Friday, September 4, 2015

Bath in the PICU September 2015

William got his first bath in over a year - "real bath" that is, in water with soap. William does get a bath every night but it's with the hospital bath cloths which isn't quite the same.

Bath Time!

Before the bath he had to get his central line dressing changed. He was pretty calm with his nurse holding him still and looking into her eyes:

Splashing his feet:

I think He likes it

Getting dried off and settled back in:

Afterwards, the water was really dirty. Soaking those feet got a lot of dead skin loose that was able to be scrubbed off.

As far as overall progress, William has been averaging 50% FIO2 and generally doing well. We are making progress toward getting him weaned off the Midaz, Morphine and Dex. If all goes well we should be off them in the next two months. 

Monday, August 31, 2015

August 2015

I still need some updates but here are some pictures from August:


Sunday, June 28, 2015

April 2015

4/1 - So with William doing better with the paralytic weaned off, they asked about reconsidering him for lung transplant. To be evaluated there were a number of things to do - testing and evaluations. One thing was an MRI to rule out any issues with bleeding or a stroke or anything that could have been missed along the way since he was born.

This week he is getting a course of steroids and he has been more stable and lower FIO2 requirements. There is risk of him dying in the MRI. He will have a different trach, be on a different ventilator, be sedated and his ICU team can't be in the room with him. If he crashes, they would have to do an emergency shutdown of the MRI machine and it would take some period (several minutes? Not sure) to get to him. The sooner they can do it the better.

I'm praying for a spot to open up on the schedule this week and for his safety and for the team to account for everything and take the precautions needed.

9PM - A little progress so far the attending physician popped in before I left and said maybe there's a spot open this week for him to go to MRI

4/2 - They call in the morning and ask how fast can we get there - there is a spot open for an MRI now! - 

11AM - He just went back a few minutes ago he was satting well and ventilating well. The only concern was they didn't have the trach tube they wanted so they used a cuffed ET tube cut down and placed where his trach was. 
That that tube stays secure and in place is my biggest concern during the MRI

Prayer for William: Dear Heavenly Father thank you for the opportunity today to get this test done. Please protect William during this procedure and help the doctors nurses and technicians to keep him safe and get the information they need from the scan. We pray always that you find a way to heal him and get him home. In Jesus name we pray for sweet William, Amen

1PM - MRI done and he is back in his room safe and sound. 

4/3 5PM - Another Prayer request: William has a pneumothorax. Sats were 30's/40's and stuck there on 100% FIO2. They gave 2 choices: chest tube or do nothing. Doing nothing meant he would not survive. Chest tube might never come out if he keeps getting these. 

I wasn't going to stop by but I switched my volunteer hours for Parking crew at church with a guy that needed to go to a wedding so I was here for everything. 

They are doing the chest tube now. I'm waiting in the waiting room.
6:30 - Tube is in, checking placement with x ray

He was having a good day, FIO2 had been in the 75% range most of the day then at 2:45 he was desatting and in the 40's/50's and he projectile pooped all over the crib, so they were thinking he just had a big blowout and it was from that. I got there unplanned around 4 something and he was drifting into the 30's and not getting better. They gave PRN's and it helped a little, they paralyzed and it helped a little for a while, but I was thinking this didn't seem like a typical William episode, he looked like crap and was not good, but his Heart rate was still good. 

I asked if it could maybe be a pneumothorax and Andy, the fellow said possibly we can get an xray so they came and took it and I could see some dark areas, but not an MD so they checked it and determined it was a pneumothorax. It's being called progression of the lung disease and a consequence of his dependence on higher pressures to keep him ventilated and the lungs are susceptible to developing leaks/holes. It's one of the many catch 22's here in the PICU. Anything can happen and it can happen in a heartbeat. 

9:00 - He's fixed for now. He was satting 89 on 70% when I first saw him after going back. Then he woke up and was a little more in the 70's so they bumped him a while. Currently 94 sats on 100%
He did good with the chest tube. I think Andy said he got 70cc of air out... Not sure how much that is.

Sometimes the docs like to blame everything on lung disease progression - well I just did some searching and found that steroids can cause a pneumothorax so maybe it was related to the steroids ?

4/6 - William had a pretty good weekend - one issue Sunday morning where I think he was startled by his nurse flushing the toilet emptying his NG drain in the room where he desatted and took a while to come up. They did xray and saw more air and pulled 20cc out the chest and he was better and had a good day and overnight.

