Age: 79.0
Sex: M
Vaccine: COVID19
Symptoms: Death, Dyspnoea, Endotracheal intubation, Enteral nutrition, Extubation
Clinical narrative: Brief Summary/Assessment: 80M with a history of NSVT, type 2 diabetes mellitus, gout, BPH, HLD, HTN, GERD, admitted for COVID-19 pneumonia, s/p intubation on 9/11/21 now s/p remdes, dex, and Baricitinib; paralysis stopped 9/21, reparalyzed 9/22 with new consolidations c/f aspiration PNA.          Hospital Course               Hospital Course:  Updated as of 9/24   ============== HPI ============== Patient is a 80 y.o. male with a history of NSVT, type 2 diabetes mellitus, gout, BPH, HLD, HTN, GERD, who presented as a transfer from  with hypoxia in the setting of COVID-19 infection.    The patient states that he had attended a party/"feast," where he believes is the event at which he contracted COVID-19. On 8/27, he called his ambulatory practice, where he noted rhinorrhea, rhinitis, post-nasal drip, and cough. He has a history of rhinosinusitus (followed by Dr.), treated with nasal lavage and ipratropium spray TID, though he only uses it once a day or less. He had received 2 doses of Pfizer vaccination earlier this year. Given his history, vaccination status, and otherwise non-concerning symptoms, he was advised to restart the nasal lavage and ipratropium sprays. He was seen on 8/31 and noted to have a cough over the last few months and a tickle in his throat. A CXR was ordered, which showed no evidence of PNA or pulmonary edema.     On 9/2, he presented to urgent care for worsening symptoms and was started on doxycycline 100mg BID for 7 days and given medication for cough. A COVID test was obtained. The patient tested positive for COVID and was found to be hypoxic to 70% on RA. EMS placed him on 10L NC with improvement to 80%. He was transferred to ICU on HFNC.   CT surgery Course Course was notable for increased O2 requirement, FiO2 increased to 80% on HFNC (60-70L), with SpO2 >85%. Desaturation to the 70%s when coughing. He was tachypneic over the past 3-4 days, with RR in the 50s. He occasionally felt that he was tiring out. FiO2 was weaned from 80% to 70%, with goal O2 of 85-88%. He was continued on remdesivir (planned 5-day course), dexamethasone 6mg daily (planned 10-day course), baricitinib 4mg daily (planned 14-day course).   ========== MICU COURSE (09/11 - 9/24 ) ========== (By problem)   # COVID-19 c/b PNA+severe ARDS, with possible superinfection/sepsis When PT was admitted to the medical facility, he was on HFNC of 60L/min and FiO2 80%. He was working hard to breathe, with more frequent desaturations and longer recovery times despite being maxed on HFNC. He was started on and completed a 5-day course of cefepime and doxycycline for possible bacterial superinfection. After a lengthy discussion with the patient (and daughter + son on the phone), he was intubated. He was paralyzed, proned, and began Veletri with improvement in his oxygenation. He was diuresed generally with net goal even. He was unparalyzed after 2 days and stopped proning given only mild improvement in oxygenation upon proning. He developed a pressor requirement originally thought to be due to sedation; however, early sepsis also on the differential due to ongoing pressor needs. Despite trying to avoid paralysis, he developed worsening oxygenation with vent dyssynchrony, and so he was re-paralyzed and re-proned on 9/17. Oxygenation and pressor requirements continued to worsen despite AC/VC settings of 420/30/12/90%, with PaO2 in the 50s. The patient was started on cefepime (switched to ceftazidime), vancomycin, and fluconazole (switched to micafungin). Blood cultures were negative. RUQUS showed a contracted gallbladder with stones. He was able to wean down on the RR, FiO2, and pressor requirements, so he was un-paralyzed on 9/21. Restarted paralysis 9/23 after oxygen requirements increased, patient's MAP started to drop to the 50s, and fever spiked on 9/22 c/f septic shock. Patient was broadened to meropenem on 9/22.  CXR 9/23 showed worsening lower lobe haziness and consolidation c/f aspiration pneumonia with residual volumes in stomach of up to 1.8 L (likely cause of pneumonia).  Patient's condition continued to decline with renal failure likely in setting of septic shock with decreased/minimal urine output. Patient was started on CVVH on 9/23 and continued to worsen on 9/24 with increased acidosis (likely metabolic) in setting of sepsis. He was given a dose of vancomycin on 9/24. Lactate continued to increase rapidly at a peak of 7.1 on 9/24. At that time, the medical team contacted the family to provide further insight into the poor clinical trajectory at which time, the HCP made the decision to change the patient's code status to DNR/OK to intubate and later to comfort measures as nothing more medically could be done. The patient was extubated and passed peacefully with family surrounding him.    # Nutrition # Hyperglycemia He was started on tube feeds with insulin to manage hyperglycemia (in the setting of a 10-day course of dexamethasone). Tube feeds were then stopped on 9/22 evening as team was concerned that patient was aspirating. Patient was started on D5 on 9/24 to provide some nutrition.    # Goals of Care Several conversations took place with the patient (prior to intubation) and family (once oxygenation status worsened despite near-maximized ventilation/oxygenation with re-paralysis, re-proning). The family ultimately decided to change the person's code status to DNR/OK to intubate and ultimately to comfort care.