Age: 52.0
Sex: M
Vaccine: COVID19
Symptoms: Dyspnoea, Endotracheal intubation, Enteral nutrition, Fluid balance negative, Haemoglobin decreased
Clinical narrative: "Patient with J+J vaccine on 05/27/21 who admitted for COVID and died of complications.  Provider note below:  "53-year-old male history morbid obesity, depression, DM2, HTN, COPD, and OSA who present on 1/13 for progressive shortness of breath and cough for 2 day duration. Denies sick contacts but has a cousin who has COVID. Initial saturation in ED 45% on room air. CTA negative for PE. COVID positive. He is vaccinated but did not receive booster. He was admitted to general medicine and immediately escalated to BiPAP support with saturation >90%. Within 36 hours he was unable to maintain spo2 >85% and ABG 82% oxygenation on 100% 16/10 BiPAP support. ICU was consulted for further management. Patient notes he would be amenable to intubation, his father is at bedside and agreed to make further medical decisions on his behalf.   1/14:  Patient admitted to the ICU this morning. Initially he looked stable overall. However, his oxygenation quickly worsened on max BiPAP settings. Emergent/ Urgent decision to intubate, place cental access and he and his father agrees- they understand the need for mechanical ventilation given the worsening illness and potential complications. PICC line placed.  1/15:  Requiring increasing sedation and now vasopressor support - Norepi started over night. Was hypotensive and hypothermic over night. Arterial line placed over night. Renal function worsening. UOP poor.  1/16: No acute events over night. Foley exchanged overnight/ this morning with 600cc output. Renal function improving slightly. Plan for gentle diuresis today. 1/17: Nimbex gtt weaned off, Kidney function improving, Start TFs, D/C Bicarb gtt 1/18:  Remains on nimbex drip as did not tolerate proning and off nimbex.  Will attempt again today with PRN nimbex dosing after prone today.  1/19:  Intermittent hypoxia overnight.  Will stop proning.  Starting Lasix.  Will stop Nimbex unless significant hypoxia or dyssynchrony.  1/20: Febrile overnight, but no other markers of infectious etiology. Scant bloody secretions. Continues to be on high degree of sedation and require high ventilatory support. Proning discontinued pending repeat ABG.  1/21: Tolerated pronation overnight. Still febrile, although labs/cx are WNL. Slightly worsening hypercapnia. Hypoxia improving. Negative fluid balance for past 24 hours. Weaning sedation. Off pressors. TF held due to high residuals. Will trial Reglan for motility.  1/22: Hypoxic overnight. Still maxed out on ventilatory support. Paralyzed now even when not proning. Increasing leukocytosis. NGT putting out frankly feculent material. TF stopped. NGT to suction. Too unstable to go for CT scan as he has significant desaturation with minimal movement or changes. Restarting empiric abx coverage.  1/23: Still having feculent output from NG despite feeding being held. Tolerated proning overnight with paralysis. Still no bowel movement. Issues with ETT cuff pressure when changing from prone to supine. Blood cx positive for staph, vancomycin started.  1/24: PICC removed on 1/23 for bacteremia, central line placed yesterday. Remains on maximum vent settings with elevated plateau pressures to 33. Continue to prone. Increase lasix for positive I/O balance. No bowel movement and continued NG drainage. Will restart trickle tube feeds and trial aggressive bowel regimen with neostigmine. ID consulted- Repeat blood cultures pending- continue cefepime, flagyl and stop vancomycin. 1/25: Proned overnight, weaned O2 to 80%. Significant bowel movements requiring rectal tube. Attempted to hold nimbex but had to restart for vent dyssynchrony, continue low dose sedation and continue proning. Negative fluid balance, continue lasix. Day 10 of decadron BID, will decreased to daily. 1/26: Worsening ABG overnight, supinated early with initial improvement. Increased hypercarbia on ABGs, will hold on proning overnight. Start lasix gtt for diuresis, with norepi low dose for pressure support. Recheck coags on lovenox to ensure adequate dosing given his weight. Increase tube feeds today as he continues to have bowel movements. Palliative care consulted for prolonged intubation with difficulty weaning, will need to consider trach. 