[Cardiac transplantation and donation in Icelandic patients - indications and outcome].

INTRODUCTION: Information on the number, indications and outcome of cardiac transplantations in Icelandic patients is scarce, as is information on the number of hearts donated from Iceland for cardiac transplantation. MATERIAL AND METHODS: A retrospective study on patients receiving heart transplantation from the first procedure in 1988 until March 2019. Clinical information was gathered from Landspitali Transplantation Clinic, patient charts, and information on donated hearts from the Icelandic Donation Registry. Age-standardized incidence of the procedure was calculated, and overall survival (Kaplan-Meier) estimated. Mean follow-up was 10.3 years. RESULTS: Altogether 24 patients (19 males, median age 38 years, range: 4-65 years) underwent cardiac transplantation; that included one re-transplantation, three simultaneous heart- and lung transplants and two heart- and kidney transplants. The transplantations were performed in Gothenburg (n=20), London (n=3) and Copenhagen (n=2). Most common indications were dilated cardiomyopathy (n=10), congenital heart disease (n=4), and viral myocarditis (n=3). Five patients were bridged left ventricular-assist device preoperatively. Overall survival at 1 and 5 years was 91% and 86%, respectively; median survival being 24 years. The incidence of cardiac transplantation was 2.7 heart-TX pmp/year but increased to 4.6 heart-TX pmp/year after 2008 (p=0.01). During the same period 42 hearts were donated from Iceland for transplantation abroad, the first in 2002 and increasing from 0.8 to 3.0 hearts/year during the first and second half of the study-period, respectively. CONCLUSION: Survival of Icelandic cardiac transplant recipients is good and comparable to larger transplant centers overseas. Number of hearts donated from Iceland have increased and currently Iceland donates twice as many hearts at it receives.

Utilization and outcomes of tracheostomies in the intensive care unit in Iceland in 2007-2020: A descriptive study.

BACKGROUND: Tracheostomies are commonly utilized in ICU patients due to prolonged mechanical ventilation, upper airway obstruction, or surgery in the face/neck region. However, practices regarding the timing of placement and utilization vary. This study provides a nationwide overview of tracheostomy utilization and outcomes in the ICU over a 14-year period. METHODS: A retrospective study including all patients that received a tracheostomy during their ICU stay in Iceland between 2007 and 2020. Data were retrieved from hospital records on admission cause, comorbidities, indication for tracheostomy insertion, duration of mechanical ventilation before and after tracheostomy placement, extubation attempts, complications, length of ICU and hospital stay and survival. Descriptive statistics were provided, and survival analysis was performed using Cox regression. RESULTS: A total of 336 patients (median age 64 years, 33% females) received a tracheostomy during the study period. The most common indication for tracheostomy insertion was respiratory failure, followed by neurological disorders. The median duration of mechanical ventilation prior to tracheostomy insertion was 9 days and at least one extubation had been attempted in 35% of the cases. Percutaneous tracheostomies were 32%. The overall rate of complications was 25% and the most common short-term complication was bleeding (5%). In-hospital mortality was 33%. The one- and five-year survival rate was 60% and 44%, respectively. CONCLUSIONS: We describe a whole-nation practice of tracheostomies. A notable finding is the relatively low rate of extubation attempts prior to tracheostomy insertion. Future work should focus on standardization of assessing the need for tracheostomy and the role of extubation attempts prior to tracheostomy placement.

[Critical care management of patients with spontaneous subarachnoid haemorrhage - a review].

Spontaneous subarachnoid haemorrhage is characterized by extravasation of blood into the subarachnoid space without a preceding trauma. The leading cause is a ruptured intracranial aneurysm. Serious neurologic complications can occur, such as rebleeding, cerebral vasospasm and delayed cerebral ischemia. Subarachnoid haemorrhage is a serious condition with a high mortality rate and those who survive often suffer long-term consequences. Prevention of rebleeding by aneurysm repair is essential and guidelines recommend this procedure should be done as soon as possible or within 72 hours. Management requires intensive care with emphasis on accurate blood pressure control, maintaining normal fluid and electrolyte balance and monitoring the level of consciousness. All patients should be treated with the calcium channel blocker nimodipine to reduce the risk of vasospasm and delayed cerebral ischemia which are among the most serious complications of subarachnoid haemorrhage.

