Thursday, October 30, 2014

Mission Supine!

10/20 - Starting I believe Wed, Oct 15th they started trying William on his back for periods of time and the plan was to increase the time by 1 hour each day and see what he would tolerate. The plan was Thursday 5, Friday 6, etc. On Friday he was at 6 hours in and doing so well they extended him for another hour and a half. Saturday I think the plan was eight and he went 19. Sunday they were going to try for 24 hours and now it's Monday and he is past 24 hours and is still doing fine so they are continuing to let him stay on his back. Go William go!

10/28 - 9 Days on his back and doing fine!!
We had another family meeting today. The basic decision was to go forward with the Tracheostomy tube surgery. There was discussion about the Gtube, Gtube/Nissen or G J Tube and hernia surgery, but the feeling was one thing at a time even if that meant more times under anesthesia. The Feeding tube issue was next in the surgical priority. ENT is going to look at him Thursday 10/30.

The one Dr, who is the pulmonary hypertension doctor was a bit pessimistic. He is the one who said at the last family meeting that they were hoping to be able to do the tracheostomy tube surgery but that that was no longer possible and that we needed to start looking at options to make William's end of life as comfortable as possible.
I had asked him at the time of the last meeting what would change his mind and he said the two things I have posted about: 1. Lower FiO2 with higher sats 2. less desaturation episodes. Basically the entire time from that day until now William's sats have been in the high 90's on 60% FIO2 and he hasn't has anywhere near the big swings in sats desatting into the low 80's or 70's at all - the worst it has been was 88,89 and they bumped his FiO2 up to 70% for an hour or so. Nothing even remotely like it had been in the moth or so prior. Plus William was on his back the original 48 hours, then the full 5 days and tomorrow he doubles that to 10 days + with no signs of issues.

So That's the story - I hope ENT doesn't come up with any excuses, this is as stable as he has been ever in the PICU. I wish they were coming sooner than Thursday. I hope we can get the same anesthesiologist as last time. She was good.

I didn't see him today - still feeling a little sick, but my wife did and read to him. 4 straight days missing my buddy

Wednesday, October 15, 2014

PICU 6 Months

It's been a while since the last update and as usual there have been a lot of ups and downs.

9/24/2014 Towards the end of September William was having a good week and they started talking about surgeries - central line and tracheostomy tube. The question that has no clear answer is how William will tolerate the anesthesia and surgery.

The risks with the PICC line in past its lifespan is infection - something He certainly doesn't need. The PICC team already said He probably wasn't able to get another PICC line.

To me this past week or so has been worse than the previous week or two as far as oxygen requirements but the anesthesiologist didn't seem to think the risk was any greater or much more if we had timed it for that window where he was doing better. She said the risk is much higher in a patient with Pulmonary Hypertension overall.

There is the option to just do the central line, but with such a high risk of any surgery, it may not make sense to just do the line and not do the trach.

Currently they are getting ready to try him on his back with more sedation and more paralytic in order to see how he will do both for the surgery.

I stayed late and they decided not to do the tracheostomy tube but they are doing the central line. They want to see that he can tolerate 2 days on his back before doing the trach.

9/25/2014: Surgery was a success!!
They said He did great and he's back in his room, He has a central line and an arterial line. I can see him in 20 minutes! actually 17 and counting!




9/26/2014: At 12:45 AM William the Warrior turned 6 months old!
We have been through a lot these past months and We certainly appreciate all the support and prayers and encouragement along the way.




9/27/2014: William is having a good day. Patti is his nurse and she said he has been on his back since 4am and is doing great.
She took our suggestion of putting him on his side and said he loves it. His FiO2 was 50% and she said he has been there for 1.5 hours. The docs suggested weaning more but Patti didn't want to push it. I told her he really hasn't ever been to 45% before and that made her even more reluctant to wean into the "danger zone"

I'm going to try to make it up there this afternoon. They made some signs for his 1/2 birthday

9/29/2014: Well he made it 44 out of 48 hours and they had to flip him on his belly. He's been there for 4 hours and is now a happy camper. They were able to come down on the FiO2 which is a good thing. So He didn't make it the full 48 - they will probably discuss the next steps on dayshift.

