Patient present to emergency room with fever 38°C, cough, SOB, sore throat & diarrhea since 5 days. She was tested Covid-19 positive from a card drive test on 08/04/21.

On room air saturation 92-93%. On nasal cannula O2 3L/min.

Visual triage score is 17.

Diagnosis: COVID-19 pneumonia, on high oxygen support.

14/04/21: COVID-19 Positive.

On 16/04/21: developed desaturation 70%, tachycardia & tachypnea with respiratory distress. Electively intubated, Respiratory failure on ARDS protocol.

  • CVP line & arterial line inserted. Stat dose of IV Toclizumab. Inj. Tazocin started.
  • 34.5°C Hypotension, inj. levophed infusion resumed.
  • Heart rate 38-40 /min, inj.
  • Atropine STAT given.
  • On ventilator,FiO2100%, saturation 90%.
  • On sedation & inotropic support.

On 18/04/21: FiO2 100%,saturation 95-96%, on prone position.

  • Inj. Toclizumab STAT dose given.
  • Febrile 37.8°C.
  • Patient having refractory hypoxia not fit to transfer to specialized Covid-19 center.  

On 06/05/21: On ventilator, FiO2 90%,Saturation 92%. Episode of transient hypotension. Plan for tracheostomy waiting for approval. Worsening inflammatory markings. With persistent lymphopenia. Bilateral lower limb edema: For Doppler  study.

On 09/05/21: On ventilator, FiO2 100%,saturation 87%. BAL culture A. baumannii (MDR) on colomycin. ECHO EF 60%.

On 10/05/21:  On ventilator, FiO2 100%,saturation 86%. Daily Renal Function Test.

On 11/05/21: On ventilator, FiO2 100%,saturation 90%.

On 12/05/21: On ventilator, FiO2 100%,saturation 89%. Continue lung protection strategy.

On 13/05/21: On ventilator, FiO2 100%,saturation 95%. Plan for tracheostomy.

On 15/05/21: On ventilator, FiO2 100%,saturation 80-81%. Dexamethasone discontinued.

On 17/05/21: On ventilator, FiO2 100%,saturation 85%. CXR: mild Rt. sided pneumothorax; ICD inserted. Urine output 10-20 ml/hr. Developed desaturation started levophed infusion. PRBC 1 unit transfused. Antibiotics: Tazocin & colomycin. CXR repeated: chest tube is out to insert new chest tube. USG chest: revealed small collapsible IVC almost kissing wall so lasix infusion stopped & rehydration started. Clinically unstable.

On 18/05/21: On ventilator, FiO2 100%,saturation 89%. Daily RFT. Considering tracheostomy.

On 19/05/21: On ventilator, FiO2 100%,saturation 94%. Sedated. RT. ICD in placed.

On 20/05/21: On ventilator, FiO2 100%,saturation 96%. Sedated. RT. ICD in place.

On 22/05/21: On ventilator, FiO2 100%,saturation 92%. Seen by cardiothoracic surgeon, no intervention to be offered except continuing negative pressure connected to ICD. CXR: bilateral infiltrates, surgical emphysema, resolved Rt. sided pneumothorax.

On 23/05/21: On ventilator, FiO2 100%,saturation 95%. On inj. Meropenem, BAL culture revealed K pneumoniae (ESBL). Clinically unstable.

On 24/05/21: On ventilator, FiO2 100%,saturation 95%. Static condition. Improving inflammatory markings.

On 25/05/21: On ventilator, FiO2 90%,saturation 98%. Still hypoxic. Rt. ICD. CXR: bilateral infiltrates. AFB sputum requested.

On 26/05/21: On ventilator, FiO2 100%,saturation 92%. Sedated. AFB 2 sets negative. 3rd set pending report.

On 27/05/21: On ventilator, FiO2 90%,saturation 87-88%. CXR: increasing surgical emphysema.

On 28/05/21: On ventilator, FiO2 90%,saturation 88-93%. Discussed with cardiothoracic surgery yesterday recommended to clamp ICD for next 12 hours & repeat CXR. RT. ICD clamped. CXR after clamping increased emphysema, RT ICD connected again to suction vacuum.

On 29/05/21: On ventilator, FiO2 90%,saturation 83-85%. CXR after clamping increased emphysema, RT ICD connected again to suction vacuum. For USG Doppler lower limbs. Plan for PICCO catheter insertion.

On 30/05/21: On ventilator, FiO2 90%,saturation 89-94%. Rt. ICD connected to high vacuum suction. Increased surgical emphysema. Discussed to ask for CT chest but unstable, desaturation during CXR. Were advised to insert another chest tube if patient developed desaturation & increase surgical emphysema. CT chest after stabilization.

On 31/05/21: On ventilator, FiO2 100%,saturation 96-97%. Tachycardia. Worsening surgical emphysema on Lt. side. Cardiothoracic did not recommend for Lt. ICD placement.

On 01/06/21: On ventilator, FiO2 100%,saturation 97%. Rt. ICD intact. CT chest after stabilization. Continue antibiotics for 14 days. Poor prognosis.

On 02/06/21: On ventilator, FiO2 90%,saturation 93%.

On 03/06/21: Developed desaturation. On ventilator, FiO2 100%,saturation 94%. Antibiotic: Cotrimoxazole for 14 days.

On 04/06/21: On ventilator, FiO2 100%,saturation 99%. Sedated no inotropes.

On 05/06/21: On ventilator, FiO2 100%,saturation 92%. CXR: no pneumothorax but still with surgical emphysema so plan for needle compression.

On 06/06/21: On ventilator, FiO2 100%,saturation 95%. RT. ICD in placed connected to suction.

On 07/06/21: On ventilator, FiO2 90%,saturation 90%. Discontinued cotrimoxazole. RT. ICD site pus noted. Swab taken & sent for culture.

On 08/06/21: developed desaturation. On ventilator, FiO2 100%,saturation 98%. CXR: large Rt. sided pneumothorax. Discussed with cardiothoracic, urgent Rt. ICD inserted. CXR repeated resolved Rt. sided pneumothorax. Worsening hypoxemia. Old RT. ICD for possible removal today.

On 09/06/21: ventilator, FiO2 100%,saturation 99%. Removed old ICD.

On 10/06/21: ventilator, FiO2 90%,saturation 93%. CXR: bilateral infiltrates, bilateral surgical emphysema, no residual pneumothorax. RT. ICD in position.

On 11/06/21: Developed desaturation. On ventilator, FiO2 100%,saturation 84-85%. Resolved Rt. sided pneumothorax.  Rt. ICD inplaced. Having fibrosed lung. Poor prognosis. Supportive care.

On 12/06/21:  On ventilator, FiO2 100%,saturation 92%.  Rt. ICD in place. Poor prognosis. Supportive care. CRP increased , Tazocin & ciprofloxacin started.

On 13/06/21: saturation dropped to 65%. On ventilator, FiO2 100%,saturation 70-80%.  Hb is 8, one unit PRBC transfused. CRP is rising. CVP line changed to Rt. femoral line. RT. ICD intact drained 15 ml / 24H. Inj. Vancomycin & Anidulafungin added inflammatory markers rising. Arterial line inserted. Septic workup repeated.

On 14/06/21: On ventilator, FiO2 100%,saturation 90%.  Maximum ventilator settings. CXR: showed new Rt. lower lobe infiltrations.

On 15/06/21: desaturation 72%. On ventilator, FiO2 100%,saturation 70-76%.  Not responding to broad spectrum antibiotics, highly suspected invasive aspergillosis. Inj. Voriconazole initial dose given. Inj. & neb colomycin started, BAL culture isolated A. baumannii.

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