Predictive variables for poor long-term physical recovery after intensive care unit stay: An exploratory study.

BACKGROUND: Elucidating factors that influence physical recovery of survivors after an intensive care unit (ICU) stay is paramount in maximizing long-term functional outcomes. We examined potential predictors for poor long-term physical recovery in ICU survivors. METHODS: Based on secondary analysis of a trial of 50 ICU patients who underwent mobilization in the ICU and were followed for one year, linear regression analysis examined the associations of exposure variables (baseline characteristics, severity of illness variables, ICU-related variables, and lengths of ICU and hospital stay), with physical recovery variables (muscle strength, exercise capacity, and self-reported physical function), measured one year after ICU discharge. RESULTS: When the data were adjusted for age, female gender was associated with reduced muscle strength (P = .003), exercise capacity (P < .0001), and self-reported physical function (P = .01). Older age, when adjusted for gender, was associated with reduced exercise capacity (P < .001). After adjusting for gender and age, an association was observed between a lower score on one or two physical recovery variables and exposure variables, specifically, high body mass index, low functional independence, comorbidity and low self-reported physical function at baseline, muscle weakness at ICU discharge, and longer hospital stay. No adjustment was made for cumulative type I error rate due to small number of participants. CONCLUSION: Elucidating risk factors for poor long-term physical recovery after ICU stay, including gender, may be critical if mobilization and exercise are to be prescribed expediently during and after ICU stay, to ensure maximal long-term recovery.

Nationwide Incidence and Outcomes of Patients With Coronavirus Disease 2019 Requiring Intensive Care in Iceland.

OBJECTIVES: To determine the nationwide demographics and hospital mortality of patients with severe acute respiratory syndrome coronavirus 2 infection requiring admission to the ICU for coronavirus disease 2019 in Iceland. DESIGN: Prospective observational study. SETTING: All ICUs in Iceland (Landspitali University Hospital and Akureyri Regional Hospital). PATIENTS: All patients admitted to the ICU for management of coronavirus disease 2019 between March 14, 2020, and April 13, 2020, with follow-up through May 5, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 27 patients were admitted to the ICU for coronavirus disease 2019 out of 1,788 severe acute respiratory syndrome coronavirus 2 positive cases, rendering an overall admission ratio of 1.5% (95% CI, 1.0-2.2%). The population rate of ICU admission for coronavirus disease 2019 was 7.4 (95% CI, 4.9-10.8) admissions per 100,000 individuals. The hospital mortality of patients admitted to the ICU was 15% (95% CI, 4-34%), and the mortality of patients receiving mechanical ventilation was 19% (95% CI, 4-46%). CONCLUSIONS: We report a lower overall ratio of ICU admissions for coronavirus disease 2019 among severe acute respiratory syndrome coronavirus 2 positive patients and a lower hospital mortality for patients treated in the ICU for coronavirus disease 2019 compared with initial reports from Italy and China. Our results could be explained by the early adoption of widespread testing and a successful national response to the pandemic.

The potential for organ donation in Iceland: A nationwide study of deaths in intensive care units.

BACKGROUND: The deceased organ donation rate in Iceland has been low compared with other Western countries. The aim of this study was to explore the potential for organ donation after brain death in Iceland. METHODS: Observational cohort study of patients with catastrophic brain injury who died in intensive care units (ICUs) at hospitals in Iceland in 2003-2016. Medical records were retrospectively reviewed to identify potential donors (PDs), using the WHO Critical Pathway for Deceased Donation. Trends in annual incidence of PDs, conversion to actual donors, and family refusals were assessed. RESULTS: Among 1537 patients who died in the ICU, 125 (8.1%) were identified as PDs. Of 103 PDs who were declared brain dead, consent for organ donation was pursued in 84 cases and granted in 63. Fifty-six became actual donors. The annual donation rate averaged 13 per million population (pmp), but rose abruptly in the final 2 years to 36 and 27 pmp, respectively. This was paralleled by an increase in annual incidence of PDs from an average of 28 pmp to 54 and 42 pmp, respectively. The donor conversion rate increased during the study period (P = .026). Twenty-three PDs (18%) were not pursued without an apparent reason. CONCLUSIONS: The donation rate increased markedly in the last 2 years of the study period after remaining low for more than a decade. This change can largely be explained by a high incidence of PDs and a low family refusal rate. Missed donation opportunities suggest a potential to maintain a high donation rate in the future.

