covid 19 death summary

1. Death Review
by
Dept. of Pulmonary Medicine
Dr. Nrusingha Charan Dash
Asst. Professor, SCBMCH, Cuttack

2. • 26 year old male
• From Barbil, Keonjhar, Odisha
• Presented at CHC Barbil, Keonjhar on 08/05/2021 with complaints of :-
• Fever for 3 days
• Cough for 2 days
• Breathlessness for 2 days
• SpO2 – 62% on room air
• After initial treatment, he was referred to SCB-MCH, Cuttack as a Covid
case for further management
• So the patient was admited to DCH-1, 4th floor on 10/05/21at 1.40 PM

3. Patient is a known case of schizophrenia since 2016 on treatment-
Tab Trihexiphenidyl 2 mg BD
Tab Clonazepam 2 mg BD
Tab Nitrazepam 20mg OD
Tab Risperidone 2 mg BD
Tab Promethazine 25 mg BD

4. 10/05/21
• TLC – 13,000/cu.mm
• DLC – N82 L15 E02 M01
• PLT – 4Lakh
• Hb - 12.2gm/dl
• Na – 133mEq/L
• K – 4.2mEq/L
• Urea – 80mg/dl
• Creatinine – 1.2mg/dl
• Bilirubin Total/D – 0.5/0.2mg/dl
• SGOT/SGPT - 454/137 IU/L
• Sr Protein/Alb - 6.9/3.8gm/dl
• HIV - neg
• HBsAg - neg
• HCV - neg
• RBS-149mg/dl
• CRP – 31.4mg/L
• IL-6 – 55.48pg/ml
• Total Cholesterol 128 mg/dl
• TG – 347 mg/dl

5. 10/05/21 contd..
• Patient was shifted to ICU-DCH1
• Conscious, irritable
• HR - 115/min
• RR-28/min
• SpO2 – 85% with O2 face
mask@ 7L/min

6. In the ICU,DCH-1 --
• Oxygen and NIV support
• Inj Piperacillin + Tazobactam 4.5g TDS
• Inj Teicoplanin 400 mg iv OD
• Inj Methylprednisolone 40 mg iv BD
• Inj Enoxaparin 0.6 mg s/c OD
• Inj Pantoprazole 40 mg iv OD
• Inj Vitamin C 1.5 gm iv QID
• Tab Zinc 50 mg OD
• Tab UDCA 300 mg BD
• And antipsychotic medication continued as such

7. 11.05.21 ( Day 2)
• Psychiatry consultation sought.
• As per their advice, Tab Nitrazepam and Tab Clonazepam was stopped
and Tab Quetiapine 100mg OD was added.
• Other medications continued.
• Patient remained stable with above medications

8. 15-05-2021 (Day 6)
• Neurology Consultation was sought for altered sensorium, increased
irritability and convulsion
• Inj Phenytoin 100mg 8hrly started as per their opinion

9. 19/05/2021 (Day 10)
• Cellulitis in right foot and surgery consultation taken and medication
changed as below
• Inj Meropenem 1g 8hrly , Inj Metronidazole IV 8hrly started and inj.
Pip/Taz was stopped.
• Alternate day dressing with Mupirocin ointment.
• Urea/creatinine – 84/1.8 mg/dl
• Bilirubin (T/D) – 0.8/0.4 mg/dl
• SGOT/PT -101/128 IU/L
• Na/K - 160/5.0 mEq/L
• Intermittent NIV, Oxygen mask with O2@4-6 L/min

10. 27/05/21 (Day 18)
• Patient conscious, oriented
• PR-110/min
• BP-96/60 mmHg
• RR-20/min
• SpO2-97% with O2 face
mask @2L/min

11. Day 19-20
• In the meantime the patient developed cellulitis of both lower
limbs
• inj hydrocortisone 50mg 8hrly was added
• As SARS CoV-2 RT-PCR was negative on 20/05/2021 and
24/05/2021, call given to medicine dept. and CICU to transfer
for better management of the multisystem involvement.

