wednesday 7/17/2013

Today Ava is more stable. The goal has been to gently wean her from the vasopressin (which is the med that is keeping her blood pressure up to keep pressure on the heart), and wean vecuronium which is the paralyzing agent. she is still getting morphine and ativan scheduled to keep her pretty sedated. So as of 11pm her vasopressin had been weaned from 1.3 to 0.8. The nurse had been able to drop it by 0.1 about every 30 minutes, so that was good. She was still mostly paralyzed but she was starting to breathe on her own "on top of" the oscillator machine. Yesterday when she tried to breathe over the machine her oxygen saturations dropped, but today she held her oxygen saturation up when she was doing this, so that was good. Her echocardiogram looked "the same" according to the nurse practitioner, which was not the kind of specific information that I sat until 11pm in the NICU to find out. This morning her urine output was zero and Shaun noticed that her belly was really hard. The NP pulled the foley catheter out and OUT came the urine...with LOTS of sediment...often indicative of a urinary tract infection (UTI).  Cultures show that she has gram negative rods (type of bacteria) infecting her lungs, typical of aspiration pneumonia (caused by food going into the lungs) and she has coag negative staph bacteria infecting the blood. This second type is all over the skin of healthy people but is very toxic in the blood system of tiny babies. She is on vancomycin, zosyn, and gentamycin antibiotics.

Last night surgery came up and surgically placed a central line through her right saphenous vein in her thigh. Then surgical anesthesia tried to find an artery for an arterial line, but couldn't so surgery came back and placed one in her right armpit. For both of these procedures they have to actually dissect the skin away to find the veins. If you think you're a tough IV stick-talk to AVA! Surgery was pretty sweet in that they deliberately put the art line in her armpit so she'd have a scar there instead of across her wrist. The arterial line continuously monitors her blood pressure. It makes it possible to more accurately wean the vasopressin and they can draw blood from it so that her poor little heel isn't being poked every hour. Last night she has vital signs done every 10 minutes for the entire shift. I'm not sure how often it was today.  We also started TPN today for artificial nutrition. 

So a likely scenario preceding yesterdays events could be that a UTI (or something else) caused sepsis (blood infection). Sepsis (very bad) caused her to slow the emptying of her GI system (stomach and intestines). The "full" stomach/intestines caused her wretching and eventual vomiting after feeds- which the nurses on her new hospital unit (the infant unit) didn't know wasn't normal for her. The vomiting caused her to get stomach contents into her lungs causing another infection, called aspiration pneumonia. It also took the infant unit at least an hour to get a chest x ray because they had to take her down to radiology whereas in the NICU they do it right at the bedside and can do it fast..so that delayed her at least an hour-not cool with sepsis. The stress and trauma on her body caused the capillaries that carry blood to get "leaky" allowing more fluid to leak into the tissues of her body (making her look swollen) causing her blood pressure to drop. Her poor little heart needs that pressure to push against the abnormally narrow passage that the blood has to get past to get to the lungs to pick up oxygen...which is why her oxygen started to drop yesterday and the solution was to bring her blood pressure up and to breathe for her.

I got the impression today that we'd still be aiming to get a g-tube before heart surgery, but I can't tell exactly what the plan is. 

Sorry about all the parentheses. Its hard to write for everyone who understands the medical terminology as well as all those who don't.