He is always preferred his stomach but it just seems like he can't take being on his back very long even though the first two months that he was in the PICU he was on his back
The 48 hours was the time that he needed to be able to remain on his back before ENT would consider doing the tracheostomy tube surgery.
This is because for recovery he has to be able to spend five days on his back to recover and heal the tracheostomy tube. The problem last night was they couldn't get him out of the 70s for his saturation even on 100% oxygen.

10/1/2014: Prayer Request: William is stuck in a place where the doctors are running out of options. The past couple of days have been worse from a respiratory standpoint. He's required more oxygen and more pressures to open up his lungs. They are even talking about going back on the oscillator.

He seemed to be in a good place on Saturday when they were able to get down to 50% FiO2 on his back and 60% for a lot of the day. Since then it's been more difficult. They thing there was some collapse of certain areas of the lung and increased fluid in the lungs while on his back so they are taking some steps to deal with that. The problem is for the Tracheostomy tube He needs to recover 5 days on his back and they are concerned He won't survive it.

We meet with them Thursday and will have pulmonary there as well as ENT to discuss what little options we have. The benefits of the Tracheostomy tube should be lower pressures, lower FiO2, more comfort, less sedation, we should be able to hold him again and hopefully all that will help in contributing to less pulmonary hypertension episodes.

10/2/2014:Overnight courtney his Nurse (back from a month ago - she had him a lot) was able to wean down to 80% by 6AM after going up on some sedation (even though he didn't "look" uncomfortable) Today I just talked to his nurse and he was at 65% FiO2 Satting 98% which is awesome anytime but compared to yesterday is HUGE!! He is more sedated, they did back off on the "Cis" one of the paralytic/sedation meds. GWG! Thank you Jesus! Thanks You Docs and Nurses!


10/3/2014:  Not good news from the family meeting. Here is a basic recap of the past few weeks and the meeting:

William has been through a lot the past few weeks - They thought they were going to be able to do a tracheostomy tube and a central line, but ENT wanted him 48 hours on his back as a test to see if he could tolerate it post surgery. They did the central line and he did good under anesthesia. A few days later they tried him on his back and he made it 44 hours and they had to flip him prone. He was going up on FiO2 even with more sedation.

The past couple of days have been bad for sats. FiO2 90-100% and desats into the upper 70's with yesterday almost 100% all day and sats in the upper 80's they weaned to 95 and he dropped to 79 like a rock. Overnight they went up on all his sedation meds and Cis paralytic and got him down to 80% FiO2 and then during the day (Thurs) he was 65% FiO2 satting high 90's.

The thing is he is really sensitive to any movement or interaction like diaper changes, cares or moving his head to reduce breakdown/sores. The only time he has really good sats is when they take him out of it and go up on sedation and paralytic and let the machine do the work.

So basically they are saying there is nothing more they can do and ENT won't do the surgery because they don't think he will survive 5 days on his back. Now they are talking about his quality of life and that they don't see a way out of this for him and to keep him heavily sedated and paralyzed is not a quality life.

It's hard to take this news - especially when I called just now and he's satting 96 @ 70% FiO2. On one level it seems like he is doing great certainly compared to the past couple of days. They haven't given any PRN's and he even tolerated a head turn without increasing his O's.

Even though they were saying He's heading in the wrong direction, I did ask what he could do to change their minds and the answer was basically get his oxygen requirements down and stop having desat episodes from minor moving and cares.

This warrior boy has been almost counted out numerous times before and Jesus has been right there with William protecting him- before he was born with docs pushing abortion after pPROM, suggesting my daughter was making a mistake risking an emergency C section for a baby that wouldn't survive the delivery room, surviving the delivery room, surviving the night, surviving the 1st week when things looked bad, surviving the infection, adenovirus, surgery. So I have no doubt Jesus is with him now and I am not really worried. No matter what happens, William wins!

Thankful for every day! Go William Go!

My prayer is: Thank you heavenly Father for sending your Son to die on the cross for William and for all of us. Thank you for William and the blessings and joy he has been to our family and everyone here pulling for him to get better. Thank you for every day with him. I pray for your will to be done. So far your will has been to protect William and I pray for that to continue. I pray for healing of William's lungs Lord, better oxygenation and comfort for him. I pray for the pulmonary hypertension to get better and respond to the medications without harmful side effects. I pray that William gets stronger and can tolerate longer periods on his back so he can get the tracheostomy tube surgery and heal from it. I ask this in the name of your Son Jesus Christ, Amen.