1/27:  Lasix gtt added, add valium and oxycodone through OG tube in attempt to decrease propfol and other drips. Tg 587 will decrease propofol as tolerates and recheck tomorrow AM.  Monitor ETT cuff.  1/28:  Had an episode of bradycardia and hypotension overnight after attempt to prone. NorEpi restarted with improvement. Will attempt to get in tough with family about poor prognosis.  1/29:  Pt stable overnight. Updated family yesterday. Will restart lovenox at prophylactic dose not therapeutic dose. Swelling to right forearm, will ultrasound today. 1/30:  Patient had no overnight events. Continues to have small blood clots from oropharynx.  1/31: Right ulnar vein DVT. Switched to heparin gtt. Responding to diuresis. Continues to require increasing ventilatory support with PEEP now at 20. Blood sugars have been 200-300. 2/1: No significant changes. Still hypoxic on maximal vent settings. Talked with family and explained poor prognosis and the fact that his settings are too high for tracheostomy. Still not tolerating proning. Continuing to diurese. Still on heparin gtt.  Lasix decreased.  2/2: ETT exchanged yesterday to 7.5 cm given cuff failure of initial tube. No significant changes. Still on maximum ventilatory support. Plateau pressures in the high 40s. Family is aware of condition. Continue with current treatment 2/3: ETT high, advanced 3cm. Remains sedated, intubated on max ventilator support with PEEP 20 and plateau pressures at 47. Desaturation with positioning remains with O2 sats in the 70s. Decreased hemoglobin but no signs of active bleeding. Discussed with sister about considering limitations of care, she will discuss with family today. 2/4: Off propofol, remains paralyzed and intubated, will not attempt to wean sedation further. Significant acidosis and hypoxia. Some improvement in plateau pressures down to 38 today, will increase PEEP to 22 in attempt to improve oxygenation, he continues to sat in the 70s and desaturates with positioning.   2/5: increased plateau pressures, PEEP reduced. Remains hypoxic to 70s. Positive fluid balance, will limit tube feed flushes to 30 Q4H and Change heparin gtt to lovenox. 2/6: significant desaturations overnight with bathing/positioning down to 18% with good waveform and taking 2 hours to recover to 60-70s. Remains in the 70s throughout the day. Family discussion with his sister, about his prognosis and futility of care. See code status note. DNR no CPR and planning for family meeting tomorrow at 4:30 to discuss goals of care.   2/7: Completed antibiotics today. Remains on high peep and plateaus with saturations in high 70s. Unable to wean sedation 2/2 paralysis. RUE with DVT with increased swelling. Difficulty with repositioning or turning without significant desaturation. Positive fluid balance. Father is decision maker, at this time he wants to continue aggressive care. Palliative care following.   2/8:  CXR shows ETT is at clavicle level, advance ETT by 2 cm. Remain on high PEEP, and worsen O2 sat at 53. Difficulty with repositioning or turning without significant desaturation. Called father, no one answered.    2/9:  AGB O2 sat63, CO2 97, bicarb: 48.4 . palliative care on board, would consult ethics.    2/10: pt is sedated. Discussed with Dr from Ethics. Planning ethics meeting tomorrow at 2pm.  Pt has a-fib rvr, start amiodarone infusion, EKG ordered.  I called sis, she was busy at the moment, she said she would call us back later.     2/11: over night pt is tachycardia, metoprolol was given. pt required 1 unit blood transfusion today.  Have ethics meetings. Pt remains full code.    2/12: Anuric overnight. Renal function decreasing, now hyperkalemic. Still hypoxic on maximal ventilator settings. Blood pressure, slightly low compared with previous trend.    2/13: Dialysis catheter placed yesterday, tolerated dialysis without any fluid removal. Remains anuric. Still on vasopressors and maximal vent settings.    2/14: Decrease Nimbex. Still anuric and scheduled for HD today. Remains on max vent settings, sedated/paralyzed.    CODE blue called today at 1256. See note for  Further details. Attending physician spoke with family, who requested to discontinue CPR. Patient expired 1304. Family at bedside shortly after. "