12. 31/05/21 (Day 22)
• The patient was eventually shifted to HDU, Dept of Pulmonary
medicine
• E4V2M5
• Bed sore of size 4cmx3cm noted in sacral area
• BP- 148/80 mmHg
• HR – 112/min
• RR – 26/min
• SpO2 – 95% with O2 @4-6L/min
• B/L VBS with Creps in b/L bases
• Inj hydrocortisone was omitted and other medications continued

13. 01/06/21 (Day 23)
• Patient become irritable, review consultation from
psychiatry
• Inj Promethazine 1amp IM BD was started

14. 03/06/2021 (Day 25)
• Altered sensorium,tremor ,muscle rigidity and high grade fever (105
degree F)
• Variable Tachycardia (PR- 160/min) and Hypertension (210/122 mmHg)
• Bed sore at sacral area increased 10cm x 8 cm
• Psychiatry, Neurology, General Surgery and cardiology consultation were
sought

15. 03/06/21 Contd..
• Psychiatry opinion- ? Neuroleptic malignant syndrome (NMS)
 Advised to stop tab trihexyphenidyl and quetiapine.
 Advised for blood creatine kinase and urine myoglobin
• Surgery opinion-limb elevation, crepe bandage, alternate day dressing
• Cardiology consultation- withhold tab nifedipine and and start Tab
Telmisartan 40mg OD and Ivabradine 5mg OD
• Neurology consultation- Inj Phenytoin stopped and Inj levetiracetam
was added

16. 03/06/21 contd…
• ABG pH- 7.42, PCO2- 32.1, PO2- 124, HCO3- 20.9, Lact- 9.02
• Inj. Meropenem, Teicoplanin and Metronidazole were stopped and
Inj Ceftazidime and Clindamycin was started
• Care of bed sore and foot ulcer was done as per standard protocol
with surgery opinion
• Color Doppler B/L Lower limbs, EEG and NCCT Brain was advised but
could not be done due to transportation issue

17. 09/06/2021 (Day 31)
Persistent high grade fever
Tremor, Muscle rigidity
Autonomic dysfunction
CPK – 3652 U/L raised ( NORMAL 25 -
200)
Urine Myoglobin - 190micro gm/L
within normal range
Renal dysfunction – Urine output <0.5
ml/kg/hr
Cause-??
? Encephalitis
? NMS
Neurologist advised for NCCT Brain

18. 09/06/21 Contd…
• In view of low GCS endotracheal intubation was done and Invasive
Mechanical ventilation was initiated
• Patient remained hypotensive despite fluid resuscitation after
intubation and vasopressor requirement progressively increased over
next 24 hour
• As per psychiatrist opinion Inj Dantrolene was advised but due to
nonavailability Tab bromocriptine 2.5 mg twice daily was added

19. 10/06/2021 (Day 32)
• Inj Ceftazidime and Inj Clindamycin
stopped
• Tigecycline and Metronidazole was started
• Psychiatry, neurology, cardiology and
Nephrology consultations were sought
and advices followed
• Neurologist advised for IgG, IgM for both
HSV-1 and HSV-2 which all were negative
Malaria ICT –ve,
Widal Anti Typhi ‘O’ +ve in titer of
1:180
D-dimer 1989 ng/ml
PT/INR – 26/2.06
ET Asp – No pus cell, No bacteria
CRP –74.4 mg/dl
PCT -100 ng/ml
Urea/ Creatinine – 136/3.1 mg/dl
Na/K – 142/3.8 mEq/L
Bil (T/D) – 3.2/2.9 mg/dl