Long-term survival after intensive care: A retrospective cohort study.

Background Limited data exist on long-term survival of patients requiring admission to intensive care units (ICUs). The aim of this study was to investigate long-term survival of ICU patients in Iceland and assess changes over a 15-year period. Methods Data were collected on age, gender, admission cause, length of stay, comorbidities, mechanical ventilation and survival of patients 18 years and older admitted to the ICUs in Landspitali during 2002-2016. Long-term survival of patients surviving more than 30 days from admission was estimated and its predictors assessed with Cox regression analysis. Long-term survival was compared to the survival of an age- and gender-matched reference group from the general population. Results Of 15 832 ICU admissions, 55% was medical, 38% was surgical and 7% was due to trauma. The 5-year survival of medical, surgical and trauma patients was 66%, 76% and 92% respectively. Significant survival differences were found between admission subgroups. Higher age and comorbidity burden was related to decreased survival in all patient groups. After correcting for age, gender, comorbidities, length of ICU stay and mechanical ventilation, patient survival improved during the study period only for patients admitted for infections. There was a high variability in the estimated time point where the ICU admission had no residual effect on survival. Conclusions Long-term survival of ICU patients is substantially decreased compared to the general population, but varies based on admission causes. Improved long-term survival of patients admitted with infections could be explained by earlier detection and improved treatment of septic shock.

Epidemiology of spinal fractures and associated spinal cord injuries in Iceland.

STUDY DESIGN: A retrospective epidemiological study. SETTING: Landspítali University Hospital, Iceland. OBJECTIVES: Assessment of epidemiological data and risk factors for traumatic spinal fractures (SFs) and associated spinal cord injury (SCI). METHODS: A retrospective review of hospital admissions due to traumatic SFs during a 5-year period, with analysis of epidemiological parameters and occurrence of concomitant SCI. Patients with asymptomatic SFs and non-traumatic SCI were excluded. RESULTS: A total of 487 patients were diagnosed with a SF or 310 PMI (per million inhabitants), 42 of them (9%, 27 PMI) with an associated SCI. The mean age was 56 years, males were 57%. Falls were the leading cause of both SFs (49%) and SCIs (43%). Low falls (<1 m) caused SFs more often in elderly women (67%, mean age 77 years) and more than 96% were without SCI. Road traffic accidents (RTA) caused 31% of SFs and 26% of SCIs. Seat belts were not used in 20% of car accidents, but information was missing in 27%. Sports/leisure-related accidents caused SFs in 12% of cases, whereof horseback riding accidents were the most common (36%). CONCLUSIONS: SFs led to SCI in 9% of patients. Several risk factors were common for SFs and SCIs but two major differences were seen: SFs without SCI were most common in older women due to low falls, while the risk of a concomitant SCI increased in young patients, in males, in falls from high levels and when driving without using seat belts. Preventive efforts should therefore be directed towards these risk factors.

[Severely increased serum lipid levels in diabetic ketoacidosis - case report].

Severe hypertriglyceridemia is a known, but uncommon complication of diabetic ketoacidosis. We discuss the case of a 23-year-old, previously healthy, woman who initially presented to the emergency department with abdominal pain. Grossly lipemic serum due to extremely high triglyceride (38.6 mmol/L) and cholesterol (23.2 mmol/L) levels were observed with a high blood glucose (23 mmol/L) and a low pH of 7.06 on a venous blood gas. She was treated successfully with fluids and insulin and had no sequale of pancreatitis or cerebral edema. Her triglycerides and cholesterol was normalized in three days and she was discharged home on insulin therapy after five days. Further history revealed a recent change in diet with no meat, fish or poultry consumption in the last 12 months and concomitantly an increase in carbohydrate intake which might have contributed to her extremely high serum lipid levels. This case demonstrates that clinicians should be mindful of the different presentations of diabetic ketoacidosis. Key words: diabetic ketoacidosis, hypertriglyceridemia, hyperlipidemia, vegan diet, carbohydrate diet. Correspondence: Hrafnkell Stefansson, hrafnkell.stefans@gmail.com.