I have an Easter Basket for him. 

4/8 - First time seeing 50% FIO2 since December. 

4/9 - Earlier he was smiling at the nurses and making them laugh after he code browned the bedding. 
Pic from head of bed:

 4/10 - Morning: I just called and last night his nurse said his oxygen Sats are 92% on 55% oxygen. She said he's been sleeping and in the evening that he had a bunch of visitors - at first I was like what visitors!? And she said it was all his nurses that wanted to stop and say hi because he was smiling and being playful. He is such a blessing and such a fighter. I love him to pieces.

Evening: Good day. He didn't sleep much, he was taking a nap when I got here and then he woke up feisty. He was a little too agitated and pulling at stuff and arching his back. He seems to be settling down but not sleeping yet.

4/11 - Today's update - Last night William's nurse Katie said he slept a total of 40 minutes! I usually try to leave when he falls asleep, well last night he was up till 12:30am when I left. 
Sounds like he is catching up on sleep today. They have weaned the vent pressures this past few days along with his breathing rate and they have come down on his midazalam IV med twice. That may be why he was a little agitated/restless. 

Anyway here are some pics and a video

4/14 - Another good day and he's slept through my visit and the 8:00 cares again.
Katie said during the day she didn't have to touch his oxygen - 60% all day long. Pretty uneventful other than a major code brown earlier today.

Of course he waits till I'm leaving to wake up.

4/16 - I can't remember if he's actually ever been in this particular chair or not he was once or twice in a bouncy chair but I think this one is more upright and they said it it's a physical therapy chair and helps with neck muscles and core strength.
He's doing good still 60% oxygen and they were able to wean his Dexmedetomidine today. 2.2 to 2.0.

4/21 - He's been good overall. Lots of time on 50% FIO2, they have been weaning slowly. The only issue has been gagging after medicine.

He was not happy last night in the chair - had been there too long I think.

Miserable William

4/22 - Just hanging out:

4/23 - Sleeping

4/27-4-28 Baltimore Riots - JHH had National Guardsmen on site. No issues with visiting.

4/28 - Satting 98% on 60% FIO2. I also removed his DNR tonight. We are back to full code status.

Saturday, June 27, 2015

March 2015 and turning 1 year old!

3/1 - William is doing fine. Yesterday he has a pretty good day, a visit from a guy from church and my brother and sister. My wife and I came up from 6-11:30.
All day he didn't need any PRNs but in the evening he was just miserable and couldn't get settled, kept lifting his head and turning it face down and wiggling. He seemed like he got 4 morphine and midaz PRNs while we were there and they didn't even last long before he was agitated. His temp went up fast and he was all sweaty and mad. We cooled him down with ice packs and he seemed to like it after the initial shock.

His poor nurse Peter had him and another needy kid both on droplet precautions so every time they had an issue he has to gown up and throw it away when done. He probably went through 30 gowns while we were there.

We got him somewhat settled and left around 11:30 exhausted. I hate seeing him like that.
I called an hour or so later @1:00 and peter said he had been doing better and was mostly sleeping, probably having tired himself out. When I called in the morning peter said he had a pretty good rest of the night. He was supine for trach care and a central line dressing change and did fine with it. I wished they had tried to leave him a little longer. They said his sats were 80, but 80 on his back isn't bad.

3/1 - 6PM Today William has been fine. A "peach" says his nurse. Well if that's the case, he was a sour lemon last night...

3/3 - William has been good the past day or so. They plan to put him on his back today to change the trach and GPS is going to possibly resuture his central line and his nurse is going to change his Gtube

Hopefully he will still be good shape after that and he can spend some time on his back. He needs it.

3/5 - I just got this email from his attending physician:
Happy snow day! William has the best chest X-ray I have seen for him...and radiology agrees! I couldn't wait to tell you...
Tuesday they did put him on his back. There was a nasty cut in his neck under the trach flange. I have pictures that I sent the wound care team but they are a little gross.

He did pretty good on his back while I was there but they rounded before I left and I heard the fellow say they were weaning the Cisatracurium again. My gut was saying don't do it but I didn't protest to the fellow. I told his nurse Peter that my preference would be that he stays on his back to heal this wound and if that means going back up on the Cis then I would prefer that to putting him on his belly.

