Thursday, October 26, 2006

10/26/06 - NICU Day #24 - Daniel's Last Day





Daniel died today at 1:22 PM.
  • Daniel's metabolic acidosis worsened during the night. He received two boluses of bicarb. His bradycardias had become less frequent.
  • The 6:30 AM gas had a pH of 6.6 and a base excess of -20. A bicarb drip was started. Blood cultures were drawn and Abelcet (liposomal amphotericin) was started to cover for fungal infection although there were very few indicators for an infection.
  • Dopamine at this time was at 20 mcg/kg/min and Dobutamine was at 5 mcg/kg/min.
  • Last night and then this morning, Daniel was making rhythmic jerking movements compatible with seizures. His attendings believed it was these intractable seizures that were most likely causing the severe metabolic acidosis and indicated a problem in Daniel's brain. Daniel had been receiving phenobarb for cholestasis and there was hope that this might also help the seizures.
  • At approximately 12:30, Daniel started to desaturate again. He was not responding to increased FiO2, suctioning, or other interventions. At this time, we made him as comfortable as possible with valium (for the seizures and anxiety) and fentanyl (for any pain). At 1 PM, we disconnected him from the ventilator so that we could hold him and say good-bye. His heart stopped at 1:22.
Thank you for all the love and support you've all shown during this very difficult time.

Wednesday, October 25, 2006

10/25/06 - NICU Day #23 (8 PM)

  • Daniel's tension pneumothorax came back this afternoon. A third chest tube was placed. Since then he has been weaned to FiO2 40% and has been saturating well.
  • His blood pressure has continued to be a problem. He is on dopamine and intravenous fluids.
  • The newest problems to add to the mix are cholestasis and spontaneous bradycardia (slowing of the heart). The cholestasis is being treated by phenobarbitol. He can't get Actigall because he's not getting enteral nutrition. The etiology for the bradycardia is unclear but he doesn't appear to be infected. Another possible cause could be vagal stimulation from the new chest tube. They may try repositioning it but they don't want to manipulate it too much because of his susceptibility to a pneumothorax.

10/25/06 - NICU Day #23

Nurse: Melissa, Maria
  • Another eventful morning.
  • Relatively stable overnight but the urine output tapered overnight along with Daniel's blood pressure. The team added back dopamine, increased his intravenous fluids, and restarted intravenous feeds. The potassium is 4.3 and the creatinine is 4.0.
  • No bleeding. His platelets are 218 and hematocrit 38.
  • He had a tension pneumothorax on his 7 AM film that did not respond to replacement of one of the chest tubes. After the chest tubes were retracted a little bit, the air collections drained. His FiO2 is down to 50%. If they can get him to 40%, then they will slowly wean the nitric oxide.
  • Between 9:30 and noon, several changes were made. He was put back on the oscillator -- his "favorite" vent. He seems more comfortable on it. The mean airway pressure is being kept as low as he will tolerate (13) to try and give his lungs a rest. The dopamine was increased to 10 mcg/kg/min and his fluids were increased again. His nurse will monitor his blood pressand urine ouput and try to wean the dopamine.
  • There is some concern that there may be a broncho-pleural fistula. Hopefully, if the current chest tubes will keep the lung up and the oscillator keeps the damage from getting worse, his lungs will heal without another intervention.

Tuesday, October 24, 2006

10/24/06 - NICU Day #22 (7 PM)


NICU DAY #22
  • The epinephrine, dopamine, and dobutamine are now all off. They'll watch his pressures closely and add back dobutamine if necessary.
  • After the transfusions, the hematocrit is up to 39.
  • The gas was good (including a potassium of 4.2). The FiO2 is still 65% but they've gone down on the inspiratory pressure.
  • The cerebral ultrasound showed a very small Grade 1 germinal matrix hemorrhage on the right. This is likely of minimal significance. There will be a follow-up ultrasound in one week

10/24/06 - NICU Day #22

Nurse: Maria, Didith
  • Overnight the epinephrine was weaned to off. His dopamine is also being weaned off. Dobutamine will be the last to go. Hopefully, dobutamine will come off quickly as its theoretical effect on the blood pressure (in his case) is minimal.
  • He continues to put out urine. 58 mL over the last 24 hours. His potassium is down to 5.3. His insulin is off. He's leaking urine around the catheter in his bladder so they've pulled the catheter and are now just weighing the diapers for volumes.
  • His 1 AM hematocrit was up to 34.7 (from 27 at 6 PM). He got another transfusion this morning and the labs will be repeated at 1 PM. He seems to be bleeding much less than last night. The output from the chest tube is also less bloody.
  • The team will continue to follow his I's and O's and monitor his glucose level. If everything continues in the right direction they'll consider restarting intravenous nutrition tomorrow.
  • The concern for NEC is rather low. On today's X-ray, gas appears to be moving through the gut normally. Barring any changes, the team is going to stop antibiotics tomorrow (Day #5).
  • The biggest problem continues to be Daniel's lungs. One of his chest tubes stopped draining last night at around 10 PM. He again developed a tension pneumothorax and his saturation dropped without recovering. The fellow took the dressing off the chest tube and the bubbling started again in the Pneumovac and his saturation shot right back up. This morning's CXR showed no pneumothorax. He is on the Jet ventilator with significant support. His FiO2 has been weaned to 75% and last night, his attending added Nitric Oxide (NO) to his mix. This is a somewhat experimental therapy with few side effects that may help reduce any effect that pulmonary hypertension has on his difficulty with oxygenation. They'll follow him on this for a day or so to see if he is responsive otherwise they'll just turn it off.
  • We hope Daniel continues to surprise us.

