Question normal

Authors: Holmen IC, Lakritz S, Kent A, Elms L, Buchanan C, Mastalerz K, Manheim J.

Date of Presentation
March 9th, 2020

Case Presentation
A 56 year old male with a history of hypertension, obesity, and scoliosis who was admitted to the hospital for 2/10, dull, substernal, atypical chest pain, and a HEART score of 4. Patient endorsed dry chronic cough for over 3 months, bilateral shin pain, increased work of breathing, family member with influenza, and travel to New York City 2 weeks prior.

Physical exam
Vitals as follows: Temp 38.0C, HR 76, BP 137/92, RR 16, and SpO2 96% on 2L NC.
Patient’s general appearance was fair, lung auscultation was limited due to body habitus but mild crackles noted at bases, his heart was regular rate and rhythm with no murmurs or rubs, no costal tenderness to palpation, and tenderness to palpation of bilateral anterior tibia.

Pertinent Laboratory values
Troponin 0.077, D dimer 748, WBC 5.5, Hgb 14.2, Cr 1.6 (baseline 1.1-1.2), influenza and RSV PCR were negative
COVID19 resulted positive on 3/12/2020
Creatinine progression:
3/14/20: 1.1; 3/15/20: 2.9; 3/16/20: 3.6; 3/17/20: 5.0; 3/18/20: 5.4, 3/31/20: 7.8.

Pertinent Imaging
CXR: Normal
CTPE: no sign of PA thrombosis, but interval development of ill-defined discontinuous ground glass opacities in both lungs.

Treatment and Outcomes
Patient initially treated with IVF resuscitation with 1L LR and 2-4L supplemental oxygen via nasal canula. Upon positive Covid-19 result, patient was started on lopinavir-ritonavir. Over the next 48 hours, patient developed increased oxygen requirement and increased crackles on exam, refractory to single dose of 20mg IV furosemide. On hospital day 5 oxygen saturations decreased to 80s on 6L NC and RR increased to mid 30s, and patient was transferred to a negative pressure ICU room where he was electively intubated. P/F ratio was 77 supine upon intubation. Patient was immediately proned, paralyzed and placed on a high PEEP ladder. ABG was pH 7.404, pCO2 38.6, pO2 77, HCO3 24.2 on Vt 550, RR 20, PEEP 22, FiO2 1.0 set for low tidal volume ventilation of 6ml/kg ideal body weight. NG tube was placed, paperwork for compassionate Remdesivir was completed (patient was not approved), patient was started on hydroxychloroquine for 10 days, and lopinavir/ritonavir was stopped.

Over the next 48 hours, P/F ratio gradually improved to >150. However, serum creatinine continued to rise to 5.0, and urine output decrease to <10cc/hr. Patient was determined to have rapidly progressive ATN, and SLED/SCUF was initiated on hospital day 9. Over the next 13 days patient continued to need ventilator support. Patient developed bloody sputum on day 16 with gradually down trending Hgb to 8.4. Patient had been on prophylactic subcutaneous heparin since admission, there had been no signs of DVT, but there was concern for clotting and emboli given D-dimer elevation to 26,489. There was also concern for diffuse alveolar hemorrhage, however Hgb stabilized and patient negative for ANA, ANCA Abs. PEEP was gradually weened to 5 at O2 of 0.4 with an ABG pH 7.44, pCO2 40.9, pO2 67, FiO2 20.2. On day 21, patient placed on SBT and tolerated a trial of IPAP 5, PEEP 5, FiO2 40% for over 2 hours.

Lessons Learned
1. Rapidly progressive respiratory failure going from SpO2 of 85 on 6L NC to a P/F ratio of 77 on intubation at a PEEP of 22 suggestive of worse lung function than suggested by SpO2.
2. Rapidly progressive ATN requiring SLED/SCUF.
3. Atypical presentation similar to NSTEMI
4. Prolonged mechanical ventilation.