Well I called when I got home and he was on his belly. They said they tried to wean and he didn't like it and even after going back up a little bit I still decide to put him on his belly. I wasn't there but I really feel like they could've waited him out on his back especially going back up on the Cis.

Yesterday I was there and they had put him on his back for the wound nurses to see him and they treated his neck, cheeks, feet, knees. They discussed everything with the medical team and basically decided keeping on his back is a priority more so than weaning so they gave him a lot of extra medicine in the morning and early afternoon but the evening actually went better.

3/6 - I talked to the attending last night and saw the images. Her opinion was that these were the best X Rays since he has been here.

They came down on the paralytic cisatracurium to .16 (.23 a few weeks ago) William is getting used to it - last night he had some desats where he was coughing and coughing better than I have seen, getting stuff visibly out of the trach tube.
Today he has had some pretty big desats (40, 50, 25) but recovered. He's got a really good nurse, but she can't be in two places at once. I'm going to go up there soon to keep an eye on him.

3/7 - Like a million other things in the Picu its a catch 22. Kristen, the attending said he could be mobilizing secretions he otherwise couldn't before so it looks like more coughing and more secretions but it's not overall. She added some additional nebulizer treatments to thin it out.

X-rays were showing more open and darker meaning more air in them. It was also on his back when they usually aren't as good and this was better than the ones on his belly.

She did say it could be worse before it's better coming off the cisatracurium as he adjusts to a different situation. Last night had some big swings up and down.

3/9 - Last night he started the shift change off with a huge desat. He was 65 when I walked in and went to 13! before they put him prone. His heart rate was high @175 and he was mad but didn't look horrible. He came back up pretty quick but it was a little stressful. The whole thing was from pooping! He had super loud gas/loose stool.

The rest of the night was calm and today was as well until they put him on his back. He's been ok with a few 60's and 50's desats but came back up with patting his butt and chest PT and a few extra medicine doses.

Her he was more awake and smacking himself in the face.

The following is a fundraiser set up after some folks asked about doing something for the other families and kids in the PICU. We have had a number of donations of items for the kids also.

3/21 - Just a short update. William has been doing pretty good this past week. We had been down to .05 for the cisatracurium from .23 and in many ways I would have said this past week was one of the best since December. He's moving, seemed happy generally, no huge desats, not a lot of coughing and sats awake in the 80's and aleeping in the 90's except for one thing - fevers.

He has had a fever every shift since monday. They have done cultures 2-3 times this week with nothing found. I did find last night that he has 2 teeth about to come in. I told the fellow last night and he said hmm I hadn't thought about that. His fevers have been a little high to have teething as the only reason but we are dealing with William and he does things his own way.

Back to the cisatracurium (paralytic), they suggested instead of continuing the .01 weans per day or per shift that we try turning it off yesterday. They did and within an hour he had slipped to 70's awake and 80's asleep for his sats. He was in the 60's when unhappy and had at least 2 times in the 50's.

So far overnight he was a little better and today he's been doing good with sats. I'm hearing some 80's and 90's again.

3/22 - He's had restraints the past week or so and been a little grabby. Apparently he did disconnect the ventilator this morning.

These no no's are nicer than the old ones. They are soft and ventilated. They let him still cross his arms and put them over his head.

This evening I found two little teeth poking through on the bottom.  one is out and the other is just starting. I had a gloved finger in his mouth rubbing his gums and he bit the heck out of my finger. I thought he bit through the glove. Little rascal.

So maybe this mystery fever they can't figure out was teething. He did not have a fever tonight at 8 pm.

3/26 12:46 AM - I got to hang out with William as he turned EXACTLY 1 year old a year to the minute from his arrival. He is a miracle and a blessing. Happy Birthday little buddy:
Got home from the hospital at 4AM. He was unsettled for a while and would not go to sleep. They were getting cultures because of a fever, agitation and lower blood pressures today.

3/26 - (day) After getting some sleep myself, I spent the day with my favorite PICU patient. He's had a lot going on. Right now he is sleeping and satting good. Earlier he was just uncomfortable. 
They are checking everything. Neurology was here and said he looks good from their perspective. They want to do some brain scan eeg? And maybe a cat scan, but are not real concerned. 
Urology was here and he's got the hernia and they had some suggestions but no big issues. 
He got an abdominal ultrasound and they are making sure he doesn't have kidney stones. 
Sounds like they are starting antibiotics in anticipation of an infection. He's just been agitated and not himself the past few days and sats have been lower. 