20. 11.06.2021 (Day 33)
• Patient developed pancytopenia with
coffee coloured RT aspirate and malena
• Hematology and gastroenterology
consultations were sought and advices
were followed
• Gastroenterology opinion ? Upper GI
bleed (stress induced) ? Mesenteric
ischemia and planned colonoscopy and
UGIE after stabilization
• PRBC 1 pack, RDP 3 pack was transfused
• Syp Sucralfate was added
• inj Pantoprazole was changed to 40mg
BD
Hb – 6.8 gm/dl
PLT – 23000/ cu mm
TLC – 4000/cu mm
Pt continued on MV with VC, PEEP –
6, Vt 420 ml, FiO2 – 70%, RR-20
ABG pH- 7.28, PCO2- 29.7, PO2- 38.9,
HCO3- 14.1, Lact- 5.33
Temp – 101 F
BP – 108/63 mmHg with NA @ 10
ml/hr, Vaso @2.4 ml/hr
HR – 124/min
SpO2 – 98%
I/O –2450/570 ml

21. 15/06/2021 ( Day 37 )
• Hematology consultation was
sought and advice followed
• Inj peg-Filgrastim 300pg s/c OD
added to treatment
• Levetiracetam was stopped
• Plastic surgery consultation was
sought and VAC therapy for bed
sore was initiated
TLC – 900/cu mm
PLT – 30000
Hb – 7.7 gm/dl
E2 M4 Vet
Malena, RT aspirate coffee color
Norad @6 ml/hr
ABG- pH- 7.57, PCO2- 23.4, PO2- 85,
HCO3- 21.8, Lact- 1.76
Bone marrow suppression ?

22. 18/06/2021 ( Day 40 )
Pus culture was +ve for klebsiella and
sensitive to Tigecycline, imipenem
and Polymixin B.
Antibiotics were changed to
Polymyxin B and Tigecycline
continued along with mechanical
ventilation
CRP - 6.82 mg/dl
Na/K – 142/3.8 mEq/L
TLC – 9.98/cu mm
P82L17
Hb – 9.2gm/dl
PLT – 74000
CPK – 530 U/L
Patient On PSV PEEP-6,
PAP-14, FiO2 – 45%

23. 20/06/21 ( Day 42 )
• As it was post-intubation day-12,
ENT consultation sought for
tracheostomy
• PR-128/min
• BP 106/66 mmHg with
vasopressor support
• SpO2 91%
• MV VC, PEEP-8, RR-22/min,
FiO2-90%

24. 21/06/21
• Patient deteriorated further and was declared clinically dead
at 12.10 AM/ 22.06.21

25. labs 10/05/21 14/05/21 19/05 22/05/21 29/
05
01/06 09/06 11/06 14/06/21 16/6 17/06 18/06
TLC 13000 14100 12200 4000 900 220
0
9900
DC N-82% N-79% N-85% N-88% N-70% N-
55%
N-82%
TPC 1.8L 4.06L 1.8L 23K 36K 1.4L 74K
Na 133 160 147 140 140 142 160
K 4.2 5.0 3.8 4.7 4.7 3.8 3.1
Urea 80 84 60 40 27 136
Cr 1.2 1.8 0.7 0.7 0.5 3.1
LFT Bil-0.5
SGOT- 454
SGPT-137,
ALP-125
Bil-0.5
SGOT-
126,SGPT
-123,
ALP-157
Bi-0.8
SGOT-101,
SGPT-128,
ALP-107
Bilrub-0.9
SGOT-85,
SGPT-76, ALP-
143
Bilrub-3.2
SGOT-89,
SGPT-96,
ALP-628
Bilrub-0.8
SGOT-
80,SGPT12
6,ALP-386
Sr.Pr
/Alb
6.9/3.8 5.5/3.6 4.8/2.9
CRP 31.4 33.8 13.34 17.4 16.82
Spl.T
est
IL 6-
55.4
Proc
al.39
Sr.CK-
3652,Pro
cal-100,
d-Dimer-
IgG,IgM for
HSV1&2 Neg
UrineMyoglbn
-129(N)
Sr.CK-
5300

26. Cause of death ???
• Young patient with schizophrenia
severe COVID pneumonia
cellulitis
NMS
sepsis with MODS
pancytopenia
VAP

27. Pneumonia with sepsis, MODS

28. Thank you