identify almost all invasive hemoglobin values >9 g/dL. In total, there were 4 false-positive values where noninvasively obtained hemoglobin observations were below while the paired invasive values were above 9 g/dL. CONCLUSION: The data in this pediatric setting suggest that the device may eliminate the need for venipuncture in nonanemic children.

Analgesic effect of a single dose of betamethasone after ambulatory knee arthroscopy: a randomized controlled trial.

PURPOSE: Glucocorticoids are reported to improve postoperative analgesia. The purpose of the study was to investigate whether a preoperative, single dose of betamethasone could reduce pain after ambulatory arthroscopic knee surgery. METHODS: This was a randomized, double-blind, placebo-controlled trial including patients scheduled for knee arthroscopy. The intervention was an intravenous injection of betamethasone 8 mg or placebo. The primary outcome was pain day 1 evaluated by a verbal descriptor scale (VDS). RESULTS: In total, 74 patients (betamethasone = 34; placebo = 40) were randomized. One patient in each group was excluded from analysis. During activity day 1 following surgery, the proportion with no or minor pain was significantly (p = 0.030) higher in the betamethasone group (22 of 33; 67 %) compared with the placebo group (17 of 39; 44 %). At rest, the corresponding figures were 26 of 33 (79 %) for betamethasone and 24 of 39 (62 %) for placebo (p = 0.062). After 3 months of follow-up, no patient receiving betamethasone experienced adverse events while six receiving placebo did (postoperative nausea and vomiting in five and delayed wound healing in one). CONCLUSIONS: An analgesic benefit was seen day 1 following surgery. This indicates that betamethasone has a place in ambulatory arthroscopic knee surgery. TRIAL REGISTRATION: https://www.clinicaltrialsregister.eu/ (identifier 2009-014717-27).

A mini volume loading test (mVLT) using 2.5-mLkg-1 boluses of crystalloid for indication of perioperative changes in hydration status.

BACKGROUND AND OBJECTIVE: A mini volume loading test (mVLT) evaluating hemodilution during step-wise crystalloid infusion has established that the arterio-capillary plasma dilution difference is inversely correlated to the body hydration level of subjects. This observational study aimed to test whether this can be replicated in a perioperative setting using a 2.5-mLkg-1 boluses. MATERIALS AND METHODS: The mVLT was performed before induction of regional anesthesia and 24h later. Step-wise infusion implied six mini fluid challenges. These consisted of 2.5-mLkg-1 boluses of Ringer's acetate infused during 2-3min and followed by 5-min periods with no fluids. Invasive (arterial) and noninvasive (capillary) measurements of hemoglobin were performed before and after each mini fluid challenge, as well as after a 20-min period without fluid following the last bolus. Hemoglobins were used to calculate the arterio-capillary plasma dilution difference which is used as an indication of changes in body hydration level. The 24-h fluid balance was calculated. RESULTS: Subjects were 69.5 (6.0) years old, their height was 1.62m (1.56-1.65), weight was 87.0kg (75.5-97.5) and body mass index (BMI) was 33.5kg/m2 (31.0-35.1). Preoperative arterio-capillary plasma dilution difference was significantly higher than postoperative (0.085 [0.012-0.141] vs. 0.006 [-0.059 to 0.101], P=0.000). The perioperative 24-h fluid balance was 1976mL (870-2545). CONCLUSIONS: The mVLT using 2.5-mLkg-1 boluses of crystalloid was able to detect the higher postoperative body hydration level in total knee arthroplasty patients.

The use of a noninvasive hemoglobin monitor for determining fluid distribution and elimination in pediatric patients undergoing minor surgery.

