Hospital course 1/31 ? 2/20/21 1/31 in ED pt was at home when children noticed his lips were blue, ems arrived and found him to be 50% on RA, on Non-rebreather pt got to 78%, covid on 01/26   Shortness of Breath   61-year-old male presents with EMS for evaluation of shortness of breath hypoxia.  History is limited due to the patient's current clinical condition and so is primarily obtained from EMS.  EMS reports that he tested positive for COVID-19 5 days ago.  He began developing shortness of breath yesterday and his family called because his lips and fingers were blue today and he appeared short of breath.  On EMS arrival he had a room air saturation of less than 50% so he was placed on nonrebreather with improvement in his saturation to 70% and he was transported to the emergency department.  Patient does admit to shortness of breath.  He denies any chest pain.  He is noted to have a cast on his left ankle and said that he broke his left ankle on 23 December but has not had surgery.  He denies any new pain or swelling of the leg.  In the ED he was placed on 15L nasal cannula and NRB mask with improvement in SPO2 to low 90s. Additional work up revealed troponin of 1.35, lactic acid 5.8, and d-dimer 14.4.  He received dexamethasone and was placed on heparin gtt.   1/31 admitted to ICU Acute hypoxic respiratory failure due to COVID-19 vs heart failure vs PE.  CXR with bilateral hazy infiltrates more pronounced in the bases and left periphery and suspected multifocal pneumonia.   At risk for PE given LLE immobility in the setting of COVID-19 with significantly elevated d-dimer. RISK of CTA outweighs benefit given AKI and iodine allergy. Continue with empiric treatment with heparin gtt.   Admitted to ICU with SO2 in 60s-70s on 15L and NRB. Attempted 50L 95% FIO2 high flow and nasal cannula. Given lasix 40mg IV with good diuresis however SPO2 still remained low 80s with RR 40s and PO2 42 so the decision was made to intubate.  Oxygenation improved following intubation, with further improvement following recruitment maneuver and increase in PEEP. FIO2 weaned to 90% with SPO2 remaining in mid 90s. Will continue to wean FIO2 as able.  ARDS net protocol as much as possible. Consider prone ventilation and/or epoprostenol if unable to improve .  VAP Bundle: HOB >30 degrees; Oral care per nursing standard and on DVT/PPI prophylaxis Sedation: Target Richmond Agitation and Sedation Scale (RASS) of 0 to -2 with propofol and fentanyl. Check baseline TG levels.    COVID - 19: Convalescent plasma: Not indicated  Steroids: Dexamethasone 6 mg / day for 10 days Remdesivir: Not indicated d/t AKI   IL-6 inhibitor: Meets criteria for tocilizumab Systemic AC: Heparin gtt. No signs of bleeding (Platelets and Hb stable).  Antibiotics: Start 3 and 7 day course of azithromycin and ceftriaxone, respectively.  Elevated troponin  Suspect demand ischemia d/t hypoxia; EKG does not show any ischemic changes    AKI: Suspect d/t hypoxia in the setting of COVID infection. Urine output and electrolytes acceptable.  Closed fracture of left ankle Suffered fracture following a fall on ice in December. Cast was placed on 12/30 by SOS. He was due to be re-evaluated this week for possible cast removal.    Inhaled epoprostenol started  Considered for ECMO but not initiated due to not a candidate  Vasopressors required at times  Antihypertensive infusion required at times  severe hypoxia with position changes  switched from heparin drip to enoxaparin prophylaxis  2/20 discharge summary 61 y/o male admitted to Hospital on 1/31 with hypoxia.  He was diagnosed with COVID 19 5 days prior to admission, and had worsening respiratory status.  He was intubated after arrival, and was on ventilator for the entire intervening time, until he was extubated on 2/20 at the time of transition to Comfort measures only.    Prior to developing COVID 19, he had received his first dose of the Pfizer vaccine, as a member of the school system.  He had a fractured L ankle after a fall on 12/31/20, and had a cast in place at the time of admission.  He received Tocilizumab on 1/31, and underwent several cycles of prone positioning, beginning on 2/2.  He completed a course of Decadron, he received  Ceftriaxone and azithromycin beginning on admission, and completed a course of these.  Anticoagulation with enoxaparin was utilized due to coagulopathy associated with COVID 19.  Vasopressor support was required at times, as well as diuresis for fluid management.    He required high levels of sedation to maintain ventilator synchrony, and high levels of ventilator support with high oxygen levels throughout his stay.  Tracheostomy was being considered, but family decided that since he was not going to have good recovery, withdrawal of support, and allowing death was the appropriate choice for the patient and for them.   He was extubated at 2100 on 2/20/2021.   Death was pronounced at 2123 on 2/20/2021.  Children were at bedside.