tag:blogger.com,1999:blog-355815142024-03-13T11:48:32.647-04:00Mr. Stein's BlogEvan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.comBlogger43125tag:blogger.com,1999:blog-35581514.post-8565253152022127252006-10-26T15:05:00.000-04:002017-08-03T23:26:10.621-04:0010/26/06 - NICU Day #24 - Daniel's Last Day<a href="http://photos1.blogger.com/blogger2/3658/4343/1600/DSCN0596.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" src="https://photos1.blogger.com/blogger2/3658/4343/200/DSCN0596.jpg" style="cursor: pointer; display: block; margin: 0px auto 10px; text-align: left;" /></a><br />
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Daniel died today at 1:22 PM.<br />
<ul>
<li>Daniel's metabolic acidosis worsened during the night. He received two boluses of bicarb. His bradycardias had become less frequent.</li>
<li>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.</li>
<li>Dopamine at this time was at 20 mcg/kg/min and Dobutamine was at 5 mcg/kg/min.</li>
<li>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.</li>
<li>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.</li>
</ul>
Thank you for all the love and support you've all shown during this very difficult time.<br />
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Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com17tag:blogger.com,1999:blog-35581514.post-57433104832858563552006-10-25T19:42:00.000-04:002017-08-03T23:26:21.226-04:0010/25/06 - NICU Day #23 (8 PM)<ul>
<li>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.</li>
<li>His blood pressure has continued to be a problem. He is on dopamine and intravenous fluids.</li>
<li>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.</li>
</ul>
Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com3tag:blogger.com,1999:blog-35581514.post-62614097696865660292006-10-25T13:02:00.000-04:002017-08-03T23:26:28.207-04:0010/25/06 - NICU Day #23Nurse: Melissa, Maria<br />
<ul>
<li>Another eventful morning.</li>
<li>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.</li>
<li>No bleeding. His platelets are 218 and hematocrit 38.</li>
<li>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.</li>
<li>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.</li>
<li>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.</li>
</ul>
Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com1tag:blogger.com,1999:blog-35581514.post-33568914725917796752006-10-24T17:58:00.000-04:002017-08-03T23:35:44.109-04:0010/24/06 - NICU Day #22 (7 PM)<div style="text-align: center;">
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<span style="font-family: Arial, Helvetica, sans-serif;">NICU DAY #22</span></div>
<ul style="font-size: 11.050000190734863px;">
<li><span style="font-family: Arial, Helvetica, sans-serif;">The epinephrine, dopamine, and dobutamine are now all off. They'll watch his pressures closely and add back dobutamine if necessary.</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">After the transfusions, the hematocrit is up to 39.</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">The gas was good (including a potassium of 4.2). The FiO2 is still 65% but they've gone down on the inspiratory pressure.</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">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</span></li>
</ul>
Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com1tag:blogger.com,1999:blog-35581514.post-23203833064991948412006-10-24T11:25:00.002-04:002017-08-03T23:27:56.899-04:0010/24/06 - NICU Day #22Nurse: Maria, Didith<br />
<ul>
<li>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.</li>
<li>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.</li>
<li>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.</li>
<li>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.</li>
<li>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).</li>
<li>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.</li>
<li>We hope Daniel continues to surprise us.</li>
</ul>
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Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com3tag:blogger.com,1999:blog-35581514.post-53204242481609883132006-10-24T11:25:00.000-04:002017-08-03T23:39:06.543-04:0010/24/06 - NICU Day #22<div class="separator" style="clear: both; text-align: center;">
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Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com1tag:blogger.com,1999:blog-35581514.post-47153399423389154892006-10-23T17:54:00.000-04:002006-10-24T20:56:36.803-04:0010/23/06 - NICU Day #21 (Evening)<ul><li>Daniel continues to keep us on our toes.<br /></li><li>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.<br /></li><li>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.<br /></li><li>The team is still working on weaning Daniel off of pressors. It's slow going but they're coming off.</li></ul>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com4tag:blogger.com,1999:blog-35581514.post-27966084459478265362006-10-23T12:23:00.000-04:002006-10-23T12:43:34.694-04:0010/23/06 - NICU Day #21 (Noon)Nurse: Maria<br /><ul><li>Already an extremely eventful morning.</li><li>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.