Saturday, October 21, 2006

10/21/06 - NICU Day #19 (late day)

  • Daniel is in critical condition.
  • He has been anuric for 3 1/2 days. His potassium tonight is 7.2 and his creatinine is 3.7. They've increased the insulin and glucose drips. He'll get dialysis if his EKG changes.
  • His right pneumothorax never fully resolved and his left lung is atelectatic and his right lung demonstrates severe PIE. They'd like to lie him on his side to hypoventilate the bad lung but he can't tolerate it.
  • Since last night, they've had trouble keeping his blood pressure up and now he is on dobutamine, dopamine, and epinephrine. They'll be weaning the dobutamine tonight as they go up on the epinephrine. If they can stabilize his blood pressure, they may dialyze him sooner.
  • Despite all his problems, he is a beautiful baby. His doctors and nurses assure us that he feels no significant pain and they have been treating his anxiety with Ativan. He looks very peaceful and we love him so much.

10/21/06 - NICU Day #19

Nurse: Michelle
  • Anuria continues. Complications of the fluid and electrolyte retention have developed.
  • The potassium is relatively stable at 6.1. After yesterday's rectal bleeding, kayexalate is being held and he is just being maintained on insulin and glucose. The abdominal radiographs are unremarkable and his belly is soft.
  • The hematocrit this morning is also down (28.9) and he will require a transfusion -- adding to both his fluid and potassium load.
  • Yesterday evening, the increasing retained fluid in the lungs required higher and higher mean airway pressures to maintain oxygenation. Simultaneously, the blood pressure began coming down. A new attending on service for the weekend felt that Daniel's blood pressure would do better on the conventional ventilator and switched him over. This was done simultaneously with increasing the dopamine to 12 (from 10). His blood pressure improved -- although I'm not sure it was the ventilator change or the increased pressors. Predictably, PIE worsened and he developed a pneumothorax on the midnight CXR. Two chest tubes were needed to re-expand the lung. He was then switched over to the Jet ventilator. I'm still waiting for the morning chest X-ray.
  • The rectal bleeding stopped last evening after Daniel got FFP. According to his nurse, his coags were normal but the FFP was given prophylactically because of three bloody diapers. He's still getting Q6H X-rays, antibiotics, and bowel rest.

Friday, October 20, 2006

10/20/06 - NICU Day #18 (afternoon)

Nurse: Debbie
  • The A-line is in and his MAP has improved on dapamine although there is room to go up on the dose.
  • Potassium on 2 PM blood gas was 5.8! No need for another kayexalate dose. Insuin and glucose will continue. 6 PM labs will let us know if the creatinine has plateaued.
  • FiO2 down to 50%.
  • He's had two episodes of bright red blood per rectum. On physical exam he has a fissure -- probably from the administration of kayexalate. Playing it completely safe, he is going to get blood cultures, non-nephrotoxic antibiotics (ampicillin, cefotaxime) and serial X-rays for a NEC work-up. The first X-ray was unremarkable (no free air, no pneumatosis) -- just a paucity of gas. Obviously, feeds will be held until the work-up is over.

10/20/06 - NICU Day #18

  • Midnight labs -- Crt 3.0, K 6.2 -- he got a dose of Kayexalate.
  • Morning labs -- Crt 3.1, K 7.3 -- more Kayexalate, insulin, glucose, bicarbonate. He didn't get calcium because his is already elevated. The base excess on his gas is -6.
  • His nephrologist recommended pushing the dopamine from sub-pressor doses to pressor doses to try and increase the renal blood flow and glomerular filtration. He doesn't think dialysis is necessary just yet but he will re-evaluate with the potassium levels.
  • Increased FiO2 (now 60%) is now required because of fluid retention in the lungs. He is, however, ventilating well.
  • The fellow will try to put in an arterial line this afternoon to follow the potassium and so that Daniel won't need so many heel sticks for blood.