In pediatric fluid therapy it would be preferable to describe distribution and elimination a fluid bolus based on repetitive hemoglobin (Hb) according to kinetic principles. Pulse CO-Oximetry is a recent advancement in patient monitoring that allows for the continuous noninvasive measurement of Hb (SpHb). The aim of this study was to describe the distribution and elimination of hydroxyethylstarch (HES) 130/0.4 in combination with crystalloids using a noninvasive Hb monitor in two cohorts of young children undergoing minor surgeries under general anesthesia. Two cohorts, 16 children aged 1-3 years and 12 aged 4-6 years, were investigated during anesthesia and minor surgical procedures. They were given a maintenance solution of lactated Ringer's and a fluid bolus of HES 130/0.4, 6 mL/kg over a period of 20 min. The whole procedure lasted 120 min, and SpHb values were measured every 10 min. The SpHb values were used to calculate plasma dilution, net volume, and mean residence time (MRT) of the infused fluid. A total of 377 measured SpHbs generated individual dilution plots that showed variability, particularly for the older cohort. Distribution and elimination rates of the infused fluid were calculated. Mean dilution plots were generated. There were no significant differences in dilution, net volume or MRT between groups. A non invasive Hb analyzer could be used to calculate fluid distribution. The variability in the data can probably be explained by reactions to anesthetic drugs, variability in measurement technique, variability in generating the complex capillary signals, and individual variability in baseline fluid status. The latter finding is important because this is a prerequisite for perioperative fluid planning for each individual.

A mini volume loading test for indication of preoperative dehydration in surgical patients.

BACKGROUND AND OBJECTIVE: Previously, a mini volume loading test (mVLT) detected signs of dehydration in healthy volunteers after an overnight fast. Our objective was to investigate whether mVLT could indicate preoperative dehydration in patients after an overnight fast. MATERIALS AND METHODS: The mVLT was performed in 36 elective primary total knee arthroplasty patients. Each subject received three fluid challenges before anesthesia induction. These consisted of 5 mL/kg boluses of Ringer's acetate infused over 3-5 min and followed by a 5-min period without fluids. Invasive (arterial, venous) and noninvasive (capillary) measurements of hemoglobin concentration were performed before and after each fluid challenge, as well as after a 20-min period without fluids which followed the last bolus. Arterial, venous and capillary plasma dilutions were calculated in every data point. Dilution values were used to calculate the plasma dilution efficacy of each fluid challenge. RESULTS: Venous dilution was higher than capillary after the first fluid challenge (P=0.030), but lower than capillary after 20 min period following the last bolus (P=0.009). Arterial dilution was lower than capillary (P=0.005) after 20 min following the last bolus. Veno-capillary and arterio-capillary plasma dilution efficacy differences decreased (P=0.004 and P=0.033, respectively) from positive to negative during mVLT. These are signs of re-hydration from pre-existing dehydration according to a transcapillary reflux model. CONCLUSIONS: Signs of dehydration were observed during mVLT in patients after pre-operative overnight fast. A revised transcapillary reflux model was proposed to explain the results.

Micturition problems after bladder distension during hospitalization in Sweden: "I'm not ill, just damaged for the rest of my life".

BACKGROUND: Urinary retention is a common complication following hospital care, which can result in overdistension of the bladder and, at worst, chronic bladder damage and persistent micturition difficulties. OBJECTIVES: The purpose of this study was to explore patients' experiences of micturition problems after bladder distension and their effects on the patients' everyday lives. METHODS: The Swedish Patient Insurance LÖF was used to identify patients from January 2007 to June 2010 who have reported micturition problems after hospital care and have had their injuries classified as avoidable bladder damage due to overdistension. Narrative interviews were conducted with 20 volunteers and analyzed by qualitative content analysis. RESULTS: The micturition problems affected everyday life through constraints (dependence on disposables and access to toilets, clothing restrictions, limitations on social life and career), suffering (pain, infections, impaired sex life, leakage), and concerns for the future (fear of worsening symptoms and fear of losing control with age). Aspects related to having been harmed by the healthcare system were the harm could have been avoided (lack of knowledge, insufficient routines, mistrust), obstacles to overcome when reporting an injury (difficulties in obtaining knowledge about the possibility of reporting an injury, ambivalence toward reporting their healthcare providers), and a wish to improve care (raise awareness, prevent harm to others). DISCUSSION: Bladder distension is a healthcare-related injury that can cause suffering and practical, emotional, and psychosocial problems with a great impact on the life of the person affected and anxiety for the future. The healthcare system must, therefore, raise awareness and improve preventive routines.