Birthday pics:


3/27 - He's still been having fevers - they cultured AGAIN overnight, they have yet to find anything, but he's just not himself overall but today for the most part hes been content - That said he had a big desat to the 20's. I talked to the attending and She said it was different with this desat in that he was off the paralytic and they were more able to see his true reaction to it, unfiltered I guess... Again they said his heart rate didn't go down so that's good. Anyway He's sleeping now, sats 80's sleeping 70's to 80's awake.
He got an EEG brain scan, no results but they were talking about a CT or MRI, but I don't know why - I think they are waiting on the EEG. Ultrasounds of the abdomen were normal.

3/29 - Had some trouble overnight desatting teens,20's and then hanging in the 40's /50's for an hour. They gave him paralytic, sedation PRNs and eventually put him prone.

He's better this morning and they went up on the vent rate and added the antibiotic back that they stopped yesterday (the 2 days on it he was better) he's on his back again.

That afternoon they called me and he has a pneumothorax and Atelectasis (some collapsed areas) the treatment is the opposite thing for each of them so they can't really treat either but he's doing fine at the moment. they did get another Xray at 4 and it looked better. It was a Supine vs Prone, but it wasn't showing the pneumothorax. He was also satting well and awake on his back.

So He seems OK, they got him back on the antibiotic for 7 days - we'll see if it helps. I suspect it will.

3/30 - called and he's having a good night for Kate his night nurse. Satting 91 and wiggling.
I'm still Leary of this idea that the pneumothorax is gone because of the supine vs prone X-rays. I hope it's fine

Morning update @6:30am - nurse Kate said he had a "great" night! They even weaned his FIO2 to 90%. Go William Go!

3/31 - William had another good night and they got his FIO2 to 65% for a while and was 70 when I called.

Last night when I was there he was wild and flailing his arms and wiping them across his face the problem was he was loosening the tape that was holding his ND tube in. At first I thought it was just a coincidence but after his nurse got it retaped he wasn't bothering it so I'm guessing either seeing it out of his periphery or feeling the tape loose was bothering him.
After all that moving his temp was 37.7 and that was the highest it was all night so no more fevers. He fell sleep after getting his diaper changed and the tape redone.

Friday, June 26, 2015

Flashes of Hope pictures from January

These were taken during the rough period in January. I am happy with how they turned out.

February 2015

February started off with the loss of two kids that I had a chance to get to know the parents during my stay in January. It was a sober reminder of the risks and dangers of life here in the PICU.

2/3/2015 - William had a bit of a temp when I got here and a trach leak and his sats were 75 on his stomach. His position was a little off - they had too many blankets over the pad. I had them fix him a little but and he's 82 now and no leak.

He's not been steady enough in the high 80's to 90's to wean yet. They will when they think he can tolerate it. He had the trach change today and was ok, but didn't stay on his back long.

Hair is getting red. He'll have to grow into those ears

2/5 - Tonight William was satting 90% on FiO2 of 95%. Yesterday they got his FiO2 down to 90% and his sats were 80-82. It's good progress.

He also got some PT and they worked with him on some developmental stuff and changed his central line dressing. They found the stitches were out of it and they had GPS come by and resuture him. He did good.

Crazy Hair:

2/9 - This guy was on 80% FiO2 this afternoon when I stopped by. They said it was at least 4 hours. So thankful. He hasn't been able to get down to 80% really since December. When I left he was on 95% because they flipped his head position.
Just called for an update and He's back on 80%  Thank you Jesus for every second with this little man. I am praying for protection, healing and growing lungs. Lord find a way to get him home for your glory Amen!

2/10 - Today was a good day overall but he's still having issues on his back. He got a trach change today to one with a flexible extension that will help with positioning but he desatted to 35 during the trach change. YIKES!

He came up a little but they put him prone right away. I was not there for it and they disconnected the vent to put him supine which probably didn't help.
That said he was in the 80's the rest of the day for sats and was on 90% FiO2 when I was there. Which is good.

2/12 - When I got there they said they said He had a rough morning - apparently his breath volumes were low and CO2 high and sats were lower than usual. They got an X-ray and saw underinflated lungs and the trach tube was kinda going into the back of his trachea not down where it belongs so they switched back to the non-flex tube. They also said he had another desat to the 30's/40's during the change and were suctioning blood from the trach tube. Poor kid.

