Discharge Provider: MD Primary Care Physician at Discharge: DO  Admission Date: 12/22/2022 COVID positive date: 12/22/2022  PRESENTING PROBLEM: Pneumothorax [J93.9] Pneumothorax on right [J93.9] Pneumothorax, unspecified type [J93.9] Bochdalek hernia [Q79.0]   HOSPITAL COURSE: The patient is an 88 year old woman who was admitted on 12/22/2022 after undergoing an outpatient thoracentesis on 12/20 which was complicated by a right pneumothorax. Although initially stable from this, she then developed increasing shortness of breath thus presented. A right chest tube was placed and the patient admitted. She was also found to be positive for covid 19 at that time although asymptomatic. Since that time the patient has remained hospitalized with ongoing challenges with the right pneumothorax and pulmonology has been actively engaged. On 1/3 in the early morning the patient began to have severe abdominal pain and was noted to have an incarcerated hernia on physical examination. CT imaging was obtained demonstrating a large known Bochdalek hernia with associated closed loop small bowel obstruction as well as multiple anterior abdominal wall hernias. With these findings, conversations were held between the patient, her family and her medical teams. After significant discussion and deliberation, the patient and her family elected for operative intervention thus she was taken to the OR emergently.   Intraoperatively she was found to have a large known diaphragmatic hernia through which the bowel was able to be reduced. Within her anterior abdominal wall hernia, there was noted to be a strangulated loop of small bowel which required resection. The entirety of the GI tract appeared to be hyperemic and threatened, without frank necrosis. The patient initially was maintained on a phenylephrine infusion in the case however was then transitioned to norepinephrine. As her norepinephrine requirements escalated to 0.14 mcg/kg/min, vasopressin was added. Prior to and throughout the case she maintained a lactic acidosis which worsened with a pH of 7.08 and she became progressively hypothermic. With this, the decision was made to maintain the patient in discontinuity, place and Abthera, and transport to the SICU for resuscitation. Of note, there are 2 laps pads which were intentionally maintained in the abdomen, packed at the diaphragm.    On arrival to the SICU the patient was initially hypertensive and able to be liberated from the NE first and then the vasopressin. Noted to have significant variation on the arterial line tracing with respirations and then became more hypotensive once again. 500 mL of plasmalyte was given and the NE was resumed while a central line was emergently placed. Her hemodynamics continued to be labile, requiring titrating doses of vasopressors which as the bolus was being instilled, were able to be discontinued once again. Shortly after completion, SBP once again fell to the low 90s and the NE was resumed. With ongoing SVV, a second 1L of plasmalyte was administered and the NE continued to be titrated. Laboratory studies returned with 7.19/33/305/-16.1 and a lactate of 10.5. Also noted to have developed AKI and evidence of shock liver with multisystem organ failure. The patient's husband and son were then brought back to the room and updated on her condition.   Subsequently despite ongoing resuscitation her lactic acid continued to increase as did vasopressor requirements. With this, concern for bowel ischemia remained thus a bedside exploratory laparotomy was performed. Upon removal of the wound vac, significant malodorous matter was encountered. On exploration, the stomach was ischemic, small bowel and colon necrotic, incompatible with life. Thus the patient's son was telephoned and this was discussed. Shortly thereafter the patient's husband, son, daughter in law and grandson were all present at bedside. After full discussion, the transition to goals of comfort was made and the patient was extubated. At 0534 noted to be in asystole without a blood pressure on the monitor. The patient was evaluated and no signs of life present.   Time of death 1/4/2023, 0534. The patient's family was present at bedside and updated, support given.