Evaluation of hydration status calculated from differences in venous and capillary plasma dilution during stepwise crystalloid infusions: A randomized crossover study in healthy volunteers.

BACKGROUND AND OBJECTIVE: A mini volume loading test (mVLT) was proposed for estimating hydration status and interstitial fluid accumulation during stepwise infusion of crystalloids. The method is based on both the transcapillary reflux model and the hypothesis that when subjects are dehydrated, venous plasma dilution induced by a fluid challenge is higher than in the capillaries, and that difference is diminished when the fluid challenge is given to more hydrated individuals. Our objective was to test that hypothesis by evaluating the veno-capillary dilution difference during mVLT in subjects with different hydration status. MATERIALS AND METHODS: In a prospective randomized crossover study, three mini fluid challenges were given to 12 healthy volunteers on two occasions. The subjects were either dehydrated or hydrated before the experiments. RESULTS: In dehydrated subjects only, capillary plasma dilution was significantly lower than venous (P=0.015, 0.005 and 0.006) after each mini fluid challenge. CONCLUSIONS: Veno-capillary dilution difference during mVLT depends on the hydration status. The mVLT method could possibly discriminate between the different states of hydration.

The use of a noninvasive hemoglobin monitor for volume kinetic analysis in an emergency room setting.

BACKGROUND: Distribution and clearance of an infused bolus can be studied by repetitive sampling of invasive total hemoglobin (tHb) using volume kinetic equations. Pulse CO-oximetry, a recent advancement in patient monitoring that allows for the continuous and noninvasive estimation of hemoglobin concentration (SpHb), would greatly facilitate the scientific and clinical use of the volume kinetic parameters. In the present study, we examined whether serial measurements of SpHb in an emergency room setting can be used to calculate distribution volume (V) and clearance (Cl) rate of an infused bolus. METHODS: This was a prospective, observational study of patients in 2 age groups admitted for various reasons to the emergency room of a tertiary care center. IV catheters were placed in both arms of the subjects to induce plasma volume expansion by infusion of a buffered crystalloid glucose solution and for withdrawing venous blood samples for analysis of tHb at 0, 5, 10, 15, 30, 45, 60, 75, and 90 minutes after start of infusion. During these interventions, subjects were simultaneously monitored by pulse CO-oximetry for measurement of SpHb (Masimo Radical-7, Rev E ReSposable Sensor). Bias, precision, and limits of agreement were calculated in Bland-Altman plots to compare the accuracy of SpHb with invasive tHb measurements. Using volume kinetic (pharmacokinetics for fluids) equations, V and Cl were determined. RESULTS: Thirty patients (14 from the young group with a mean age of 30 years, and 16 from the geriatric group with mean age of 84 years) were enrolled in the study. When all data were included, this yielded 242 data pairs with a bias of -0.47 (95% confidence interval, -0.62 to -0.32) between SpHb and tHb. However, 5 patients were omitted because of low quality signals, leaving 193 hemoglobin data pairs for further analysis. Bias was then -0.24 (95% confidence interval, -0.39 to -0.09). The biases show that the device on average slightly underestimates tHb values. The precision of SpHb decreases when the low signal quality indicator is present. For the 27 subjects for whom the V and Cl were calculated, there were no significant differences in the estimation of the distribution volumes using either tHb or SpHb values. Clearance constants were also estimated, but with less accuracy. CONCLUSIONS: Our data show that SpHb by pulse CO-oximetry may be used to calculate volume of distribution in an emergency room setting.

A randomized double-blind clinical trial of tourniquet application strategies for total knee arthroplasty.

