25 6/7 24 hours post op

Zane was off the epi. by the morning and his blood pressures remain stable, they are looking for a goal of 25-30 on his maps.  Usually they like the map to be greater than gestational age anything 25 and above is good. His dopamine has been anywhere from 8-20mcq.  He did receive another blood transfusion today, which is interesting as their are some theories that blood transfusions can increase the risk of NEC., was it the neoprofen, prematurity or blood transfusions that lead this to happen?
His belly looks dusky and dark to me and is firm and tender, he still has drainage coming out of the site, it will be a few days before the surgeon can tell whether the drain fixed the problem or if a lap. is required. The encouraging sign is that his blood gases are not acidotic, if they were acidotic you would think he might have dead bowel also his lactates are low, this is all encouraging and perhaps Zane only had an isolated perforate bowel.  A PIV was placed even with his UAC still in place they needed another form of access to run his blood through.
Zane was started on Zosyn last night and fluconazole today, his platelets keep dropping so the thought is he might have a fungal infection. His fluids are at 150ml/kg as he appears to be dry based upon his labs. His sodium is low and his BUN is 60 and creatine is 2.0 (indicated kidney failure) The attending came and spoke with us today and he answers all our questions, it is also interesting to me to hear the reasons why they start a new drug or increase fluids as each attending wants to do the best for the infant but they all have their own focuses.

bedside surgery

Zane had surgery at the bedside. His surgeon  (the best) placed a drain in the right lower quadrant of his abdomen.  His xray showed a lot of "free air" and the drain allows the air to escape.  He  has a replogle in place-- this is a tube that goes into the belly and helps to decompress the stomach and remove any buildup of fluids. His dopamine is now at 15mcq/kg/min.  He is on 150ml/kg of fluid and he has had no urine output. It would not surprise me if he is placed on epinephrine to help maintain his blood pressure. This poor baby is going through so much and he is so young, I pray that his parents have  the strength to endure the road ahead of them.

25 4/7 Free Air

Free air is not a good thing. In fact it is one of those terms that the NICU nurse hates to hear. It is an indication that at some point the baby's intestines had less oxygen and became compromised. The bacteria in the intestines builds up and actually is released, which causes the air to escape. This air can be seen on xray as a bubble over the liver. Surgery is called and either a drain is placed or a laparotomy can be done. The laparotomy actually examines the bowels and determines how much has been affected and either an ostomy is placed or the infant is closed back up. Unfortunately for Zane he is too little and compromised to withstand a laparotomy right now, so only the drain will be placed. The hope is that the drain will allow the air to escape and give his bowel time to heal.

video of a PDA ligation

It is difficult to explain the surgery. I found a video on you-tube that can be viewed of another preemie who had the same surgery., http://www.youtube.com/watch?v=SOj6K_BoIAc

Zane is currently on dopamine as his urine output dropped to less then 1mg/kg, hopefully tonight he will get another blood transfusion to "tank him up" before surgery as he needs all the red cells possible for oxygenation.

25 3/7

Zane remains on the JET ventilator and his lungs have several areas of PIE.  He still has not stooled and his urine output has decreased to ~ 1.4ml/kg/hour.  He had his last dose of neoprofen Wednesday night but he still shows signs of a PDA.  He was echoed today and I would not be surprised if the echo showed that his PDA was still open.  If the PDA remains open he will need to be ligated and hopefully that will occur in the next day or two.

His UVC (umbilical venous catheter) was removed as he had a PICC line placed.  A PICC (peripherally inserted central catheter)  will allow Zane to receive intravenous fluids (TPN ) and lipids and is a long term IV, so he will have fewer peripheral IV sticks during his stay.  Kudos and thank God for the nurse who placed his line :-)
Zane was lucky that he had a great neonatal nurse practitioner on service last night; she kept close tabs on him and took the time to explain the xrays and what her plan was for him for her shift.   As each day passes I realize how much the "luck" of the patient is dependent upon the nurses and doctors who care for them. When newer nurses and inexperienced physicians work in tandem, the results can be disastrous for the patient.

25 1/7

Zane's day was filled with multiple ventilator changes and blood gas draws. Today he had a resident (new MD) taking care of him, who in my opinion should not be in the intensive care units.  They are learning how to take care of patients, but this particular population is too fragile.  Samantha wanted to  know what a grade II bleed meant and the resident  handed her a paper and told her to "read this" as, "it explains it in terms you can understand".  This was really rude in my opinion and it did not answer her questions.


When I saw Zane tonight he just looked like he was getting "septic" (sick) with some sort of infection. His white count is up again and he was not moving as much.  His BUN is high >80 and his creatine is high 1.4 which indicates he can be dehydrated, which he is, as his fluids are kept lower to help close up the PDA and also he has immature kidneys.


I am thankful for the wonderful nurses he has, as they are the ones who make all the difference in his care, they are the ones who reviews labs, anticipate orders and can help make suggestions on what Zane likes best, the public does not realize what an important part the nurse plays in the care of the patient. The knowledgeable nurse can make a great save whereas the newer inexperienced nurse may follow orders that are not in the best interest of the infant

One of the great things our unit does is called primary care nursing, this helps to ensure that each baby has a team of nurses who will take care of him when they are scheduled to work. This allows the nurse to learn the babies "natural" behaviors and also to alert the health care team when the baby is just not right. It allows the parents to bond with a team of nurses and to feel more confident that anyone who cares for their infant is taking care of him on a daily basis.