[Epidemiology of Spinal Cord Injury in Iceland from 1975 to 2014].

INTRODUCTION: Traumatic spinal cord injury (TSCI) is serious and often has long-term consequences. Since no cure has been found the emphasis has been on preventive measures. The incidence of TSCI varies between countries and the epidemiology has been changing. The aim of this study was to gather epidemiological data on patients with TSCI in Iceland and search for risk factors. MATERIAL AND METHODS: Hospital records of everyone diagnosed with TSCI in 1975-2014 admitted to Landspitali University Hospital were reviewed and information gathered on incidence, age, gender and causes of injury. The American Spinal Injury Association Impairment Scale (AIS) was used to assess the extent of TSCI. RESULTS: A total of 233 patients were diagnosed with TSCI during the study period or 26 per million annually on average. Males were 73% and the mean age was 39 years. Traffic accidents were the most common cause of TSCI. The majority were car rollovers in rural areas. Around 50% did not use a seatbelt. The second most common cause of TSCI were falls. The most common sport/leisure accidents were those related to horseback-riding and winter sports. A third of patients had a complete SCI. At discharge 9% had gained full recovery. CONCLUSIONS: Safe roads and good traffic culture are essential factors in the prevention of serious traffic accidents. Strict safety regulations in the work place and an investigation of causes of falls amongst the elderly could decrease SCIs due to falls. Further preventive measures and protective equipment could possibly be of use in sport- or leisure-related activities. Key words: Traumatic spinal cord injury, incidence, age, gender, causes, extent. Correspondence: Pall E. Ingvarsson, palling@landspitali.is.

The incidence and mortality of acute thoracic aortic dissection: results from a whole nation study.

OBJECTIVES: Acute thoracic aortic dissection (ATAD) is a devastating condition associated with a high mortality rate. Recent reports suggest that its incidence is rising. Utilizing nationwide data comprising the whole Icelandic population, we aimed to determine the incidence, mortality rate and time-dependent mortality risk of ATAD. METHODS: Data were retrospectively collected using centralized hospital discharge registries, autopsy records and Cause of Death Registry in Iceland from 1992 to 2013. RESULTS: Age- and gender-adjusted incidence of ATAD was 2.53/100 000/year, and no significant change in incidence was observed during the study period. The mean age was 66.9 ± 13.6 years and 66.0% (101/153) were Stanford type A. Of the whole group, 17.6% (27/153) died prior to hospital arrival, whereas the risk of death for patients who arrived alive to a hospital was 21.4% (27/126) within 24 h and 45.2% (57/126) at 30 days. During the course of the study, patients with type A dissection were more likely to undergo an operation and the management of type B dissection changed from open to endovascular repair. The 30-day mortality rate declined every year and the 5-year survival rate improved in the last third of the study. CONCLUSIONS: The incidence of ATAD was 2.53/100 000/year and remained constant throughout the study, contradicting recent perceptions of a rising incidence. ATAD, type A in particular, remains a highly lethal condition: Over half of all patients die within 30 days of the index event. A reduced 30-day mortality rate and an increased long-term survival rate indicate improved overall outcomes in patients with this complex condition.

[Injecting drug abuse: survival after intensive care admission and forensic toxicology reports at death]. / Notkun vímuefna í æð: Afdrif sjúklinga eftir innlögn á gjörgæslu og niðurstöður réttarefnafræðilegra rannsókna við andlát.

INTRODUCTION: Injecting drug abuse is a worldwide problem with serious consequences for the individual and for society. The purpose of this study was to gather information on the most serious complications of injecting drug use from two perspectives, intensive care admissions and forensic toxicology reports. MATERIAL AND METHODS: Firstly, intensive care admissions related to injecting drug abuse during a five year period were reviewed for demographics, complications and 5 year survival. Secondly, information from forensic toxicology reports regarding deaths amongst known injecting drug abusers were gathered for the same period. RESULTS: A total of 57 patients with a history of active injecting drug use were admitted to intensive care or approximately 1% of admissions, most often for overdose (52%) or life threatening infections (39%). Median age was 26, males were 66%. The most common substances used were prescription drugs. Hospital mortality was 16% and five year survival 65%. Average time from hospital discharge to death was 916±858 days. During the study period 38 deaths of individuals with a history of injecting drugs were identified by forensic toxicology reports or 4.1/10(5) population/year (age 15-59). Cause of death was most often overdose (53%), usually from prescription opiates but multiple drug use was common. DISCUSSION: The life expectancy of injecting drug abusers after intensive care admission is substantially decreased, with 35% death rate within five years. A widespread use of prescription drugs is of concern. Injecting drug abuse seems to be a similar health problem in magnitude in Iceland as in other Scandinavian countries.

