Age: 43.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Nitrite urine present, Oropharyngeal pain, Pleural effusion, Polyuria, Prone position
Clinical narrative: Hospitalized (1.24.22 - PRESENT; in ICU);  COVID-19 positive (1.18.22);  Fully vaccinated (no booster) 1.24.22 - Intubated in ED of outside hospital - HPI: 44 y.o. with Down Syndrome, per father fairly high functioning.  She has a history of OSA not treated (noct O2), and respiratory failure in the past that led to prolonged trach and eventual decannulation in 2012.  She was COVID-19 positive on 1/18 and presented to the ed with worsening hypoxemia, and was intubated in the ed.  A 6.5 ETT was placed due to her prior tracheal stenosis.  She was given 2 L of ivf in the ED, and CT angio showed no PE but did show small bilateral effusions and extensive bilateral airspace disease, more posterior. She was transferred to hospital for continued care. Labs were also notable for AKI.   ASSESSMENT / PLAN:  44 y.o. female with Down Syndrome, remote resp failure/trach with history of tracheal stenosis, untreated OSA, admitted on 1/24/2022 with acute respiratory failure with hypoxemia.     Assessment and Plan Acute respiratory failure with hypoxemia  Assessment & Plan Due to covid-19 Intubation date: 1/24/22 Current respiratory support: Device (Oxygen Therapy): ventilator Vent Settings:   Lung mechanics: Plateau Pressure: 34 cmH2O Peak Pressure: 39 cmH2O Patient-ventilator interaction: o synchrony ? Neuromuscular blockade: Yes  ? Proning:Yes  ? Body Position: prone, head left facing Sedation: o RASS goal: -5 o propofol o fentanyl VAP prophylaxis: Chlorhexidine  GI prophylaxis: PPI DVT prophylaxis: subcutaneous heparin Plan: Goal TV 4-6 ml/kg with pPlat <30, ph 7.24 - 7.4 Goal SpO2 88-92%, PaO2 55-65  Initiate proning PEEP 16   * COVID-19 Assessment & Plan Vaccinated x 2, not boosted Positive test: 1/18 Severe respiratory isolation until 2/8/22 and fever-free   Secondary infection workup: MRSA swab pending Sputum culture pending   Treatment: Remdesivir: none due to AKI Tocilizumab: none due to shortage   Steroids: Methylprednisolone 40 mg iv q8h 1/24 - (1mg/kg)   Antibiotics: Ampicillin-sulbactam 1/24 -    Shock  Assessment & Plan Hypotensive Suspect largely due to sedation, possible pulmonary hypertension Check echo Empiric antibiotics (ampicillin-sulbactam) Follow up cultures   AKI (acute kidney injury)  Assessment & Plan UA Foley Follow I/O  Progress Note from 2.1.22:   Plan:  Intubated and sedated in the ICU  N: Continue RASS-5 while paralyzed and proned.  CV:  Contd. Diuresis Pulm: Stop prone, keep paralyzed, optimize PEEP GI: Continue goal feeds, having stool Renal: Lasix to keep even to net negative Heme: NAI, baseline anemia, on prophy lovenox due to BMI ID: On unasyn, last day today for 7 day course Endo: Continue current basal bolus schedule, reduce Lantus PLAN 2/1/2022 - Optimize PEEP back to 16 - Keep Pplat < 30 and DP < 15 - Monitor ABG - Control alkalemia as able - Continue on deep sedation and paralytics - Wean steroids by 10mg q5 day given relative improvement - Completed course of abx for MSSA - Sedation related hypotension, low requirement of norepi, stable - Continue diuresis with Lasix 20mg daily to keep even to net negative - Tube feeds are at goal - Bowel regimen acceptable - BS acceptable on BBI - GI / VTE ppx