Treatment of Severe Hypercapnic Respiratory Failure Caused by SARS-CoV-2 Lung Injury with ECCO2R Using the Hemolung Respiratory Assist System.

Acute respiratory distress syndrome (ARDS) due to COVID-19 leads to a high rate of mortality in the intensive care unit (ICU). A lung-protective mechanical ventilation strategy using low tidal volumes is a cornerstone to management, but uncontrolled hypercapnia is a life-threatening consequence among severe cases. A mechanism to prevent progressive hypercapnia may offset hemodynamic instability among patients who develop hypercapnia. We present the case of a woman in her mid-60's with severe acute hypercapnic respiratory failure secondary to COVID-19 pneumonia who was successfully treated with early implementation of lung-protective ventilation facilitated by extracorporeal carbon dioxide removal (ECCO2R). This patient's multiple comorbid conditions included obesity, hypertension, type 2 diabetes mellitus, and hypercholesterolemia. On her fifth day of admission at the referring hospital, her worsening hypoxemia prompted endotracheal intubation during which she developed pneumothorax. She was transferred to our institution for advanced care where upon arrival, she had profound hypercapnia and respiratory acidosis. She met the criteria for treatment with an investigational ECCO2R device (Hemolung Respiratory Assist System) available through FDA Emergency Use Authorization. ECCO2R is similar to extracorporeal membrane oxygenation (ECMO) but operates at much lower blood flows (350-550 mL/min) through a smaller 15.5 French central venous catheter. Standard heparinization was provided intravenously to achieve appropriate levels of anticoagulation during ECCO2R therapy. Unlike ECMO, ECCO2R does not provide clinically meaningful oxygenation but is simpler to implement and manage. The use of ECCO2R successfully corrected and controlled the patient's hypercapnia and acidosis and enabled meaningful reductions in ventilator tidal volumes, respiratory rates, and mean airway pressures. The patient was weaned from ECCO2R after 17 days and from mechanical ventilation 10 days later. With low tidal volume ventilation facilitated by expeditious implementation of ECCO2R, the patient survived to discharge despite her many risk factors for a poor outcome and an extended duration of invasive mechanical ventilation.

Colectomy among Fee-for-Service Medicare Enrollees Coded as DRG 330: A Potential Platform to Allow Consumer Cost Transparency?

The use of Centers for Medicare and Medicaid Services Diagnosis Related Group (CMS-DRG) codes define hospital reimbursement for Medicare beneficiaries. Our objective was to assess all patients with comorbidities on admission who were discharged in the DRG 330 category to determine the impact of postoperative complications on Medicare costs. The 5% Medicare Database was used to evaluate patients who underwent a colectomy and were coded as CMS-DRG 330. Patients were divided into two groups: No surgical complications (NSC) and surgical complications (SC). Length of stay (LOS), complications, hospital charges, CMS reimbursement, discharge destination, and inpatient mortality were assessed. Statistical significance was set at p < 0.05. In total, 13,072 patients were identified. The SC group had higher inpatient mortality, a longer LOS (p < 0.0001) and was more likely to be discharged with post-acute care support (p = 0.0005). The use of CMS-DRG coding has the potential to provide Medicare fiscal intermediaries, beneficiaries, and providers with a more accurate understanding of the relative impact of their baseline health. The data further suggest that providers may benefit by more fully understanding the cost of preventive measures as a means of reducing total cost of care for this population.

Sociodemographic determinants of non-accidental traumatic injuries in children.

BACKGROUND: Traumatic injuries account for 18% of child abuse cases and 1680 children die from abuse annually. We set out to determine the impact of sociodemographic characteristics on resource utilization and outcomes in nonaccidental trauma (NAT). METHODS: We used the Kid's Inpatient Database to identify children with two main subgroups of child abuse diagnoses: NAT and other forms of child abuse. Income was represented by quartiles. Statistical analysis included descriptive statistics and regression analyses. RESULTS: We identified 5617 children requiring hospital admission due to NAT. Medicaid insurance payer status was associated with higher rates of traumatic injuries than private insurance. Black race, male sex, and high-income-quartile were independent factors associated with increased cost. We identified an increased risk of mortality in younger children and those with self-pay/uninsured status. CONCLUSION: NAT represents a prevalent cause of childhood mortality. This study identifies sociodemographic factors associated with increased occurrence, higher resource utilization, and increased mortality in NAT.

Family Matters: Development of new family interrelationship variables for US IPUMS data projects.

In demographic datasets, researchers frequently want to identify how members of a household are related. In this paper, we develop a new method of estimating parental and spousal relationships using data on fertility patterns and family interrelationships. The improved method includes cohabiting and same-sex couples and is comparable across all modern US IPUMS data projects. A detailed variable indicates how the relationship was inferred and the level of ambiguity around that inference. The new IPUMS family interrelationship variables are very accurate, matching self-reported spouse/partner for 99.99% and parent for over 99.00% of respondents. Among those identified as same-sex couples, we match self-reported spouse/partner for 100% of respondents, 87.57% of whom self-identify as lesbian, gay, or bisexual. We further demonstrate that the new family interrelationship variables closely track temporal variation in teenage fertility.