[Visits to an emergency department due to head injuries]. / Komur á brádadeild Landspítala vegna áverka á höfdi.

INTRODUCTION: Head injury is a common consequence of accidents and violence. It can result in permanent disability and is one of the leading causes of premature death worldwide. Our aim was to review all visits to Landspitali University Hospital (LUH) from head injuries, to study the incidence, nature and severity of head injuries. MATERIAL AND METHODS: A retrospective study on all visits of Reykjavik's inhabitants to LUH for head injuries in the years 2000-2005 and 2008-2009. Data were collected from patient records at LUH. One main diagnosis was used if head injury diagnoses were many. They were categorised into 5 groups; soft tissue injury, eye injury, injury to cranium, intracranial- and cranial nerve injury and multiple trauma. RESULTS: During the study period 35.031 patients presented with head injuries to LUH. Males were 67%. Mean age was 26 years (0-107). The highest rate was among infants and children aged 0-4 years (20.8%), followed by 5-9 years (11,5%) and 20-24 years (9.4%). The annual incidence decreased between the study periods from 4.2% to 3.3%. The annual incidence for admitted head injury patients decreased from 181/year/100.000 inhabitants to 110/year/100.000 inhabitants. Most often injuries were caused by accidents (80,5%) and violence (12.7%). Soft tissue injury was the most common injury (65%), followed by eye injury (15%) and intracranial- and cranial nerve injury (14%). The injuries that most frequently led to hospital admission were intracranial bleeding (90.1%), followed by skull fracture (79.2%). CONCLUSION: Accidents and violence caused most head injuries and they are more common among men than women. Patients with intracranial haemorrhage were usually admitted. Incidence of hospital visits and admissions because of head injuries in Reykjavik has decreased over the last decade. Key words: Head injury, accident, violence, brain injury, intracranial bleeding.

Evaluation of clinical efficacy and safety of cervical trauma collars: differences in immobilization, effect on jugular venous pressure and patient comfort.

BACKGROUND: Concern has been raised that cervical collars may increase intracranial pressure in traumatic brain injury. The purpose of this study was to compare four types of cervical collars regarding efficacy of immobilizing the neck, effect on jugular venous pressure (JVP), as a surrogate for possible effect on intracranial pressure, and patient comfort in healthy volunteers. METHODS: The characteristics of four widely used cervical collars (Laerdal Stifneck(®) (SN), Vista(®) (VI), Miami J Advanced(®) (MJ), Philadelphia(®) (PH)) were studied in ten volunteers. Neck movement was measured with goniometry, JVP was measured directly through an endovascular catheter and participants graded the collars according to comfort on a scale 1-5. RESULTS: The mean age of participants was 27 ± 5 yr and BMI 26 ± 5. The mean neck movement (53 ± 9°) decreased significantly with all the collars (p < 0.001) from 18 ± 7° to 25 ± 9° (SN < MJ < PH < VI). There was a significant increase in mean JVP (9.4 ± 1.4 mmHg) with three of the collars, but not with SN, from 10.5 ± 2.1 mmHg to 16.3 ± 3.3 mmHg (SN < MJ < VI < PH). The grade of comfort between collars varied from 4.2 ± 0.8 to 2.2 ± 0.8 (VI > MJ > SN > PH). CONCLUSION: Stifneck and Miami J collars offered the most efficient immobilization of the neck with the least effect on JVP. Vista and Miami J were the most comfortable ones. The methodology used in this study may offer a new approach to evaluate clinical efficacy and safety of neck collars and aid their continued development.

[The incidence and mortality of ARDS at Landspítali - The National University Hospital of Iceland 2004-2008]. / Brátt andnaudarheilkenni á gjörgæsludeildum Landspítala 2004-2008.

