Age: 43.0
Sex: M
Vaccine: COVID19
Symptoms: Hypernatraemia, Hypertension, Hypotension, Hypovolaemia, Hypoxia
Clinical narrative: Patient male 44 y presented to the ED with right-sided abdominal pain, with radiation to the chest. He was noted to have bilateral pleural effusions and infiltrates and was positive for SARS-CoV-2. Additional the patient was also noted to have multiple pulmonary nodules, some of which were cavitary. Pericardial effusion and abdominal wall edema was also discovered during his work-up. The patient was admitted to Hospital Medicine with Pulmonary and ID consultations. He was started on doxycycline, ceftriaxone, dexamethasone, remdesivir.    The patient developed increased respiratory distress and was transferred to the ICU. He was intubated and central line was placed as well.    Hospital Course.  11/08: patient remained on mechanical ventilation support. Start Precedex. Wean down Fentanyl infusion as able. Spiked a fever. Pan culture was requested. Hypernatremia: Free water and D5 was initiated. Give a dose of Metolazone. Taper down dexamethasone.  Procalcitonin and CRP are downward trending.  11/09: patient remained on mechanical ventilation support. Patient is more responsive and able to follow some basic commands. On Precedex infusion. Hypertensive. Nicardipine infusion. Add po hydralazine. Hypernatremia is improved. Discontinue D5W. CPAP+PS trials. RC grew GNR. Continue Meropenem. Discontinue Vancomycin.  11/10: more interactive and intermittently able to follow some basic commands. Tolerating CPAP+PS but not ready for extubation. Increase Hydralazine PO dose. Discontinue Nicardipine. Continue diuresis.  11/11: patient remained on MV. CPAP+PS trials resulted in tachypnea and hypoxia. Patient is more interactive. Dicussed tracheostomy. Family in agreement. General surgery consult was requested.  11/12: patient failed SBT. Remained Vent dependent. S/p tracheostomy and PEG placement. ABG showed PH 7.53, Pao2 of 67, Paco2 of 40. Developed subcutaneous emphysema and small left apical pneumothorax.  11/13: patient has subcutaneous emphysema extending to the left side of the face. Repeat CXR showed left sided tiny pneumothorax that has decreased in size. Bronchoscopy was done by surgery. Trach is in good position.  ABG were noted. Patient is agitated and restless at time. Sedation with propofol and Precedex. Cr and BUN trended up.Hold off Diuretics. Start gentle hydration concerning intra-vascular volume depletion. Transaminase trended up likely due to hypotension. Requiring vasoactive support with norepinephrine.  11/14: increase in work of breathing and vent dyssynchrony despite of continuous sedation, increase in FIO2 requirements up to 100%. CXR showed near resolution of small left apical pneumothorax. Start NMBA infusion. CXR showed worsening bilateral air space disease. Add Mycamine.    11/15: increase in O2 requirements and worsening gas exchange. Started on inhaled NO. Remained on sedation and NMBA infusion. Will resume diuresis. Repeat CXR showed no very tiny left apical pneumothorax, improvement in subcutaneous emphysema and bilateral air space disease. Respiratory culture continue to grow GNR.  11/16: patient remained in critical condition. Has increase in FIO2 requirements. FIO2 at 100%. Continue sedation and NMBA infusion. Off norepinephrine. Increase IV diuresis. MDR pseudomonas. ABX coverage was changed to Ceftazidime-Avibactam. Continue Mycamine.discontinue IV vancomycin. CXR showed tiny left sided pneumothorax.  11/17: he developed left lung collapse 2/2 mucus plug. Underwent bronchoscopy and wash out with improvement. FIO2 requirements improved down to 70%. Remained on continuous sedation and NMBA infusion. Continue Bumex infusion.  11/18: remained on MV support. Discontinue rocuronium. Wean down inhaled NO. Down to 5 PPM. FIO2 at 70%. Transaminase are downward trending.  11/19: remained on MV support. Weaning down sedation. Non communicative. Weaning down inhaled NO. ABG revealed PH 7.30, Pao2 of 74, Paco2 of 51. P:F 124. CXR was reviewed. Pneumothorax is resolved. Worsening kidney function. Hold off Bumex infusion. Off vasoactive support. Leukocytosis downward trended. High gastric residual. Add Reglan. HTN: resume Metoprolol.  11/20: patient is off continuous sedation. Remains non purposeful. Has sporadic episodes of desaturation, some times unprovoked. CXR showed relatively similar appearance. Remained on inhaled NO at 5 ppm. FIO2 at 100%. Will obtain 2DE with Bubble study to assess for intra-cardiac shunt. Resume diuresis with Bumex 1 mg Q12H.  11/21: patient is off sedation. Arousable. Has generalized myopathy but able to follow some basic requests. FIO2 iis down to 70%. Failed weaning off iNO due to Hypoxia. Back on iNO AT 2 ppm. Continue diuresis. Add Metolazone. 2DE study with Bubble study was inconclusive. Small pericardial effusion, preserved LVEF at 60%.     11/22: did not tolerate weaning off inhaled NO due to hypoxia. At 2 PPM. FIO2 is down to 60%. Continue diuresis. Patient is communicative. CRP and PCT are downward trending.  11/23: off inhaled NO. Did have an episode of desaturation. Resolved quickly. FIO2 at 60%. CXR continues to show significant air space disease right > left. Continue diuresis.  11/24: remained off inhaled NO. FIO2 requirements are down to 45%. Communicative but has genralized myopathy. Decrease Metolazone to 2.5 mg.  11/25: patient is more interactive. Failed CPAP+PS due to tachypnea in 40s. Remained off inhaled NO. Off vasoactive support.  11/26. Trach. Vent 26. 18/400/6/40%. 7.46/47/99. tolerating off nitric and vasopressors.  11/27.  Trach.  Vent 27. 18/400/6/40%.  7.48/42/96.  Low urine output and multiple fluid boluses.  Discontinuing diuretics.  11/28.  Trach. Off vent. Resuming diuretics.    11/29/2021. O2 req's/WOB remain stable on t-piece. Hemodynamically stable. Not req vasopressor support. Afebrile. Arouses and follows commands. Feeds.  11/30/2021. Doing well with t-piece. WOB appropriate. O2 req's stable. Thick secretions. Requires suctioning. Blood pressures controlled. Afebrile.