10/24/06 - NICU Day #22

Monday, October 23, 2006

10/23/06 - NICU Day #21 (Evening)

  • Daniel continues to keep us on our toes.
  • The newest complication today is bleeding. Daniel is bleeding from his rectum and oozing blood from the sites of blood draws and from chest tubes. His blood counts have been low for most of the day. The team sent special coagulation labs. His PT, PTT, and INR are all elevated and his Fibrinogen is low. These findings are consistent with DIC. DIC is very dangerous because it essentially means that there is uncontrolled bleeding. Fortunately, Daniel's DIC is not severe and he is getting FFP, platelets and blood to try and stay ahead of his losses. Unfortunately, the etiology is non-specific. The usual suspects of infection and liver disease do not appear to be present. Hopefully, this is just a consequence of his current "sick" status and will improve with his improvements.
  • He continues to urinate. His potassium is slowly coming down. His creatinine is holding stable. His nephrologist says it will take a week to correct. The acidemia has significantly improved. All of these things have led to the ability to reduce the number of drips Daniel is on. With less fluid input, they can replace the drips with nutrition.
  • The team is still working on weaning Daniel off of pressors. It's slow going but they're coming off.

10/23/06 - NICU Day #21 (Noon)

Nurse: Maria
  • Already an extremely eventful morning.
  • When we returned to the NICU at 9:30 AM, the weekday attending was placing a new chest tube for a tension pneumothorax. Daniel's blood pressure was stable but he was oxygenating very poorly.
  • After the chest tube was in, the team noticed that the pad Daniel was on had become wet. They began to replace the foley catheter and he started to urinate. They measured an output of 9-10 cc. He'll get regular doses of Lasix during the day today to try and keep his output up. Labs will be drawn at noon and again at 6 to follow his electrolytes.
  • He had bright red blood from his rectum with a few clots again. A surgeon will come to examine him but in the meantime he will get red blood cells, FFP, antibiotics, and serial X-rays to follow for NEC.
  • After the chest tube was in, his follow-up CXR showed almost complete resolution of the the pneumothorax. However, his oxygen saturation continues to be very labile. His weekend attending came to check on him at 10 AM. The attending did not leave the bedside during the time we were present. He monitored the vents while the weekday attending rounded. They're going to check his gas levels regularly and wean his oxygen as he requires.
  • His blood pressure stayed up throughout the morning and the plan is to reduce the epinephrine every hour and see if he can do a better job of supporting it on his own.

10/23/06 - NICU Day #21

Nurse: Michelle
  • The creatinine and potassium are very mildly increased (after increases in the insulin and glucose drips). A bicarb drip was also added last night and his base excess as fallen to -5.
  • The pressors are the same and his lungs are largely unchanged.
  • As you can see Daniel's numbers are all relatively unchanged this morning; however, he continues to defy expectations. There was a tiny drop of fluid (?urine) around his catheter today. We really don't know what this means or what to expect. They gave 1 mg of Lasix as we were leaving to try and coax more.

Sunday, October 22, 2006

10/22/06 - NICU Day #20

Nurse: Ebony

  • Daniel has not made any urine in four-and-a-half days. In the neonatologist's opinion, recovery of renal function after this long state of anuria is very unlikely. Daniel's potassium and acid levels continue to slowly, inexorably rise. They will eventually reach a critical level and Daniel's heart will no longer be able to function normally. Peritoneal dialysis may delay this outcome but it has many risks and, sadly, a dysrhythmia probably cannot be avoided.
  • In an attempt to give Daniel's kidneys the best possible chance of healing, his blood pressure is being maintained with dopamine, dobutamine, and epinephrine. Attempts were made today to lower the levels of these medications because they come with their own risks but they have all proved necessary.
  • The most improvement today was seen in Daniel's lungs. His right pneumothorax almost completely cleared and the left lung shows much better expansion. He is oxygenating and ventilating well.
  • He is still resting comfortably.