OBJECTIVE: A retrospective study of the incidence, causes, mortality and treatment of patients with ARDS at Landspítali The National University Hospital of Iceland during the five year period 2004-2008 and comparing the results with an earlier study for the period 1988-1997. MATERIALS AND METHODS: All ICU admissions during the period 2004-2008 were reviewed, selecting patients according to the American-European consensus criteria for ARDS. Data were collected on age, gender, causes, length of stay, ventilator treatment and survival. RESULTS: A total of 6413 patients were admitted to the ICUs at Landspítali during the study period and 120 patients were found to have ARDS giving an incidence of 7,9/100.000 inhabitants. Average age was 55 years, 55% were males, length of stay was 13 days and hospital stay 24 days. ICU mortality was 30% and 90 day mortality was 39%. CONCLUSION: The incidence of ARDS seems to have increased some-what during the period 1988-1997. Mortality has decreased significantly probably due to improvements in intensive care treatment, especially ventilator treament with the use of lung protective ventilation, high frequency oscillation, prone position and ECMO.

[Epidemiology of acute kidney injury in a tertiary care university hospital according to the RIFLE criteria]. / Bradur nyrnaskadi a Landspitala 2008-2011 og ahaettupaettir og afdrif sjuklinga med alvarlegan skada.

INTRODUCTION: Acute kidney injury (AKI) is a common problem in hospitalized patients, requiring extensive treatment and carries a high mortality rate. This study was designed to assess the epidemiology of AKI, and risk factors and outcome of patients with severe AKI in a tertiary care university hospital in Iceland. MATERIAL AND METHODS: All adult patients with measured serum creatinine (SCr) in Landspitali University Hospital from January 2008 to December 2011, who had a measured baseline SCr in the preceeding six months, were included. Patients were categorized according to the RIFLE-criteria into risk (stage 1), injury (stage 2) and failure (stage 3) groups based on their highest SCr, using the lowest SCr in the previous six months as baseline. RESULTS: A total of 17,693 individuals (out of 74,960) had a baseline SCr and their data were used for analysis. AKI occurred in 3,686 (21%) with 12%, 5% and 4% of stage 1, 2 and 3, respectively. There were more females in stage 1 and stage 2 and more males in stage 3 (p< 0.001). Contributing causes for AKI in patients with stage 3 AKI were surgery (22%), circulatory shock (23%), sepsis (14%), cardiovascular insult (32%), respiratory failure (27%), bleeding (10%), trauma (7%) and AKI associated drugs (61%). Dialysis was required in 11% and in 0.7% for longer than 30 days but none > 90 days. One year survival was 52%. CONCLUSIONS: Acute kidney injury is common in Iceland and the prognosis of those with severe AKI is dismal. Majority of those patients were taking drugs that increase risk of AKI, providing a target for preventive measures.

[Clinical aspects and follow up of suicide attempts treated in a general intensive care unit at Landspitali University Hospital in Iceland 2000-2004]. / Sjálfsvígstilraunir medhöndladar á gjörgaesludeildum Landspítala árin 2000-2004.

OBJECTIVE: To gather information on patients admitted to an intensive care unit (ICU) after a serious suicide attempt (SA). METHODS: Retrospective analysis and follow up of admittances to ICUs of Landspitali University Hospital after SA years 2000-2004. RESULTS: Admittances because of SA were 251 (4% of ICU admissions, 61% females, 39% males, mean age 36 yr +/- 14 ). Ten percent were admitted more than once and 61% had prior history of SA. Drug intoxication was the most prevalent type of SA (91%) and the most frequent complication was pneumonia. Following ICU stay 36% of the patients were admitted to psychiatric wards and 80% received psychiatric follow up. The main psychiatric diagnosis was addiction (43%). Majority of patients were divorced or single and the rate of unemployment was high. Mortality during ICU stay was 3%. During 3-7 year follow up 21 patients died (10 %), majority due to suicide. In a survival analysis only the number of tablets taken, APACHE II score and number of somatic diseases predicted risk of death. CONCLUSION: The patient group is young (36 yr), majority are women (61%), repeated attempts are frequent, social circumstances are poor and death rate after discharge from hospital is high (10%) even though the vast majority (80%) receives psychiatric follow up.This raises the question if the offered treatment is effective enough. Key words: Suicide attempt, suicide, drug poisoning, intensive care, mental health care.