</li><li>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.</li><li>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.</li><li>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.</li><li>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.<br /></li></ul>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com3tag:blogger.com,1999:blog-35581514.post-61967946361372820932006-10-23T08:21:00.000-04:002006-10-23T12:26:10.137-04:0010/23/06 - NICU Day #21Nurse: Michelle<br /><ul><li>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.</li><li>The pressors are the same and his lungs are largely unchanged.</li><li>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.<br /></li></ul>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com2tag:blogger.com,1999:blog-35581514.post-24586109581152664632006-10-22T20:00:00.000-04:002006-10-22T21:09:07.809-04:0010/22/06 - NICU Day #20Nurse: Ebony<br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://photos1.blogger.com/blogger2/3658/4343/1600/DSCN0544.jpg"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer;" src="http://photos1.blogger.com/blogger2/3658/4343/320/DSCN0544.jpg" alt="" border="0" /></a><br /><ul><li>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.</li><li>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.</li><li>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.</li><li>He is still resting comfortably.<br /></li></ul>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com3tag:blogger.com,1999:blog-35581514.post-50845311402589622742006-10-21T20:20:00.000-04:002006-10-21T20:29:49.605-04:0010/21/06 - NICU Day #19 (late day)<ul><li>Daniel is in critical condition.</li><li>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.<br /></li><li>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.</li><li>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.</li><li>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.<br /></li></ul>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com10tag:blogger.com,1999:blog-35581514.post-7296310089427794702006-10-21T07:00:00.000-04:002006-10-21T09:54:12.382-04:0010/21/06 - NICU Day #19Nurse: Michelle<br /><ul><li>Anuria continues. Complications of the fluid and electrolyte retention have developed.<br /></li><li>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.<br /></li><li>The hematocrit this morning is also down (28.9) and he will require a transfusion -- adding to both his fluid and potassium load.<br /></li><li>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.</li><li>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.<br /></li></ul>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com2tag:blogger.com,1999:blog-35581514.post-73034151010671709372006-10-20T15:29:00.000-04:002006-10-20T16:06:39.717-04:0010/20/06 - NICU Day #18 (afternoon)Nurse: Debbie<br /><ul><li>The A-line is in and his MAP has improved on dapamine although there is room to go up on the dose.</li><li>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.<br /></li><li>FiO2 down to 50%.</li><li>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.<br /></li></ul>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com1tag:blogger.com,1999:blog-35581514.post-10339741092525667932006-10-20T06:02:00.000-04:002006-10-20T12:34:31.010-04:0010/20/06 - NICU Day #18<ul><li>Midnight labs -- Crt 3.0, K 6.2 -- he got a dose of Kayexalate.</li><li>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.</li><li>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.</li><li>Increased FiO2 (now 60%) is now required because of fluid retention in the lungs. He is, however, ventilating well.</li><li>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.<br /></li></ul>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com1tag:blogger.com,1999:blog-35581514.post-13441804994712303022006-10-19T14:06:00.000-04:002006-10-19T20:00:47.446-04:0010/19/06 - NICU Day #17Nurse: Debbie, Serica<br /><ul><li>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.<br /></li><li>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.<br /></li><li>OG tube feeds were started at noon today at 0.5 cc/hr. Daniel is tolerating them well.<br /></li><li>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. </li></ul>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com1tag:blogger.com,1999:blog-35581514.post-20906081164688848992006-10-18T08:58:00.000-04:002006-10-22T21:58:45.283-04:0010/18/06 - NICU Day #16Nurses: Debbie, Sarika<br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://photos1.blogger.com/blogger2/3658/4343/1600/DSCN0534.jpg"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer;" src="http://photos1.blogger.com/blogger2/3658/4343/320/DSCN0534.jpg" alt="" border="0" /></a><br /><ul><li>Today Daniel is doing well while sedated.<br /></li><li>His vent settings are being gradually weaned and he is maintaining his saturation with a relatively low FiO2 (30-40%).</li><li>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."</li><li>PO feeds were delayed again because of the kidney problems. Maybe tomorrow.<br /></li> </ul>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com4tag:blogger.com,1999:blog-35581514.post-35525660242250270582006-10-17T08:29:00.000-04:002006-10-17T18:44:21.823-04:0010/17/06 - NICU Day #15Nurses: Jodi, Rachel<br /><ul><li>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.