10/14/06 - NICU Day #12

Nurse: Shanti

• Today was a bit of a rough day.
• Daniel's oxygen saturation spent a lot of the morning bouncing up and down.
  
• His noon CXR showed a mix of atelectasis (partial collapse) and pulmonary edema. His breathing tube was also a little low. He also squirmed a lot and wouldn't settle down to sleep. His attending believes the findings and behavior are related to his recent surgery.
• At around 4:30 PM, he received two doses of fentanyl (to relax him), a dose of lasix (to dry him out), and albuterol (to open his airways). His vent settings were increased to 20/5 at that time as well. Since then, he's been very stable and they were able to reduce his oxygen requirements. His 7 PM gas demonstrated improvement in his CO2 and O2 levels.
  

10/13/06 - NICU Day #11 - end of night

Nurse: Michelle

• Daniel's numbers contintued to improve all day today. His vent settings have been decreased to 18/5 and a rate of 50. When we left him tonight he was finally overbreathing the vent. The plan for the weekend is entirely pulmonary. He'll continue to get intravenous feeds (TPN) but there is no plan to give him PO nutrition until at least Monday.
  

10/13/06 - NICU Day #11

• Jenny changed Daniel's diaper this afternoon and then I changed his diaper tonight.
• Besides the pictures on the blog, there are other pictures of Daniel online.
• PicasaWeb

10/13/06 - NICU Day #11

Nurses: Kristi, Maria

• The chest tube came out this morning. His MAP is 32 and he rested comfortably all night.
• His settings were weaned to 20/5 overnight. His gas was good at 6:30 AM but no changes were made in the vent because the chest tube was removed. They'll keep weaning him throughout the day and watching for him to breathe more on his own.
• Feeds are still off until his ventilation improves.
  

10/12/06 - NICU Day #10

• PDA ligation successful and uneventful.
  
• We visited at 7 AM and then again at 9 AM. He looked great both times but his blood pressure was 51/19. The very wide pulse pressure belied his stability.
  
• He passed a lot of dark stool (probably meconium) at around 9:30 and then again just prior to the start of the surgery.
  
• The anesthesiologists started at around 10:45 AM. We waited in the Family Room. The surgeon sent a message in that the start had been delayed because the endotracheal tube needed to be replaced again. Better that it require replacement before the procedure than in the middle. At around 12:15, the surgeon came to the Family Room to inform us that the PDA ligation had gone smoothly. The recurrent laryngeal had been visualized and moved and was identified after the placement of the hemoclips so any potential damage should be minor.
• We went to see Daniel immediately after the procedure was over. His blood pressure had already improved to 55/31. He was still limp from the anesthesia but it was such a relief just to see him.
• The post-procedure CXR demonstrated the hemoclips by the aortic arch and a minimal left apical pneumothorax. Also, his lungs already looked clearer than the prior mornings film. Of course, that is likely due to fluid restrictions and the lasix from the prior 24 hours but it was still terrific to see. The images of the abdomen looked unremarkable.
  
• Now, we just wait for him to wake up and start moving around again -- that could take 24 to 48 hours. The chest tube will most likely come out in 24 hours. His tube feeds probably won't restart until after the weekend.
• A few hours after surgery Daniel's blood pressure was down to 44/18. Repeat checks with various cuffs measured pressures as low as 40/15, MAP 23. We discussed this with the attending and the fellow and they assured us that the pressure will normalize over the next 24-48 hours. The earlier higher pressures may have been due to mucking around near the baroreceptors in the arch of the aorta. If the pulse pressure stays wide, they'll re-echo him.

10/11/06 - NICU Day #9

• We spoke to the surgeon and Daniel will have PDA ligation surgery tomorrow either at 7:30 AM or 10 AM.

10/11/06 - NICU Day #9

• Daniel had an echocardiogram this morning. The preliminary finding is that there is a 1.5-2 mm PDA. The increased flow to the lungs because of the PDA is probably the cause of the increased difficulty aerating Daniel's lungs.
• The options for correcting this problem are medical (indomethacin) or surgical (ligation). The medical option was attempted when Daniel was 3 days old and it appeared to work, briefly. However, the experience of our neonatologist is that repeat indomethacin treatments don't usually work and the side effects (gastritis, bowel perforation) are increased due to his now more advanced age. Also, he has some GI findings on his abdominal X-ray since the feedings were started (they are now stopped).
• Our plan at this time, therefore, is to go ahead with PDA ligation. The surgery is done in the NICU by a pediatric cardiothoracic surgeon. The most significant risks are bleeding, infection, and unilateral vocal cord paralysis (the left recurrent laryngeal nerve curls around the ductus arteriosus). We hope to talk to the surgeon today.
• Also, Daniel is back under the UV lights because he had a slight elevation of his bilirubin level on this morning's labs.
  