10/6/2014: Basically for the majority of the weekend he was getting 60% oxygen and satting in the 90s. He was even tolerating most of the cares and episodes where they were turning his head or changing his diaper things that in the past have caused him the desat or get mad heart rate goes up that kind of thing

Today around 4 o'clock in the morning they decided to replace his arterial line and in order to do that they put him on his back. They did not manage to get a new arterial line installed but they decided to leave him on his back so as of this moment he's been on his back for about 16 hours and so far you doing great.

When I left him a few minutes ago his heart rate was in the 120s his oxygen was 60% and he was actually setting 96 to 100.

We did have a visit from the chaplain and we talked about a bunch of different things but before he left he prayed with me for William and William had an interesting reaction at the end of his prayer it's hard to describe but it was like it was like he all of a sudden got like a burst of energy and I almost thought for a second there he was actually going to get up off the bed he raised both of his arms up and moved the whole rest of his body and he's mostly been sedated pretty heavily and paralyzed so it was just interesting to see.

10/10/2014: Seems a little better today - when I was there he was mid to high 90's for sats but heart rate was 150. I read a few books and put him to sleep and he was HR 120 and satting high 90's and when I left he was pegged at 99-100 sats all on 60% FiO2. Go William Go!
Edit: Nitric was weaned to 3 today.

10/13/2014: He had a good quiet weekend - Still satting high 95-100% on 60% oxygen. They have weaned nitric I think to 1 ppm. Beth is his nurse today and she had him last 2-3 months ago when he was first in the PICU so I will be interested in her thoughts on his progress since they last met.



Tuesday, September 16, 2014

PICU @ 5 Months old Video

I would like to start doing a better job of updating here. I fell down on the job for a while, but I did put together an update and a video of the last 5 months. I managed to cram it all into one song, but I have a lot more so maybe I will add a song or two and make an longer version with more pics and video.

Update:  Since the pneumothorax, things have been up and down (no surprise right?) Basically after the pneumothorax, he did good for a week or so on the conventional vent, then as things were weaned, he seemed to have some ups and downs. He did finally get over the adenovirus - at the last family meeting, all the docs mentioned that that was both a big setback and a big deal that he was able to get over it. Around this time they weaned the steroids that were giving him a boost and that caused a dip and some instability. Somewhere in there they weaned off the nitric gas as well, but after a few days they had to put the nitric back on.

The new plan was to bring up the treprostinil (works similar to the nitric) even higher and take the nitric down more slowly. It was last weekend I think Sat 9/6 that the nitric came off. William had some bacteria in his ET tube culture so he's been on antibiotics for almost a week.

He still loves his Horton - I posted this on MDShooters.com Friday:
"Stopped in after work. Heart rate in the 165 range, sats ok in the lower 90's but with 80% FiO2. They had just put him prone. The good thing was he lasted about a day on his back and had been OK. He had just been flipped an hour or less before I came.
I did some book reading, green eggs and ham and Horton and He was down in the 145's for HR and they were able to turn the FiO2 to 75. I spent some time combing his dry skin and cradle cap and rubbed some lotion onto his head and as I was massaging his head his heart rate kept dropping into the 130's and they were able to wean him to 65 before I left and I just called and he was at 60%."

Horton is usually good for a 20 point drop in HR and a couple of points boost for his sats. Go William Go!

Video: Link to High Res on Youtube: https://www.youtube.com/watch?v=dTPxU03GToQ


 







Wednesday, August 13, 2014

Pneumothorax

On Friday morning 8/8 William's sats all the sudden went down and they were having trouble getting him above 70 with 100% FiO2 and had checked everything else that might be wrong so they got a chest X-ray and confirmed his right lung had developed a leak and was collapsed.
They put in a chest tube drain and ended up switching him over to the conventional ventilator. So far in the past couple of days since this change William has been doing better. We thank God for his continued blessings and healing. William has been tolerating weaning of the ventilator settings and weaning of the PH medicines. As of Wed 8/13 he is almost off the nitric, down to 1ppm and satting in the 90's with 60-70% FiO2. He has been more consistent with his oxygenation since the switch to the conventional ventilator.