They also did a trach culture and it came back with staph so they started antibiotics again. His day was OK, 2 fevers and generally happy.

Overnight he was OK, but was not tolerating his head repositioning from side to side earlier today. I just called for an update and he's been in the 80's with a few 70's dips, but I'm sure the infection is contributing to this recent dip. THey did a repeat X-Ray and it was improved from yesterday. I didn't see him today, we have a class at church tonight so I will probably see him tomorrow.
Sad news - another family I became friends with - their Son passed away the other night.

2/13 - I went to work, doc called just before 11. I'm at the hospital William sats dropped to 8 as in 08. Looked like some more lung collapse on the quick X-ray they got but his nurse hit the code button or whatever it is. They went up on some vent pressures and got him in the 60s. I got here 11:15 after he was stable. He's 82 as I type.
I may have exceeded the speed limit on I-83 while using a handheld phone sorry!!

So they think it's more pneumonia than just tracheaitis this time and it can all be related The increased pressures will help and they can go down on the rate if the co2 gets too low ( over ventilated)

Edit 2:40 pm Ugh. Just watched William desat to the teens. It was sedation related. They were getting blood and had paused his drips and he literally did a push-up off the bed had his whole head in the air and crashed. He has recovered. I need a drink though.

There is no way I'm leaving him!

10PM - He's been 80's for the most part. Upper 80's for a bit. Seems to be somewhat wiggly at times and a little irritated. No more desats. No fevers. They got a peripheral IV in. One of my favorite docs Eric helped his nurse - they were not sure if it was just going to be a stick for blood or not but they used the ultrasound and got a good vein with an IV so they won't have to stop the sedation meds to give his Cefepime.

2/14 7AM We had a pretty good night overall they tried twice to get a urine culture but they could not get the catheter in him he didn't appreciate it either.
Evening: Tonight has been such a roller coaster. His sats are in the high 80's and he seems comfortable and resting. Then all of the sudden he starts coughing and arching his neck and back and turning red and clearly agitated and his sats drop at least to the lower 60's and as low as 34 one of the times. It seems like if the nurse is here to check on him and auctions right away it stays in the 60's to 50's. Then it takes a lot of butt patting and head rubbing and talking to him to get him back into the 80's.

We have been doing this every 30-40 minutes for the past couple of hours and it wears on you. I would appreciate it William if you could turn in for the night and I would be more than happy to resume this in the morning.

2/15 - Morning update: Better as the night went on. He was also having a lot of poopy diapers. I think the cefapime upsets his bowels - poor guy.

I went to bed @1 something after another desat that his nurse Michelle was in the room for and because she caught him coughing and suctioned right away he went from 88-60ish but didn't totally drop to the 30's,40's. So I felt better about that (and was super tired)

I did wake up @5 to them getting ready to lift him and turn the padding and rotate his head and the vent circuit but it sounded like it was going fine so I resisted worrying or helping and they did fine.

Getting a recap from Michelle, she said he basically settled out after 1:00 with the exception of one giant #2 diaper she said she heard him going from out in the hallway! She said he freaked out a little and desatted with that but otherwise was good and didn't require as much suctioning and even had a few "episodes" without the desats or ones where he recovered on his own.

At shift change though like the past 2 on the 7:00 hour he did a desat to 61, but recovered fine.

2/16 - They repeated the lab draw from the central line where the sedation meds had to be paused last night. This was the one that caused the desat to ~20 on Friday while I was there where he did a push-up off the bed and I could see his chest.
This time I made sure they had a solid plan and suggested PRNs of his sedation meds before they broke the line and suggested they have extra syringes of pain and paralytic meds ready since 30 seconds at almost no oxygen makes a difference.
We did go home and they called @1:30 and it went fine.

Stable day. 80's and weaned pressures back to 26/11 from 28/11 and oxygen was down to 90 from 100 for part of the day.