• In the meanwhile, if you would like to say a mishabeyrach for Daniel, his name during this period of illness is Chaim ben Yosefa Avigayil. We hope that he will take strength from this name both for its call for life and because it is the Jewish name of his Great Grandfather Louis Stein.
  

10/11/06 - NICU Day #9

Nurse: Rachel

• This morning his numbers remain stable. His lungs are slightly clearer on CXR. The team is going to order another echocardiogram to evaluate for a PDA.
• He's still very dynamic. As you can see in the picture above, he wouldn't hold his hand and foot still for a picture.
  

10/11/06 - NICU Day #9

Nurses: Shift Change (Christy overnight, Rachel during the day)

• At 3 AM Daniel was changed back to a traditional ventilator because he continued to desaturate. He was started at 15/5 initially and was lowered at around 6 AM to 14/5. His FiO2 is at 45%, which is also comforting. There was a 7:30 AM Chest X-ray (CXR) that we'll follow-up on after the nurse shift change along with another blood gas. Fortunately, through all of the trouble yesterday and overnight his heart rate and blood pressure remained stable. He continues to move around and be his usual ornery self.
  
• The fellow also told me this morning that there was a little perihilar haziness on his CXR from yesterday and his pulse pressure had widened slightly. These findings suggest that his ductus arteriosus has re-opened.

10/10/06 - NICU Day #8 (11 PM)

Nurse: Christy

• Daniel's challenges continued into the night. He wasn't adequately ventilating or oxygenating despite the changes in the vent settings. His feedings through the OG tube were stopped. When his nurse suctioned his airway there was a large volume of secretions. Ultimately, his team concluded that his endotracheal tube was occluded and replaced it. His O2Sat improved but he still required high FiO2. However, his 10:30 ABG was "excellent" and with subtle changes in position his numbers significantly improved. The plan for overnight is getting a chest X-ray and stabilizing his position to maximize his ventilation and oxygenation. We'll follow-up during the night.

10/10/06 - NICU Day #8

• Daniel had a rough afternoon. His oxygen saturation levels dipped into the 70's a few times. The team increased his ventilator settings, pushing up both his amplitude (delta-P) and mean airway pressure.
• While we were visiting he desaturated again. When Rachel would disconnect him from the vent and give him small puffs he would recover but then he would fall again on the vent. Finally, they increased the mean airway pressure setting back up to 12 and he appeared to recover and stabilize.
  
• We hope this is just Daniel's way of indicating that he wants to slow down a little bit. Ultimately, it's a very minor setback.
  

10/10/06 - NICU Day #8

Nurse: Rachel

• Continues to improve overnight.
• The UV phototherapy was discontinued today. His eyeshields will be removed and his isolette will usually be covered by a blanket.
• He gained weight to 950 grams.
  
• The rate of his feeds was increased to 0.5 cc/hr.
• His vent settings continue to be reduced.
  

10/10/06 - Daniel

Today Mr. Stein has a name. He will be known as Daniel Louis.

• He is named for both of his great grandfathers, Louis.
  
• They both came from Poland.
  
• Louis Krieger, Jenny's maternal grandfather, worked as a painter for New York City and lived in Brooklyn.
  
• Louis Stein, Evan's paternal grandfather, worked as a butcher in the Bronx.
  
• As Daniel grows, we are happy to know that he will be watched over by these two very strong men.
  
• We leave it to Daniel to determine if he will be a Yankees fan like Louis Stein or a Mets fan like Louis Krieger.
  

10/9/06 - NICU Day #7

Nurses: Maria, Didith

• Still doing well.
  
• Continues to wean from the rapid oscillation ventilator. The mean airway pressure (10-11), the amplitude (14-15) and the FiO2 (35-37) have all been coming down steadily.
• He has been tolerating his feeds overnight and his belly remains soft. He even had a small bowel movement.
• The nurse reports that he has been very active. He has been pulling on all of his lines. He pulled out his OG tube once and insinuated his hand between the skin and another line, partially dislodging it. Hopefully, he'll be weaned sufficiently before he gets the strength to go after his endotracheal tube.
  
• This afternoon the UAC and UVC were removed and a PICC line was placed. The procedure went very smoothly and when we visited tonight, Mr. Stein was calm and peaceful. As one of his visitors commented yesterday, "Give him a beer and a remote and he'd look like any other guy on Sunday."
  

10/8/06 - NICU Day #6

Nurses: Maria, Maureen

• Very stable over night.
  • FiO2 down to 35%
  • Amplitude of the oscillator weaned to 15.
• 6 AM CXR with no PTX.
• As of 9:30 AM - Plan to remove chest tube today and remove UAC and UVC on Monday. Maybe start tube feeds of breast milk on Tuesday.
• Chest tube removed at 11 AM.
• 11:30 AM - The plan was accelerated and tube feeds were started at 0.1 cc/hr at noon with colostrum. As of 8 PM, his belly is still soft and non-tender.