PURPOSE: The optimal timing of pneumatic lower limb tourniquet application during primary elective total knee arthroplasty surgery (TKA) is a matter of debate. Most previous reports have failed to show significant differences between different tourniquet timings. The aim of the work was to determine how three strategies of lower limb pneumatic tourniquet application affect the outcome for TKA patients. METHODS: Forty-three patients who undergo TKA were randomized into one of the three groups, and 36 of these patients completed the study. The tourniquet was inflated just before incision and deflated after the hardening of the cement for twelve patients (Group 1), it was inflated just before cement application and deflated after its hardening for another twelve patients (Group 2), and it was inflated before incision and deflated after the last suture of the skin for a further twelve patients (Group 3). Fit-to-discharge criteria and six methods for calculating estimated blood loss were used. RESULTS: The estimated blood loss in Group 1 was lower than in Group 2, as determined by six methods of calculation (p < 0.05). Estimated blood loss in Group 3 was lower than in Group 2, as determined by one method (p = 0.050). The mobilization performance in Group 1 was better than in Group 2 (p = 0.023) and in Group 3 (p = 0.033). Group 1 was better fit to discharge than Group 3 (p = 0.030). CONCLUSIONS: Inflation of an automatic pneumatic lower limb tourniquet before skin incision and its deflation after hardening of cement tends to give better outcomes in TKA patients during six postoperative days. The estimated blood loss was highest when the tourniquet was inflated just before cement application and deflated after its hardening.

The distorted memories of patients treated in the intensive care unit during the COVID-19 pandemic: A qualitative study.

BACKGROUND: During the COVID-19 pandemic, patients cared for in the intensive care unit were exposed to many risk factors for developing delirium and subsequent distorted memories. Further, seeing healthcare professionals who have been dressed in personal protective equipment and face masks could have affected the patients' memories. Therefore, the aim of this study was to explore memories and how they are experienced and managed by former patients who have been treated for COVID-19 in an intensive care unit. METHODS: Sixteen former patients treated for COVID-19 at a large emergency hospital in Sweden were interviewed 3-8 months after discharge from the intensive care unit. The data were interpreted using thematic analysis. The Consolidated Criteria for Reporting Qualitative Research checklist was followed in the reporting of the study. FINDINGS: Participants' descriptions of their memories of treatment in the intensive care unit for COVID-19 generated three themes: 'Distorted truth' the content in the memories which implied facing death in an unreal distorted environment. 'Captive,' was the experience and feelings linked to memories with a feeling of being exposed and alone, and 'Coping with memories' explained how participants managed the implications of the memories using a mixture of strategies. CONCLUSIONS: For former patients who were admitted to an intensive care unit after a diagnosis of COVID-19, memories caused considerable distress, which were similar to other intensive care patients experiences, before the pandemic. Emotion-focused and problem-focused strategies could be used to cope with these memories. Healthcare professionals wearing protective equipment gave the patient a distant feeling, but more important was to be treated with attention/care and respect. IMPLICATIONS FOR CLINICAL PRACTICE: Awareness of the impact of distorted memories on patients who are severely ill and their needs and strategies to cope with these memories can form the basis for early interventions that promotes well-being during care and recovery. Healthcare professionals have an important task to inform patients and their family members about the existence of distorted memories, and talk about the patients' experience of them, to facilitate their recovery.

Shifting focus: A grounded theory of how family members to critically ill patients manage their situation.

OBJECTIVES: Critical illness is a life-threatening condition for the patient, which affects their family members as a traumatic experience. Well-known long-term consequences include impact on mental health and health-related quality of life. This study aims to develop a grounded theory to explain pattern of behaviours in family members of critically ill patients cared for in an intensive care unit, addressing the period from when the patient becomes critically ill until recovery at home. RESEARCH METHODOLOGY/DESIGN: We used a classic grounded theory to explore the main concern for family members of intensive care patients. Fourteen interviews and seven observations with a total of 21 participants were analysed. Data were collected from February 2019 to June 2021. SETTING: Three general intensive care units in Sweden, consisting of a university hospital and two county hospitals. FINDINGS: The theory Shifting focus explains how family members' main concern, living on hold, is managed. This theory involves different strategies: decoding, sheltering and emotional processing. The theory has three different outcomes: adjusting focus, emotional resigning or remaining in focus. CONCLUSION: Family members could stand in the shadow of the patients' critical illness and needs. This emotional adversity is processed through shifting focus from one's own needs and well-being to the patient's survival, needs and well-being. This theory can raise awareness of how family members of critically ill patients manage the process from critical illness until return to everyday life at home. Future research focusing on family members' need for support and information, to reduce stress in everyday life, is needed. IMPLICATIONS FOR CLINICAL PRACTICE: Healthcare professionals should support family members in shifting focus by interaction, clear and honest communication, and through mediating hope.