Wednesday, July 30, 2014

Week 3 in the PICU

Today is Tuesday morning 7/29/2014 that I am starting this post. Today is day 126 overall and day 19 in the PICU. The past few days have been good. They have been able to come down on the FiO2 in the 65%-75% range and he was satting well. They went up on the Treprostinil from 8 to 10. Blood pressure has been stable for the most part without any medicine.
They placed a new ND tube further down into his intestines and started feeding him pedialyte at first and now formula. They had talked before about a blood clot history and there had been some difficulty in visualizing it. Apparently it is near the tip of the inferior vena cava in the right side of the heart. The concern is that if it would break free it would travel to the left side of the heart and could reach the brain and cause a stroke so they started a course of heparin to dissolve it.
There was an additional sedative medicine (pheno-something) started a few days ago and that seems to have worked well for stabalizing heart rate and oxygenation. They were talking about adding Dexmedetomidine but haven't needed it.

Wed AM 7/30 They reported a good night overall and FiO2 was down to the lowest it has been 60% They did give a 2nd dose of cidofovir and probenecid, the antiviral and the antibiotic to protect the kidneys Tuesday.
Fluid levels - Overall the past few days have been fluid negative which has reduced his weight and his appearance overall had looked better. Tuesday was the exception because of the fluid required with the cidofovir.
There was a fracture of his right collar bone that was difficult to see on the xray so the doctors are not convinced that the diagnosis is conclusive. He has had so many xrays, it's hard to imagine it was missed before but the focus of those fils was on the lungs and ET tube/ND tube placements so who knows.

The ophthalmologists gave him an eye exam Tuesday night and there are basically no issues from the ROP. He said his blood vessels are almost fully formed and no need to see him for another 4 weeks.




Wednesday PM update 7/30: His FiO2 was up a little bit (70-75) They had one issue with the ET tube being down too far and one lung was not inflated fully, but they repositioned and retaped the tube. You couldn't tell though. When I left he was satting 99-100!!
He was back to fluid negative ~70 for the day and looking better overall fluid wise. He was moving a little bit which Courtney his nurse said was fine as long as heartrate and blood pressure were good. I was holding a hand on his head and foot and felt him pushing his foot and moving his head a little and his eyes were kinda blinking and moving his eyelids. I could also see some movement in his torso/chest.

Thursday AM update 7/31: Doing well still - has a short blood pressure drop and bumped up on the O's but is settled back down to 60% and He is getting all his nutrition in his gut now through the ND tube - no IV nutrition. Emma is his nurse again and she said he is 1 Kilo smaller than the last time she saw him (a good thing-fluid loss)

Thursday PM update 7/31: PM Update - Today was good! FiO2 ~60 most of the day and satting in the 90's, they were able to wean some ventilator settings and blood pressure was stable, went up on the lasix, switching to lovenox from heparin.

Friday AM 8/1:  Technically this is starting the 4th week in the PICU but I'm keeping this post going. Had a good night, 1st gas was off at 7PM last night so they went back up on a wean they had done earlier. He was a little fluid positive for Thursday, but that was expected some with the feeds at the target amount. Apparently the fluid from feeds is better than the fluids from IV nutrition. Hemoglobin was 10.7 so he got some blood, not unexpected from all the blood draws for labs. Megan was his nurse.

Friday PM 8/1: Had some ups and downs today. Sats when I was there were anywhere from 81 to 93. O2 had been up to 90 but came down to 70% I think. We read some books. He seemed pretty sedated, but heart rate was creeping up a bit into the 150's - He does better in the  130's,140's.  Just before I left he had a diaper that could have peeled the paint off the walls P...U. Treprostinil was increased from 10 to 11.

Saturday AM 8/2: (This is week 4, but I'm editing this post still.) Pretty good night overall with Shannon his nurse. Said they went up and down on the ventilator settings currently:  MAP 21 Delta P 34 Hz 8 60% FiO2. Sats in the mid 80's. Fluid  +40 for yesterday so better than Thursday. At 3am his blood pressure and heart rate were up so they gave some PRN's.  Treprostinil was increased to 12 - I was surprised they are going to 20. Beth is his nurse again today.

Saturday PM 8/2: Courtney was back with William and when I called it was late so the details are a little hazy. They were up to 14 I believe on the treprostinil and blood pressure was still fine. He was fluid positive again so they combined 2 IV fluids that should save some fluid volume over time FiO2 was 60, sats good.

