Age: 76.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Mechanical ventilation, Positive airway pressure therapy, Procalcitonin, Pyrexia, Respiratory failure
Clinical narrative: Patient presented to urgent care on 8/23/21 with c/o exposure to COVID illness at church,  cough, fever, shortness of breath and chills. Subsequently presented to BHL 8/26/2021 with worsening dyspnea, tested positive for COVID-19, and was noted to have bilateral pulmonary infiltrates and significant hypoxemia.  Was admitted to the floor and received Decadron, Remdesivir, Actemra, and broad-spectrum empiric antibiotics. Despite therapy developed progressive hypoxemic respiratory failure requiring transfer to the ICU and intubation 9/3/2021.  Seem to improve on mechanical ventilation and passed a pressure support trial at which point he was extubated 9/12/2021.  Unfortunately the morning of 9/13/2029 he became increasingly confused, agitated, and could not keep his mask on.  Attempts at Precedex and Haldol were not successful so he was reintubated and placed back on ventilatory support 9/13/2021 (has been on ventilator a total of 15 days now).  WBC was noted to jump to 47.41 at the same time as above event despite being on linezolid, Merrem, and micafungin (although was on Solu-Medrol).  There was noted to be gastric distention and an NG tube was placed with resolution of distention.  By 9/16/2021 patient had improved and had had good UOP after Lasix with no decrement in renal function.  Was essentially afebrile off all antibiotics although WBC remained persistently elevated at 21,000 (presumably secondary to CLL).  In addition procalcitonin was only 0.04.  Patient tolerated pressure support/CPAP  (although pressure support was 15).  Plans were to proceed with respiratory mechanics 9/17/2021 and again attempt to wean and extubate. Unfortunately patient dropped his blood pressure 9/16/21 without obvious GI losses and required volume and pressors.  At 3:20 AM hematocrit was checked and had dropped from 40 yesterday morning, to 22.  Had complaints of abdominal discomfort and underwent a CT scan which revealed large acute bilateral retroperitoneal hematomas right greater than left (13 x 9 x 8 cm).  Blood was ordered but after 3 units hematocrit had only gone from 22, to 23.  CT angiogram was then performed revealing 3 separate sites of active arterial extravasation which short interval enlargement of the previously noted bilateral large retroperitoneal hematomas.  Areas of active extravasation or along the left psoas musculature at the level of L3 and bilaterally within iliac musculature.  Additional 3 units of blood were ordered as well as 2 L of normal saline infused and situation discussed with interventional radiology who indicated that they could attempt to proceed with angiogram and attempted ablation.  Unfortunately patient was now totally anuric with a jump in his BUN to 49 and 1.41 creatinine with serum bicarb of 16.  In addition was developing increasing hypoxemia with all the fluids. Interventional radiology indicated the they would place a dialysis catheter at the time of his angiogram.  Situation discussed with wife who indicated that he had discussed the situation with her before and would not wish to be on dialysis.  At this point in time the patient was made a DNR and family had accepted the fact that he would not recover. Comfort care was initiated per family wishes. Following comfort medication administration, the patient was palliative extubated. He was pronounced deceased at 1511 on 9/17/21 by Hospital Supervisor.