Risk of myocardial infarction after invasive outpatient procedures.

OBJECTIVE: To assess the short-term risk of acute myocardial infarction (AMI) associated with procedures performed at outpatient specialised hospital clinics. METHODS: In this case-crossover, population-based study, we identified first-time AMI cases aged ≥40 years via patient registries and linked them to their surgical intervention in Norway (2008-2016) and Sweden (2001-2014), respectively. The number of individuals with AMI who underwent procedures 0-7 days (hazard period) prior to the AMI diagnosis was compared with cases who were exposed 29-36 days (control period) before the AMI. A total of 6176 patients with AMI who underwent a procedure either during the defined hazard or control period contributed to the analyses. ORs with 95% CIs were computed using conditional logistic regression. RESULTS: The mean age of the total population was 74.7 years and 64.6% were male. The relative risk was higher following procedures performed under general/regional anaesthesia for gastrointestinal endoscopy (ORsummary, 4.23, 95% CI 1.58 to 11.31), vascular (ORsummary, 3.12, 95% CI 1.10 to 8.90), urological/gynaecological (ORsummary, 2.30, 95% CI 1.50 to 3.53) and orthopaedic (ORsummary,1.78, 95% CI 1.30 to 2.44) procedures, and for ENT (ear, nose and throat) and mouth procedures (ORsummary, 1.53, 95% CI 1.19 to 1.99) performed under local anaesthesia. CONCLUSION: This large population-based register study from two countries suggests that outpatient procedures are generally safe with regard to the postoperative risk of AMI. However, some procedures, such as gastrointestinal endoscopy, vascular procedures and urological/gynaecological procedures may increase the risk of AMI by twofold or threefold within the first 8 days after the procedures. Further studies are warranted to assess whether the effect is modified by cardiovascular medication or other clinical factors.

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

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.

Preoperative ultrasound monitoring can reduce postoperative bladder distension: a randomized study.

OBJECTIVE: The aim of this study was to explore whether close preoperative ultrasound monitoring starting in the emergency room (ER) could prevent postoperative bladder distension among acute orthopaedic patients. MATERIAL AND METHODS: A randomized controlled trial was conducted at a 650-bed level-2 centre in Sweden. Inclusion criteria were admittance via ER to an orthopaedic ward for acute surgery. Bladder volumes were measured with a portable ultrasound scanner (Bladderscan BVI 3000). In the intervention group, all patients were scanned in the ER and then regularly at the ward at predefined times until surgery. In the control group, no regular scanning was performed before surgery. During surgery, the same procedure was performed for both groups: bladder scanning immediately after arrival to the recovery room and continuous postoperative scanning until voiding. The primary outcome was postoperative bladder distension, defined as a bladder volume ≥500 ml. Secondary outcomes were postoperative urinary tract infection and hospital length of stay. RESULTS: A total of 281 patients completed the study, 141 in the intervention group and 140 in the control group. Postoperative bladder distension was significantly higher in the control group (27.1% vs 17.0%; p = 0.045, 95% confidence interval 4.9-19.8) in the intention-to-treat, per-protocol and as-treated analyses. No statistical difference was found between the intervention group and the control group regarding the secondary outcomes. CONCLUSIONS: Frequent bladder monitoring starting in the ER can reduce postoperative bladder distension among acute orthopaedic patients. A preoperative bladder monitoring protocol should be implemented early in the ER for all patients admitted for acute orthopaedic procedures.