Age: 76.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Pulmonary thrombosis, Pulse abnormal, Pulseless electrical activity, Renal impairment, Renal tubular necrosis
Clinical narrative: This is a 76yo male with a PMHx significant for chronic diastolic heart failure, CKDIII, cirrhosis of the liver, hepatocellular carcinoma, and HTN admitted on 9/4/2021 with increasing shortness of breath. He was tested positive for COVID and received the monoclonal antibodies on 9/2. His shortness of breath continued to worsen. He was admitted to Hospital and was originally requiring 10L nasal cannula. His troponin was mildly elevated with a maximum of 0.21. He received ceftriaxone and azithromcyin. His d-dimer was elevated and he was started on enoxaparin BID because CTA could not be obtained to rule out PE because of his renal function. He was transferred here to the medical unit. Cardiology, Vascular surgery and Nephrology were consulted. ECHO was obtained and showed no right heart strain, normal EF and increased right systolic pressure. Vascular surgery advised no thrombolysis therapy and to continue treatment dose enoxaparin. Cardiology felt his troponin elevation was due to supply demand mismatch and not ischemia. He was kept on dexamethasone but increased to BID dosing, ceftriaxone and azithromycin. Due to a CRP >4, he was started on baricitinib, renally dosed. In the early morning of 9/6 his Optiflow cannula came out while he was sleeping. The nurse found him saturating in the 50s and pulse was thready. Rapid response was called and then he went into PEA and vfib. ACLS protocol was followed and patient received 2 rounds of epinephrine. He was not defibrillated because he came out Vfib prior to shocking. ROSC was achieved in 9 minutes. He was intubated and moved to the ICU. He was following commands and opening his eyes after the incident. Pulmonary/CCM was consulted. His hemoglobin dropped to 6.3 so was transfused 1 unit. Heme + stool, so PPI BID ordered. Baricitinib discontinued due to worsening renal function. He was extubated on 9/8 to high-flow nasal cannula. Unfortunately, he did not do well overnight with tachypnea and was re-intubated. His kidney function continued to worsen due to ATN from his cardiac arrest. Trialysis catheter was placed, and dialysis was initiated 9/10. Patient with hemoptysis 9/13. He underwent bronchoscopy, which revealed proximal clot but no active bleeding, and no active bleeding or endobronchial lesions in either lung. Patient started on high-dose steroids for alveolar hemorrhage. Pathology shows atypical cells suggestive of malignancy. CT chest performed shows extensive bilateral infiltration verses edema with consolidative airspace disease in bilateral lung bases, large bilateral pleural effusions, large subcarinal lymph nodes, left 1-7 rib fractures with right 4-6th rib fractures. Repeat bronchoscopy performed 9/17, showing some evidence of nodularity. No biopsies done due to risk of bleeding, washings were performed. CRRT started 9/17. Patient was not showing sign of improvement. Family presented to bedside to discuss goals of care. They ultimately chose to proceed with withdrawal of care and transition to comfort measures.