25 0/7

Today was the day we were to hear about the results from Zane's head ultrasound, along with his echo.  No surprise regarding the echo: his PDA is still open with a L-R shunt present.  A PDA is a patent ductus arteriosus. The ductus is a vessel about the width of a plastic coffee stirrer that connects the pulmonary artery with the descending aorta.  When Zane was in utero the DA takes the blood and shunts it away from the lung since the infant does not need to use his lungs for oxygenation while in utero.  If Zane had gone to term his DA should have closed 12- 24 hours after birth.

Why did Zane's DA not close at birth? First he is premature. Infants who weight less than 1000 grams have a >80% change of having a PDA

Next he  received 3 doses of surfactant to treat his respiratory distress; surfactant helped to increase lung compliance and increases the alveolar expansion (which helps with oxygenation) but surfactant can increase symptomatic PDA

Some of the signs Zane showed was a murmur, increase need for respiratory support (higher oxygen and higher settings) he will be treated with another 3 rounds of ibuprofen (this closes the PDA) and he will have another echo on Thursday if the PDA remains open then the only option left is surgical ligation.

  His xray also showed atelectasis  on his right side and a  increase in  pulmonary edema (wet looking lungs) and PIE. PIE  is pulmonary air leaks that happens from over distention  of the air ways, this is something that occurs with frequent vent changes when trying to balance the need for minimum ventilator support but enough support to maintain good oxygenation and blood gases. Placing the infant on the JET helps to minimize this trauma.

The other notable lab values was a 2x increase in Zane's white blood count (which indicates infection) he was started on vancomycin and gentamicin.

Zane's hemoglobin also dropped (due to the frequent blood sampling)  and he required a 5ml/kg  blood transfusion.

The head ultrasound showed a grade II bleed on the right side only, this occurs because the blood vessels are very thin and highly vascular and fluctuations with the cerebral blood flow can cause a bleed. What causes fluctuations, increase/decrease of blood pressure, changing the baby's diaper and lifting him too high, turning him and not keeping him in a midline position -- and just being so premature, he will have additional head ultrasounds to monitor this bleed during his stay at the hospital

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24 5/7 mommy gets to hold

Just some quick facts, first for those who are reading this blog but are unfamiliar with myself or my daughter Samantha,, prior to Zane birth she had two miscarriages.  When she found out she was pregnant with Zane I really did not acknowledge the pregnancy for fear that she might miscarry again --when she hit the 23rd week mark I relaxed and started to prepare for my upcoming grandson birth in March....when Sam went into premature labor I panicked because I realized what an up hill battle this would be, I am a NICU nurse (neonatal intensive care unit) and taking care of premature infants is second nature to me but I am  all too aware of the ups and downs associated with their care...so every day I hold my breathe waiting to I hear from one of my colleagues about Zane's progress


Today Zane was taken care of by Ashby who allowed Samantha to hold Zane (in his isolette) while she changed out his snuggle.  Samantha held him very careful and she was afraid to move she said she could feel his heart beating and him breathing  but she did a wonderful job and Zane tolerated the handling well,  He is back on his bili lights and still has a metabolic acidosis, a loud murmur can be heard and he is receiving his last does of neoprofen tonight.  A echo will be ordered on Monday to see if his PDA has closed----my bet he will need another round. Because of the PDA he has extra fluid shunted to his lungs and it is harder to get off the ventilator, his settings are not horrible rate of 32 18/5 he seems to like his pressure.

24 4/7

Samantha was able to help with Zane's diaper change, she was also shown how to use containment to help settle Zane during assessments, she was grinning from ear to ear especially when he held onto her finger, she claims that he "mouths" the words I LOVE YOU when she talks to him...

24 4/7

Zane is holding his own he has been put back onto the conventional ventilator he was given blood today to help his metabolic acidosis, he was off his bili lights today, although we expect them to be back on in the morning from a rebound bili level. He has a great urine output but has not stooled yet, with only hypoactive bowel sounds. His pda is still open and he is being treated with neoprofen, his weight is now 475 grams he is down 125 grams from birth.

24 2/7 from gummy bear to prune

This blog will be used to give quick updates on Zane's progress so that others who are going thru this will have a point of reference.  One thing that my daughter found very helpful was to hear from others, the good and bad news so that she could brace and prepare herself for the next few weeks

Zane was put on the JET ventilator this is easier on the lungs and helps the baby to blow off excess CO2, the jet gives 420 breaths a minute and the baby jiggles while on this vent he looks like the spokes model for the jello commericals

Jet

Zane enters the world 600 grams

24 0/7 weeks, Zane decided that he no longer wanted to wait to see the world,  and he proceeded to kick his way out,  30 mintues later via an emergent c-section Zane was born. He did cry but his heart rate was less than 70, he was intubated and given surfactant and brought back to the NICU- neonatal intensive care unit. As you can see from this photo he was bruised on his legs from all the kicking he was doing, he is very ruddy and he is under bili lights.....as a good friend said he looks like a gummy bear