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.

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.

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

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.
  

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.
  

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.
  

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.
  

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.

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.
  

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.
  

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.
  

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.

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.

10/7/06 - NICU Day #5

Nurses: Rachel, Maureen

I figured out how to white balance the camera under the blue lights in order to take natural looking pictures. This is a great long shot.

• Stable weight of 890 grams.
• Oxygen saturation and blood gases are good.
• Chest X-ray today with no PTX, vacuum turned off and the chest tube was placed on water seal. He'll be followed for a while on water seal with no plan for pulling the tube on any particular day.
• He was particularly active today. His nurse gave him a pacifier to calm him.

10/7/06

 

10/6/06 - NICU Day #4

Nurses: Rachel, Relany

• Uneventful. A welcome respite after yesterday's pneumothorax.
  
• Just laying around calmly all day with good numbers on the monitor and the labs.
• The neuro ultrasound from 10/5/06 was officially read as negative - no sign of an intra-ventricular hemorrhage. There is a choroid plexus cyst but this is a common finding in preemies.

10/5/06 - NICU Day #3

Nurses: Jincy, Carolyn

• Mild-moderate (20-30% lung volume loss) right pneumothorax (PTX). The 6 AM X-ray was interpreted as PTX versus pneumomediastinum. The 9 AM follow-up showed a slightly larger PTX. A right-sided chest tube was placed at around 10 AM and a chest x-ray (CXR) showed improvement.
• After the tube was placed we held him in his isolette for a little while. His blood type is O+. Jenny and I must both be AO.
• The PTX failed to completely resolve on a repeat CXR so the chest tube was adjusted. This still didn’t fully succeed so the chest tube was replaced (after confirming that the PleuraVac was working correctly).
• Final CXR of the day shows the tube in the appropriate location and no residual PTX.
• Last dose of indomethacin given. Pulse pressure down to 15-20 mm Hg
  
• Blood pressure remains strong.
  

10/4/06 - NICU Day #2

Nurses: Jincy, Carolyn

• Weaned from the dopamine overnight.
• PDA not seen on echo. However, pulse pressure is wide (~25) so PDA is presumed and plan for 3 doses of indomethacin (has received 2 so far).
• Lungs clear on X-ray. Minimal residual RDS with a question of hyperinflation.
• The official report identified PIE (pulmonary interstitial emphysema). Started on high frequency oscillatory ventilation with great success.
• Spontaneously diuresing. They expect to see this day 3 or 4, so he’s early. Early diuresis appears to be good for the lungs.

10/3/06 - NICU Day #1

Dr. Williams, Dr. Kasat
Nurses: Melissa

• Mr. Stein's exam (Ballard Score) is more like that of a 27-28 week-old than 25-26 weeks.
• Hypotensive with MAP 15-20. Needs dopamine to support blood pressure.
• Intubated but spontaneously breathing. Moderate to severe respiratory distress syndromes (RDS) on X-Ray. Group B Strep (GBS) pneumonia not excluded. Receives 3 doses of surfactant with improved aeration.
• Under lights for hyperbilirubinemia (Bili ~4-5). Evolving post birth ecchymoses are a likely source.
• Echocardiogram pending to evaluate PDA.
• Hematocrit 36. Will transfure to keep above 40 until extubated (anemia induces increased cardiac output and stresses the lungs) Will keep above 35 thereafter. Most of the anemia is probably iatrogenic, the consequence of necessary medical care (due to blood drawn for tests and cultures). His entire blood volume is about 80 mL.

10/2 Yom Kippur

• Midnight – On the monitor at NYU contractions are one minute long, one minute apart. Exam by Jackie shows 1 cm dilated. Preterm labor is official. One SQ shot of tertbutaline stopped the contractions for 15 minutes. Then a 2 mg load of magnesium and 2 mg/hr drip with the expectation of minimum 48 hours. Contractions space out to q3-4min. Plan for indomethacin.
• 2 AM – Received PCN G (q4) for potential GBS.
• 4 AM – Mg increased to 2.5 mg/hr and 1 extra dose of tertbutaline given.
• 5 AM – Jenny gets IM injection of betamethasone to mature the baby’s lungs
• 8 AM – Dr.Schweizer arrives and changes the plan. The terb has been more effective than the Mag so magnesium is stopped and a terb drip starts. Contractions start to spread out to 2-4 painful (6-8/10) contractions an hour. UA is positive with leukesterase and bacteria. Macrobid planned for but changed to keflex. Azithromycin added for coverage of mycoplasma or ureaplasma.
• 9 AM – Ultrasound normal for dates (estimated weight 887 g)
• 2 PM – Temperature 100.4
• 4 PM – Temperature 101, BP on cuff 88/55. Coverage increased to Gentamicin.
• 5 PM – SCD boots to the thighs are placed.
• 6 PM – Painful contractions start to come more frequently. Contractions are associated with bleeding.
  
• 8 PM – Dr. Schweizer does a manual exam and finds the cervix is 8-9 cm dilated. The baby has to be delivered. Caesarean section had been discussed earlier as the plan if the pregnancy had progressed but since delivery would be at 25 weeks, a vaginal option was still considered viable. The baby’s heart rate was strong and the delivery of such a small baby would be fast.
• 9 PM – Jenny is moved to a Labor and Delvery room (805) and starts pushing. Contractions are coming only every 5 minutes so pushes are far apart.
• 10:06 PM – Baby Boy Stein is born crying. His nurse (Belle) insists on a name. When none comes she declares him "Mr. Stein." Apgar 8/8. 1035 grams. 35 cm. He is whisked to the NICU. He is intubated electively about 2 hours later.
  

10/1 Erev Yom Kippur

• Noon – Brunch with Amy, Ken, Stanley, Sol, Gustine, Judy, Marc, Joseph, and Orly at Lundy’s in Brooklyn
• 4:45 PM – Dinner at Joseph and Orly’s
• 5:30 PM – Walk from stuy town to shul for Kol Nidre
• 9 PM – Walk home from shul. Jenny is uncomfortable. Couldn't get comfortable on the seats in the shul balcony. Feels “full.”
• 11 PM – Jenny wakes from sleep with abdominal pains every 6-8 minutes and GI upset. Over the next hour the pain doesn’t change and, in fact, starts happening more rapidly.
• 11:45 PM – Dr. Nath is covering Dr. Markoff. She suspects gas pain but to find out for sure we go into NYU to be monitored