Age: 46.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Computerised tomogram pelvis, Computerised tomogram thorax, Computerised tomogram thorax normal, Continuous positive airway pressure, Cough
Clinical narrative: 46 y.o man, s/p J&J vaccine on 5/8/2021, with a PMHx which includes per-DM (not on any meds), obesity (BMI 36.9), hypertriglyceridemia who initially presented on 7/28 with cough, fevers, chills and worsening DOE that started on 7/25.  + for SARS- COV-2 on 7/28.  All of his family members in his house have COVID. He was admitted on HFNC 30L and 50% FiO2, started on levaquin for possible CAP, Dexamethasone, Remdesivir and was instructed to self-prone.  He received Toci on 7/30.  O2 requirements continued to increase to 60L and 100% HFNC and was transferred to ICU on 7/29 for CPAP and iloprost.   On 8/4, he required intubation and remained hypoxic with O2 sats in the 70s despite max vent settings (PEEP 20, FiO2 100%), proning, and paralysis.  Abx were broadened to vanc/cefepime.  Referred for VV ECMO and was accepted.  Cannulated by ECMO PRN.  ABG 7.30/56/122 when proned, paralyzed, vent setting rate 28, TV 360, 95% FiO2 and PEEP 20.      Pt arrived in CVICU early 8/5/21 (3am), on propofol 30, fentanyl changed to dilaudid, levophed 0.04, cisatracurium.  Vent VC converted to PC 16/12 with Vt 300, FIO2 100 weaned to 60.   About 1 hour after arrival, pt with polymorphic VT requiring shock x 1, as well as amio, lido, calcium, bicarb, and Mg boluses followed by ROSC, rhythm new afib 80's.  Levophed started (had been off) and then switched to vasopressin, amio gtt started.   TEE showed normal LV function, Dilated RV with RVH, mild RV apical hypokinesis, ECMO cannulae in good position. Lactate 2.3.  Low iCa and Mg 2.2. CT Head wnl and CT PE/chest/abd/pelvis obtained   8/6/21: Attempted to wean propofol -- > chugging on circuit and desaturation, no purposeful movements -- > required going back up on propofol, albumin 250 mL, and vecuronium to achieve stability again   8/7/21: Added dexmed gtt, propofol weaned off, awaiting neuro eval. Diuresis with furos gtt, FG net even over 24 hours.  CT head unremarkable and CTA of C/A/P showed no PE, diffuse air space disease, fatty liver, and diverticular disease.     8/8: No major issues overnight. Per report, wakes up and moves all extremities grossly but does not follow commands.    8/9: No issues overnight. About 1L net negative (on his own) for 24H. This AM, eyes open with saying his name, was still too sedated to follow commands    8/10: Early this AM, while X-ray was in the room and moving the board out from under him, the ECMO circuit flows dropped/chattering with a desaturation and he had a 15-second pause (asystole), CPR initiated for 10 seconds, and HR returned to sinus brady 40-50 without further intervention, MAPs in the 70s. He was more awake this AM, eyes opening, looking around but not following commands.  He later self extubated and was reintubated.  8/11:  ETT pulled back 2 cm and had brief asystolic event.  Gapapentin and lorazepam oral dosing added to help wean gtts and precedex/propofol dose lessened to avoid bradycardic events.  Chattering on ECMO circuit after 5 mg dose of lasix requiring albumin infusions. 8/12: Remains sedated with repeated chugging requiring colloid/crystalloid.  Completed course of cefepime.  D5W for hypernatremia. 8/13: D5W for hypernatremia.  Less chattering today. Metop 12.5mg PO Q8 added to lower HR.  8/14: D5W dc'd after Na improved.   8/15: Woke up and followed commands, moved all 4 extremities.  Requiring volume for chugging. +sinus drainage, septic appearing -> cultured, empiric vanc/zosyn. 8/16: Vec x 1.  Woke up and followed when sedation lightened. 1 PRBC with appropriate response.  Bival to 0.15 with PTT 68.  Sespsi resolved, started lasix 5 BID.   8/17: More chattering in AM. Belly breathing, got vec x2-3 doses.  Diuresing well 8/18-8/19: Received vecuronium around 8:30pm on 8/18 for belly breathing and desaturations. PTT continues to be therapeutic. TVs poor - < 100mL. No major issues overnight. This AM, is sedated and intubated, not following commands.  8/20: No issues overnight. Still sedated and not responsive this AM.  8/21: LDH 796, ivabradine started to assist with HR control 8/22: increase PTT goal 60-80 given small stable clots in circuit.  Minimize opiates as able..  1u pRBC.  Intermittent shivering. 8/23: PTT mid-60s, inc'd bival to target goal more toward 80 given rise in LDH still.  Still shivering. Lasix gtt for diuresis.  8/24: Long pauses asystolic events during suctioning ETT this am, recovered. Metop and ivabradine held. LDH and LFTs continue to rise -> circuit changed.  Had oozing from mouth -> bival decreased to 0.12.  Tachycardic leading to desats, restarted metop 12.5mg PO BID.  8/25: Overnight received IVFs and ativan with increased versed for shivering/chattering.  This am had gauze in mouth, no active bleeding noted.  +rectal tube output. Minimal OGT output.  Diamox added for alkalosis.  1u PRBC.   Note pt is still on ECMO at Hospital