<br /></li><li>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.<br /></li><li>PO feeds by OG tube might start tomorrow.<br /></li></ul>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com2tag:blogger.com,1999:blog-35581514.post-470553803917320592006-10-16T10:19:00.000-04:002006-10-16T20:58:51.197-04:0010/16/06 - NICU Day #14Nurse: Jodi, Rachel<br /><ul><li>Daniel had a very difficult day.<br /></li><li>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.<br /></li><li>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.<br /></li></ul>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com5tag:blogger.com,1999:blog-35581514.post-70019619724998923472006-10-15T18:30:00.000-04:002006-10-15T20:14:21.700-04:0010/15/06 - NICU Day #13 - late afternoonNurse: Shanti<br /><ul><li>Stable today with continued pulmonary issues. Antibiotics and lasix continue.<br /></li><li>Echo was repeated this afternoon. Prelim normal but final read will be tomorrow.</li><li>Today Daniel got a hat - some modifications were required to make it fit. He's also opening his eyes a little.</li></ul><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://photos1.blogger.com/blogger2/3658/4343/1600/DSCN0532.jpg"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer;" src="http://photos1.blogger.com/blogger2/3658/4343/320/DSCN0532.jpg" alt="" border="0" /></a>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com3tag:blogger.com,1999:blog-35581514.post-13082504857391328962006-10-15T06:24:00.000-04:002006-10-15T07:28:29.742-04:0010/15/06 - NICU Day #13Nurse: Jodi<br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://photos1.blogger.com/blogger2/3658/4343/1600/DSCN0515.jpg"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer;" src="http://photos1.blogger.com/blogger2/3658/4343/320/DSCN0515.jpg" alt="" border="0" /></a><br /><ul><li>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.</li></ul>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com1tag:blogger.com,1999:blog-35581514.post-4369263033026377712006-10-14T18:02:00.000-04:002006-10-15T14:57:44.823-04:0010/14/06 - NICU Day #12Nurse: Shanti<br /><ul><li>Today was a bit of a rough day.</li><li>Daniel's oxygen saturation spent a lot of the morning bouncing up and down.<br /></li><li>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.</li><li>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.<br /></li></ul>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com1tag:blogger.com,1999:blog-35581514.post-85844037978897835232006-10-13T22:14:00.000-04:002006-10-27T21:52:10.855-04:0010/13/06 - NICU Day #11 - end of nightNurse: Michelle<br /><ul><li>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.<br /></li></ul>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com3tag:blogger.com,1999:blog-35581514.post-86525745260719342302006-10-13T15:17:00.000-04:002006-10-13T22:19:05.483-04:0010/13/06 - NICU Day #11<ul><li>Jenny changed Daniel's diaper this afternoon and then I changed his diaper tonight.</li><li>Besides the pictures on the blog, there are other pictures of Daniel online.</li><ul><li><a target="_blank" href="http://picasaweb.google.com/steine01"><span onclick="BLOG_clickHandler(this)" class="blsp-spelling-error" id="SPELLING_ERROR_0">PicasaWeb</span></a></li></ul></ul>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com0tag:blogger.com,1999:blog-35581514.post-8950098639144532982006-10-13T11:25:00.001-04:002010-05-25T06:14:31.949-04:0010/13/06 - NICU Day #11Nurses: Kristi, Maria<br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://photos1.blogger.com/blogger2/3658/4343/1600/DSCN0501.jpg"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer;" src="http://photos1.blogger.com/blogger2/3658/4343/320/DSCN0501.jpg" alt="" border="0" /></a><br /><ul><li>The chest tube came out this morning. His MAP is 32 and he rested comfortably all night.</li><li>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. </li><li>Feeds are still off until his ventilation improves.<br /></li></ul><center style="text-align: center;"><br /></center><div style="text-align: center;"><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dyGmpaGWz52PsZ6KqGLJTELmD5jHnnlItML0NjLNFuQokstX-A03VACi2x8Y8v_wmur2pqovdHijA8' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com2tag:blogger.com,1999:blog-35581514.post-76403908285628849202006-10-12T09:10:00.001-04:002006-10-12T19:09:13.806-04:0010/12/06 - NICU Day #10<ul><li>PDA ligation successful and uneventful.<br /></li><li>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.<br /></li><li>He passed a lot of dark stool (probably meconium) at around 9:30 and then again just prior to the start of the surgery.<br /></li><li>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.</li><li>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.</li><li>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.<br /></li><li>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.</li><li>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.</li></ul>Evan Steinhttp://www.blogger.com/profile/04119759966034073385noreply@blogger.com11