Age: 58.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Hypertension, Hypotension, Ileus, Intensive care, Jugular vein thrombosis
Clinical narrative: Hospitalized (1.14.22 - PRESENT - in ICU; intubated, sedated; s/p pericardial window 1.23.22);  COVID-19 positive (1.14.22);  fully vaccinated PLUS booster  HISTORY OF PRESENT ILLNESS: Patient is a 58 y.o. male who presents today with acute substernal chest pain radiating to his back that started this morning while he was working on his desk. He presented to the ED and further w/u inc a CT chest is corroborative for a type A dissection. He denies any focal weakness, weakness or abdominal pain. He is alert and oriented with no signs of focal deficit. He denies any previous such pain. He does endorse family h/o similar dissection in his father that required emergent surgery.  ASSESSMENT / PLAN:  58 yr old male with no known past medical or surgical history presenting with acute ascending aortic dissection extending up to iliacs.  Remains hypertensive in the ED: nicardipine gtt ordered ( brady with HR in 50s).  No signs of mal-perfusion; Equal pulses bilaterally. To OR for emergent repair of type A dissection. 1.15.22 - arterial line insertion;  1.16.22 - intubation;  1.16.22 - bronchoscopy;  1.17.22 - corpack placed under fluoroscopy for dysphagia;  1.23.22 - intubation;  1.23.22 - bronchoscopy Progress note from 1.24.22:  Plan:  58 year old male p/w type A aortic dsxn s/p emergent repair - elephant trunk and total arch 1/14/22 whose course c/b acute hypoxic resp failure requiring reintubation 1/16/22, pericardial effusion w tamponade s/p pericardial window 1/23/22. Given abdo distension, CT a/p obtained today after which our service was contacted. Evidence of ileus and non specific enterocolitis. Imaging limited to eval bowel ischemic given lack of IV contrast (in setting of AKI) however given normal lactic, patient stability and soft abdomen w/o peritonitis, this is not an active concern.  No acute indication for operative intervention. Continue non op management of ileus w gastric decompression via NGT, NPO status. Given the non sp bowel thickening of the sm and large bowel, recommend a 7 day course of abx to cover risk of translocation esp in setting of new aortic graft - zosyn or ceft/flagyl would suffice. Hold PR bowel regimen at this time.  Progress Note 1.25.22:  The patient was visited at bedside. His wife was also present for visit. He is sedated and intubated on 35 ugr/kg/min of propofol and 0.02 ugr/kg/min of norepinephrine. He does not open his eyes to verbal or noxious stimuli. Anasarca with 3-4+ edema on 4 extremities. Abdomen distended tympan on palpation. Unable to assess tenderness due to sedation. Surgery will continue to follow. Problem List: - Type A Aortic Dissection s/p Elephant Trunk Repair w/ AV resuspension 1/14/22 - Pericardial Tamponade s/p Window 1/23/22 - Distributive shock, NE PRN.  Discuss antihypertensive meds an needed. - Hypoxemic respiratory failure s/p failed extubation attempt 1/15/22 - Ileus, NPO, OG to LIS - Nonspecific small and large bowel thickening, zosyn x 7 days - Leukocytosis, increasing - AKI, follow, appreciate nephrology recommendations - Left IJ DVT, SQH prophylaxis Daily Events/Procedures: 1/14: admit Type A dissection, COVID-19 positive, OR for Type A dissection repair/elephant trunk/total arch and resuspension of aortic valve with Dr.  1/15: extubated, CTCC 1/16: worse hypoxia, repeat COVID negative, hypotension, 2 units of blood, ETT, CTA H/C/A/P: Nothing acute. B/l pleural effusions and atelectasis, echo with underfilling and normal EF, small pericardial effusion 1/17: 2 units blood, 2 FFP, TEE neg for tamponade 1/18: Extubated; bipap overnight; enteral BB and hydralazine initiated 1/19: Increasing PO antihypertensives; bilateral IJ DVT noted on UE US, VAD heparin started; cardene changed to labetalol (pulmonary shunting) 1/20: USV w/ LIJ DVT 1/23: Febrile, leukocytosis, hypotensive, worsening AKI. Anti-htn held, diuretics held.  Afib; Amiodarone. Tamponade, emergent pericardial window; ETT. 1/24: ongoing abdominal distention, CT thorax/abdomen/pelvis with mediastinal hemoatoma (post-pericardial drain), small and large bowel wall thickening, left posas hematoma, Gen surg recommend NPO, holding enema, continue PO bowel regimen   1/25: Strict NPO; serial abdominal exams, tenuous ileus