Age: 75.0
Sex: M
Vaccine: COVID19
Symptoms: Stridor, Tracheal aspirate culture
Clinical narrative: Hospital Course:  =========== Admission HPI =========== Patient first presented to the Hospital 8/25 for low blood pressures and lightheadedness for several days. He had exposure to non-vaccinated friends visiting the week prior and reports he and his wife developed a cough afterwards. Of note he received the COVID vaccine x2 in Feb/March.    In the ED, he tested positive for COVID 8/25, CXR at the time with patchy R sided infiltrate. He was admitted to medicine floor. COVID treatment initially deferred as he was doing well without asx, initiated 8/26 with remdesivir and dexamethasone. Was not a tocilizumab candidate given that he was too far out. Convalescent plasma considered but not available. He was also treated for potential superimposed CAP given patchy airspace opacity on CXR in RLL with Ctx and azithro (8/26 - 8/29). Patient also had asx pyuria, felt to be adequately covered by CTX.    Patient then began to have desats with increasing O2 requirement, eventually requiring ICU transfer 8/29 for HFNC. Patient endorsing pleuritic chest pain thus treated empirically for PE with heparin gtt, unable to transfer safely to CT-PE, though recent 8/28 CT-PE negative. LENIs negative for DVT. On 8/31 decision was made to intubate given worsening respiratory status.In the setting of intubation, patient was hypotensive with systolics down to 60s. He was started on levophed and antibiotics broadened to cefepime due to concern for shock. He was transferred to main campus.    On arrival to the ICU, patient was intubated and sedated.   ========================= MICU Hospital Course (8/31 - 10/6/2021) ========================= #Acute Hypoxemic Respiratory Failure 2/2 COVID-19 #ARDS Patient presented initially with hypotension and lightheadedness to Hospital, found to be COVID+ (PCR date 8/26) for which he has been initiated on a 5 day course of remdesivir and 10 day course of decadron. Then developed progressive O2 requirement, intubated for acute hypoxemic respiratory failure. Patient with bilateral opacities on CXR, clear injury within 1 week (COVID infection and ARDS). P/F ratio 135 at admission, consistent with moderate risk. He treated empirically for PNA with vanc (9/2 - 9/7) +cefepime (8/29 - 9/4) and broad infectious workup sent. Tracheal aspirate ultimately grew coag negative staff thus continued on vanc empirically and d/ced cefepime, ultimately repeat tracheal aspirate negative for growth thus vanc discontinued 9/7. For treatment of COVID, he ultimately was treated with additional 5 days of remdesivir (8/26-8/30, 9/1-9/5), complete 10 days of dexamethasone (8/26 - 9/4) and baricitinib 4mg (total 14 days).  After multiple days of improved P:F ratio and tolerating pressure control then subsequently pressure support the patient was extubated on 9/13. At the time of extubation he was following commands and had positive cuff leak. However, shortly after extubation he was noted to have quite severe stridor that didn't resolve with racemic epinephrine or dexamethasone. He was ultimately re-intubated within the hour by anesthesia who noted edema/swelling of the glottic structures. Upon re-intubation he immediately tolerated SBT again and was ultimately extubated on 9/16 to high flow, which he tolerated with some subjective dyspnea. Unfortunately in the setting of likely aspiration event (rapid increase in O2 requirement, fever, HDUS) patient was re-intubated for a third time on 9/18 and treated with broad spectrum abx, paralysis, and proning  with resolution of fevers and improved oxygenation. Given hx of immigration and rising covid cycle threshold (clearing virus effectively) w/ continued lung pathology ID recommended empiric treatment for strongiloides w/ ivermectin x2 doses + TB PCR which was ultimately negative.  Unfortunately, despite initially improving, he continued to struggle when sedation or paralysis were weaned down producing vent dyssynchrony. Additionally, despite broad spectrum antibiosis he developed a worsening pressor requirement and third spacing resulting in broad edema with intravascular dryness. Liver and kidney function continued to deteriorate, and after long discussion with the family, the decision was made to transition to comfort care. HE was extubated on 10/6 and passed away peacefully at 2:46 PM.