Managing hospitalized patients with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States and is a common diagnosis in outpatient and inpatient settings. COPD exacerbations account for more than 800,000 hospital admissions annually and are most commonly caused by viral or bacterial infections. This article reviews management of patients with COPD exacerbations, including recommended diagnostic evaluations and treatments.

Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients.

OBJECTIVE: To determine the effect of blood component ratios in massive transfusion (MT), we hypothesized that increased use of plasma and platelet to red blood cell (RBC) ratios would result in decreased early hemorrhagic death and this benefit would be sustained over the ensuing hospitalization. SUMMARY BACKGROUND DATA: Civilian guidelines for massive transfusion (MT > or =10 units of RBC in 24 hours) have typically recommend a 1:3 ratio of plasma:RBC, whereas optimal platelet:RBC ratios are unknown. Conversely, military data shows that a plasma:RBC ratio approaching 1:1 improves long term outcomes in MT combat casualties. There is little consensus on optimal platelet transfusions in either civilian or military practice. At present, the optimal combinations of plasma, platelet, and RBCs for MT in civilian patients is unclear. METHODS: Records of 467 MT trauma patients transported from the scene to 16 level 1 trauma centers between July 2005 and June 2006 were reviewed. One patient who died within 30 minutes of admission was excluded. Based on high and low plasma and platelet to RBC ratios, 4 groups were analyzed. RESULTS: Among 466 MT patients, survival varied by center from 41% to 74%. Mean injury severity score varied by center from 22 to 40; the average of the center means was 33. The plasma:RBC ratio ranged from 0 to 2.89 (mean +/- SD: 0.56 +/- 0.35) and the platelets:RBC ratio ranged from 0 to 2.5 (0.55 +/- 0.50). Plasma and platelet to RBC ratios and injury severity score were predictors of death at 6 hours, 24 hours, and 30 days in multivariate logistic models. Thirty-day survival was increased in patients with high plasma:RBC ratio (> or =1:2) relative to those with low plasma:RBC ratio (<1:2) (low: 40.4% vs. high: 59.6%, P < 0.01). Similarly, 30-day survival was increased in patients with high platelet:RBC ratio (> or =1:2) relative to those with low platelet:RBC ratio (<1:2) (low: 40.1% vs. high: 59.9%, P < 0.01). The combination of high plasma and high platelet to RBC ratios were associated with decreased truncal hemorrhage, increased 6-hour, 24-hour, and 30-day survival, and increased intensive care unit, ventilator, and hospital-free days (P < 0.05), with no change in multiple organ failure deaths. Statistical modeling indicated that a clinical guideline with mean plasma:RBC ratio equal to 1:1 would encompass 98% of patients within the optimal 1:2 ratio. CONCLUSIONS: Current transfusion practices and survival rates of MT patients vary widely among trauma centers. Conventional MT guidelines may underestimate the optimal plasma and platelet to RBC ratios. Survival in civilian MT patients is associated with increased plasma and platelet ratios. Massive transfusion practice guidelines should aim for a 1:1:1 ratio of plasma:platelets:RBCs.

Assessment of cardiovascular regulation after burns by nonlinear analysis of the electrocardiogram.

Critical illness and hypovolemia are associated with loss of complexity of the R-to-R interval (RRI) of the electrocardiogram, whereas recovery is characterized by restoration thereof. Our goal was to investigate the dynamics of RRI complexity in burn patients. We hypothesized that the postburn period is associated with a state of low RRI complexity, and that successful resuscitation restores it. Electrocardiogram was acquired from 13 patients (age 55 +/- 5 years, total body surface area burned 36 +/- 6%, 11 +/- 5% full thickness) at 8, 12, 24, and 36 hours during postburn resuscitation. RRI complexity was quantified by approximate entropy (ApEn) and sample entropy (SampEn) that measure RRI signal irregularity, as well as by symbol distribution entropy and bit-per-word entropy that assess symbol sequences within the RRI signal. Data (in arbitrary units) are means +/- SEM. All patients survived resuscitation. Changes in heart rate and blood pressure were not significant. ApEn at 8 hours was abnormally low at 0.89 +/- 0.06. ApEn progressively increased after burn to 1.22 +/- 0.04 at 36 hours. SampEn showed similar significant changes. Symbol distribution entropy and bit-per-word entropy increased with resuscitation from 3.63 +/- 0.22 and 0.61 +/- 0.04 respectively at 8 hours postburn to 4.25 +/- 0.11 and 0.71 +/- 0.02 at 24 hours postburn. RRI complexity was abnormally low during the early postburn period, possibly reflecting physiologic deterioration. Resuscitation was associated with a progressive improvement in complexity as measured by ApEn and SampEn and complementary changes in other measures. Assessment of complexity may provide new insight into the cardiovascular response to burns.