Breakthrough Covid: Fully vaccinated, Preliminary cause of death: Respiratory arrest due to: COVID-19 infection.   61y/o M with.  He presents with shortness of breath since yesterday and discoloration noted,  no new medications otherwise no new changes.  He had body aches, headache and chest pain reported.  He was sent for CTA with 1.  No evidence of pulmonary embolus.2.  Findings compatible with bronchitis, and superimposed bronchiolitiMultivessel as coronary artery calcifications. 1. There is no acute intracranial abnormality.  There is no evidence for an acute infarct, acute hemorrhage, intracranial mass, or hydrocephalus. 2. Mild mucosal thickening and frothy secretions in the left maxillary sinus.  Correlate for symptoms of acute sinusitis.  her records when patient was in CT there was a CODE BLUE however it was more seizure activity and in unresponsiveness.  However it is noted that he did have a pulse and breathing spontaneously on physician arrival.  He had continued mottling, his H&H was 5/17, he was hyponatremic, per ED to lab said his blood could not be processed because it may have been too cold and it was hemolyzed.  The patient was excepted to the ICU.  On arrival the patient is breathing spontaneously however not able to follow commands or respond,  hemodynamically stable actually he had an elevated blood pressure.  However he had diffuse mottling that was progressive very quickly.  I was speaking with the mother to get his history, infectious disease came to the room and states she was concern for infections and had recommended plasma exchange.  I spoke with the mother for consent for dialysis catheter central line, intubation and the plans with plasma pheresis and she agreed.  Dialysis catheter was placed there was difficulty placing central line but this was eventually placed.  I spoke with nephrology for plasmapheresis, however given his low sodium levels Dr. Discussed with me that this would have to be corrected first because this is decreases with plasma exchange.  He was given bolus of hypertonic saline.  There is also a delay in the plasma exchange secondary to the hemorrhoids, the dialysis nurse has to calculate the treatment depending on the hematocrit however the blood draws are all hemolyzed and intact hematocrit was not able to be obtained.  however Dr. is said to use the hematocrit of 17 that was taken on arrival.  Patient became hypotensive, started on Levophed. Blood was ordered however patient unfortunately had antibodies and this is still pending screening and matching sounds.  Unfortunately the blood that was drawn was too hemolyzed and diluted for them to get accurate results.   COVID swab was obtained on arrival to the ICU and this was positive.   07/03 Patient has on mechanical ventilation, sedation with propofol and fentanyl, he had an area overnight, he is noted to have worsening  again of his skin mottling, his temperature goal was increased,  he was given 4 units PRBCs overnight, with plans for IVIG per hematology, plasma exchange was not able to be performed secondary to not having enough blood volume, he was started on dialysis, he has apparently the last 2 units of available PRBCs which are being given now, istat labs can only be obtained  for now because any blood being sent is hemolyzed by the time it is at the lab even with being warmed, livedo reticularis is almost all cleared however he does have ischemic fingers bilaterally 07/04 head CT  negative for acute changes 7/6: Pt did not tolerate plasma exchange. Continues to hemolyze due to cold temps. CRRT is probably contributing to inability to warm him up.   7/7: Pt's counts have improved. Discussed with Heme. continues to be sedated and mechanically ventilated. Will attempt SBT. Temp is finally controlled off CRRT. Tmax 102, WBC 13. 7/8: No overnight events. Has had a lot of subglottic secretions and NG tube was in the esophagus. Some coffee grounds? reported. Started on PPI bid. Small drop in Hg, but continues to hemolyze by labs.   7/9: failed SBT. Still not following commands. reducing sedation and using more precedex instead. Bone marrow biopsy results seen. 7/10: Gets agitated off sedation. Attempting SBT, seems to be tolerating, however, still encephalopathic, precluding a safe extubation. Bone marrow underwhelming as per oncology.  Severe volume overload. Continues to have a little bleeding and clots in the urethra. Urine is red. No overt hemolysis and relatively stable Hg. + balance. Hypothermic and intermittently febrile.  07/11: +5.2L/24hrs.  He is using accessory muscles with breathing, on fentanyl.  Ischemic hands bilaterally.  Tmax:38.3F.  CRRT failed due to hemolysis.  He received plasmaphoresis x1 yesterday (Failed due to clotting previously).  07/12: -1.2L/24hrs.  He had vent dyssynchrony overnight and required versed/fentanyl pushes.  He has an agonal breathing pattern when sedation weaned and nasal flaring.  07/13: +9.5L/24hrs.  He successfully completed the 2nd plasmapheresis session 07/12.  Pending HD today.  Despite aggressive care, he continued to decline. After discussion with his mother, she understood his prognosis was poor and did not wish for him to go on living in his current condition and she elected to withdraw care and pursue comfort measures.  Patient was then transitioned to inpatient hospice and withdrawal of care implemented. the patient ultimately passed away at 18:56 on 07/13/2022.