2/17 - Supine

2/18 - Overnight William did pretty good considering he was supine. He is still on his back this morning so that's 15 hours and counting. His nurse did have to give some extra pain medication but I think it's worth it to give his face a break and the area and skin around the trach some time without pressure on it. 
Basically they did the same thing as they did on Friday morning when he desatted to 8. This was the first time since then they even attempted it. All weekend they were just rolling him on his side to do things like trach care, changing his central line dressing etc. 
I had requested a heads up before they did it so I could be there. I felt like I wanted to be there for him in case he didn't tolerate it but also to compare how they were doing it with what has worked in the past. 
My suggestions were to give extra medicine PRNs before repositioning him, to have the angle of the bed at 15 degrees vs the 20-25 I believe they had before and to make the transition slowly and pause a second once he was vertical and make sure his head and neck was controlled. I also asked to to start from his head facing left so the vent circuit was on that side and could stay connected during the move. Otherwise it would have to pass over his head (complicated) or be disconnected. 
I don't know which things helped or if he was just in a better place with the infection, but I'm glad to see him on his back. It's been about 2 weeks or so since he's tolerated more than a few minutes in that position. 
Praying for better oxygenation, lungs to grow, less secretions and coughing and for William to be comfortable and to thank Jesus for saving and protecting him every day.

27+ Hours and very awake:

2/19 - 40 hours on his back. Did good overnight.

2/20 - He was very awake at the moment of this pic, but we tried to make some adjustments and it's been a little rough the past 2 hours.

They went down on the Cis (paralytic) and he was really not comfortable and moving all over the place and his oxygen sats were low. So they went up on his sedation morphine for now.
The concern is that by paralyzing him, it can mask pain and discomfort even though he is experiencing it.
His respiratory rate was all over the place. Hopefully they can get the right amounts of medicine to keep him in a good place but not be snowed.

2/22 - He's taking a break from being on his back. He went 4+ days. We hung out yesterday during the storm. My wife got to hold him today. Sats in the 90's.:

MD Shooters stuff:

2/25 -  5:00 PM -  been OK, not great. Sleeping a lot. Mostly prone, however they put him supine for his trach change. I unfortunately was dealing with a work issue and missed being there for it and they didn't keep him supine for some reason even though his sats were in the 70's. I am off to see him in a few minutes so I will have a report. They are still adjusting medicines for weight and they still are down on the Cisatracurium from .23 to .20
7:00 PM - William is fine. I am glad I come here every day. It's not a huge deal but his foam pad under him was all out of place. There is basically supposed to be a pad under his chest and then there are side bolsters that come down to kinda keep him from rolling off of it. The one side bolster on his left was completely under him. The nurse that has him tonight has only had him once 3+ months ago. 

If William got a flattop:

2/26 - 11 Months old! Brother and Sister visit:

2/27 - I was late to our church small group because I was at the hospital with william. They were putting him on his back which is always stressful. It didn't go great and his oxygen was low for a long time and we were talking to him, rubbing his head and patting his chest and trying to get him to settle and they had to give him extra medicine. 

After I left he had his oxygen drop low twice and they had to put him back on his belly. 4 hours is better than zero. 

Overnight he had a fever, so they are worried he has yet another infection(ugh) so they sent blood and trach cultures and tried unsuccessfully to get a catheter in the poor guy to get a urine culture and he pooped all over the bed. Since they had so much trouble they got urology involved. Then they found his central line has torn all the sutures so they called general surgery to see if they want to re stitch it. 

I'm not sure if I should go to work or be up there with him.

I went to the PICU and I hope this wasn't like this all night... but, when I left last night his VT Tidal Volumes (going in) were .150, .160 and his VTe expiratory Tidal Volumes (going out) were .030, .040 but his sats were OK and his chest was rising. 

This morning I walked in and his sats were 77, not great and VT.150, VTe .030, .040 again. I asked for respiratory to come down and the high tidal volume alarm was alarming (common) but I heard a soft whistle sound that was out of place... that did bother me and I looked for the source and there was a hose connection loose enough to leak, but not loose enough to fall off. it was moving with each breath, so I shoved it back on securely and his VT and VTe went to .070 -.080 both number basically the same and his sats came up a bit. 

Blue hose from left
Anyway other than that, his doctor Kristen said his white cell and CRP were up so she is starting antibiotics. They still need to cath him for urine, but urology is coming soon to do it since the nurses are having a 20% success rate with it. hopefully he will be back to himself. They did come down on the paralytic Cisatracurium to .18 from .20 (was .23 last week) and have gone up on other meds for weight he gets enterally.

2/27 - they are treating him with Cefepime again. He seems stable so I am going to say goodnight to him. Sats had been hanging 79-81, but now he's 91.