Sunday afternoon 8/3: Beth had William again today. We visited William for a few hours. He was up and down in his sats and FiO2. Sats from 73-90 and FiO2 80-60. Pastor Paul and Mrs Vicky paid William a visit. (for free) Blood pressure was a little lower today overall. Treprostinil was up to 15. Courtney is back tonight and I will call later for an update. We did take a picture:

Fluid compared to a week and a half ago:


Monday 12:45AM 8/4: Doing pretty good, up on treprostinil to 16, 8pm weaned delta p mid night gas acidotic so unweaned (is that a word) back to original deltaP. 60% FiO2, sats-mid 80's, BP lower 90/50
30 positive end of the day which is better than the past 2. 

Tuesday, July 22, 2014

PICU Day 118 - 122



Monday July 21 2014

Day 118 overall, 11 Days in the Johns Hopkins PICU - Go William Go!

Monday 7/21- Sats were pretty much in the 70's and 80's. I took a few pictures and he's got a good bit more fluid on him. They were having to give him a little more.



Tuesday 7/22/2014 Day 119 - We met with the doctors today and went over his care in general. The past 2 days have been up and down with sats in the 75-85 range for the most part with an occasional dip into the 60's and 50's for a short time and then up into the low 90's a bit as well. This is all with FiO2 of 100%. They have needed to give him some fluid to increase his volume and that made his sats go up. Sometime today they also gave him some blood to boost his hemoglobin.

While we were here he came up into the 88-92 range for his sats. They started him today on cidofovir which is an antiviral that can be used against adenovirus but there is a risk of renal toxicity so they have a protocol where it is given with probenecid to reduce the risks.


Tuesday 7/22 11:00pm: We called for an update and Elizabeth said he's been doing fine. No desats and keeping himself at 75 and above so far.

Day 120 - Go William Go!!  Thankful for another day with our little warrior. 
Wednesday 7/23 6:30AM: William's nurse Elizabeth said he had a good night. He was up in the 90's with his saturations so they decided to wean his FiO2 to 90%. His Sats were 81 an hour later. His PO2 in the blood gasses last was 39 and they may decide to change the FiO2 if the next blood gas is not improved.

Wednesday 7/23 10:00AM: William is back up to 100% FiO2 after having a little bit of desatting during morning cares so they increased the Dilaudid a little based on that and that he needed a little more overnight. At the time I called he was in the 80's.

Wednesday 7/23 2:00PM: William is back up in the upper 80's low 90's for sats. They were able to go up a little bit on the lasix to try to get some more of the fluid off. So far there are no signs of issue with kidney function from the cidofovir. 

Wednesday 7/23 6:00PM: visited my favorite baby William and read Clifford and Horton. He looked a little less puffy and had warm hands and feet. They had turned up his temperature a little bit. His saturation numbers were 80 when I got there and 85 when I left. His last blood gas was better 47? (I think)

Wednesday 7/23 11:00PM: Emma returned as William's nurse tonight. When I called she said they had weaned the FiO2 to 80% and sats were 90. They went down on the lasix and down on the blood pressure medicine. Keep up the good work William!  Praise God!!!






Thursday 7/24 day 121: Overnight they were able to get The O2 down to 85% 
Thursday 7/24 9:30pm: 

Friday 7/25:  6:30 update: nurse Emma said the art line was working better than she initially expected. They are getting a good wave form on the monitor and are able to get blood from it so maybe it was just spasms from when they first placed it. 
He got a little bit of blood and they were able to come down on O2 to 80% and down on the blood pressure medicine (vaso)
12:30 update - Was on 75% FiO2 and they stopped the Flolan at 11am which is one of the medicines for the Pulmonary Hypertention. Julie is his nurse today and she said that she tried to reposition him on his side slightly and that made him mad and his sats went down such that they bumped him up to 100% again but they are going to try to bring that down again slowly.
When I visited at 5:30-6 he was in the upper 70's with his sats and 90% FiO2 and then he had a desat into the lower 70's and Shane from RT and Julie his nurse were planning to take him off the ventilator and bag him for a bit and try to suction but just as they were about to start they got a call to hold off. They let him settle out and he climbed back up into the mid 80's. He was back to 100%



9:00 update. Courtney was his nurse again and said he had been fine and no changes were planned. He was in the 80's and she said he had recovered earlier and had been in the 90's for sats so they weaned him to 90% FiO2.