Age: 77.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Metabolic acidosis, N-terminal prohormone brain natriuretic peptide increased, Oxygen saturation decreased, PCO2 increased, Platelet count decreased
Clinical narrative: She had been in her usual state of health until tonight. Assisted living facility staff called. He mentioned that the facility staff had earlier noticed that she was dragging her right foot and and has been needing more assistance with activities. The patient was walking and did not feel well. She was lowered to the ground and had a witnessed cardiac arrest. The ambulance was called and she was reportedly found to have pulseless electrical activity. She was given Epinephrine and Amiodarone with return of pulse. The patient was brought to the Emergency Room and was evaluated by ER physician. EKG showed atrial fibrillation, ventricular rate = 66, RBBB with Brugada pattern. She was emergently brought to the Cath Lab. Cardiac catheterization showed normal coronary arteries but EF 35-40%. Repeat EKG showed atrial fibrillation with rapid ventricular response = 110, RBBB. Therapeutic hypothermia was initiated. The patient was admitted to the ICU on mechanical ventilation with TV 350 RR 14 PEEP 5. She is sedated with Propofol and Fentanyl IV. She is on Levophed IV. ABG showed pH = 7.22, pCO2 = 53, pO2 = 66, O2 sat = 88%. Lactate level = 9.5. WBC 8.8, Hgb 13.4, Hct 46, Platelets 138. Na 138, K 3.2, Cl 102, bicarb 20, BUN 16, Crea 1.19, estimated GFR = 44 mL/minute. Magnesium 2.7. Glucose levels have ranged from 273-312. Pro-Calcitonin = 0.26. Albumin 3.7. SGOT 262, SGPT 294. Troponin elevated at 47. Pro-BNP = 600. Urinalysis showed large blood. Chest x-ray showed vague peripheral pneumonitis. Endotracheal tube is in place. COVID-19 test by PCR is negative (2/5/21).    COURSE IN HOSPITAL  The patient was admitted to the ICU and was followed by Pulmonary/Critical Care.  Patient was maintained on mechanical ventilation, sedated with propofol and fentanyl IV.  Vasopressors were administered (Levophed IV).  She was managed with therapeutic hypothermia.  She was followed by Cardiology.  Foley catheter was inserted for close input/output monitoring.  Neuro checks, vital signs, daily weights, pulse oximetry, cardiac telemetry and fingersticks were monitored.  She was given sodium bicarbonate IV due to metabolic acidosis.  She was also given insulin IV drip.  Potassium chloride IV was administered due to hypokalemia.  The patient was given amiodarone IV.  Platelet count was noted to be low but stable.  Glucose levels were within acceptable range.  Metabolic acidosis resolved.  Hypokalemia resolved.  Hypomagnesemia resolved.  There were elevated LFTs which improved.  Elevated CPK also improved.  She was taken off hypothermia protocol.  Sedation was decreased and she was able to open her eyes with verbal stimulus but unable to follow commands.  Ammonia level was normal.  Neurology evaluated the patient.  EEG showed left periodic epileptiform discharges consistent with severe diffuse encephalopathy.  Chest x-ray revealed right upper lung and left mid lung increasing opacity for which meropenem IV was started.  Levophed was discontinued.  Initially she had peripheral cyanosis, but this resolved upon discontinuation of vasopressors.  Brain MRI was done demonstrating diffuse bilateral small and moderate-sized ischemic foci throughout the cerebellum and cerebellar region suggestive of embolism.  There also was chronic marked atrophy and moderate small-vessel gliosis.  CIRCUMSTANCES SURROUNDING DEMISE  Based on neurologic evaluation, her prognosis for meaningful neurologic recovery was thought to be extremely poor.  The patient was evaluated and followed by Palliative Care. She does not have family members and had designated her neighbor friends as her power of attorney. They have known the patient for a ling time and they know that she does not want to live like this. A decision was therefore made for comfort care measures only. Compassionate extubation was performed on February 12, 2021. The patient passed away on February 12, 2021, at 6:39 p.m.