Thursday, October 19, 2006

10/19/06 - NICU Day #17

Nurse: Debbie, Serica
  • Daniel has been anuric (no urine production) for about 30 hours. He is gaining a lot of fluid weight. Today he is 1330 grams -- that's 3 ounces heavier than yesterday. His creatinine this morning was 2.5, his potassium was 5.6 -- both elevated. Repeat electrolytes in the evening showed a continued but slower rise -- Crt 2.7, K 5.9. Daniel got a dose of Bumex (a potassium-wasting loop diuretic) tonight and they started low-dose dopamine. It may take 4-5 days for his kidney function to return, in the meantime they're doing everything possible.
  • FiO2 is still at 35%. They're hyperventilating him to compensate for a metabolic acidosis. He's been oxygenating much better since he was sedated.
  • OG tube feeds were started at noon today at 0.5 cc/hr. Daniel is tolerating them well.
  • The head ultrasound was repeated a third time today. There is an increase in the amount of fluid in the interlobar fissure and the anterior horns but no evidence of a bleed. The radiologist is not alarmed by this finding and thinks it should just be followed with another ultrasound next week.

Wednesday, October 18, 2006

10/18/06 - NICU Day #16

Nurses: Debbie, Sarika

  • Today Daniel is doing well while sedated.
  • His vent settings are being gradually weaned and he is maintaining his saturation with a relatively low FiO2 (30-40%).
  • There is now renal dysfunction (the fellow and attending are hesitant to call it "failure") which is probably a result of a combination of the indomethacin (about 10 days ago) and vancomycin (after 48 hours, stopped yesterday). Daniel made about 28 cc of urine yesterday and about 5 cc today (25 is about his required minimum). The team put in a catheter to measure output accurately and they've given albumen and lasix at the recommendation of a pediatric nephrologist who was consulted. The attending hopes the condition will reverse in 4-5 days. In the meantime, he's getting a little "puffy."
  • PO feeds were delayed again because of the kidney problems. Maybe tomorrow.

Tuesday, October 17, 2006

10/17/06 - NICU Day #15

Nurses: Jodi, Rachel
  • Today, Daniel is doing better. His FiO2 is down to 40% this evening after not being able to tolerate anything other than 100% as late as this morning. The NICU started a little Ativan and increased the Fentanyl because he does much better when he is sedated.
  • His CXR is unchanged to slightly worse. The PIE is more pronounced. However, the lungs will take a little while to heal so the improved clinical picture is heartening.
  • PO feeds by OG tube might start tomorrow.

Monday, October 16, 2006

10/16/06 - NICU Day #14

Nurse: Jodi, Rachel
  • Daniel had a very difficult day.
  • The X-ray this morning demonstrated worsening pulmonary interstitial emphysema (PIE). On top of this he also has pulmonary edema. In order to protect him from continued damage, he's been put back on the rapid oscillating vent. However, he's been oxygenating poorly for the last 36 hours and won't even tolerate decreases to FiO2 of 98%. His follow-up CXR showed improvement in the lungs but oxygenation is still a problem.
  • His new attending (they take two week blocks) is very on top of things and has a plan (both long and short term) that we hope will be successful.

Sunday, October 15, 2006

10/15/06 - NICU Day #13 - late afternoon

Nurse: Shanti
  • Stable today with continued pulmonary issues. Antibiotics and lasix continue.
  • Echo was repeated this afternoon. Prelim normal but final read will be tomorrow.
  • Today Daniel got a hat - some modifications were required to make it fit. He's also opening his eyes a little.

10/15/06 - NICU Day #13

Nurse: Jodi

  • Daniel continued to have mild desats (high 60s) overnight. His morning gas was still fine but his CXR was diffusely hazy. With a differential of pulmonary edema and infection, the fellow gave a dose of Lasix, cultured him and started Vancomycin and Cefotaxime. He'll get an echo on Monday. Given all this he still looks stable and comfortable on his belly.