ex machina
the eric update - day 38: improving. but bugs and decreased lung function looming.
the good news is that eric's overall clinical picture is improving, even though he is still on the vent, which is to say that his blood counts are showing that his systemic infection is nearly gone and his blood gas profile is looking great. the shortest answer as to why he's on the vent for longer than he's ever been is that they are concerned that they want to make sure that his bowels are completely recovered after shutting down the other day before they put him back on cpap. the armchair reseachers in the crowd can investigate why cpap is bad after an illeus ( the technical term for the lower bowels stopping to function ) because i haven't had the time to put all the pieces together.
although his overall status is improving, we were warned about a few new issues that are developing. after 5 weeks of not needing much supplemental oxygen, eric is starting to need to have his 'ooooooh' increased; in other words, while he's done remarkably well in the past breathing unenriched room air ( with around 20-21% oxygen) , he's now consistently needing 25-40 percent oxygen in his air supply. of course, there are several reasons why he might be needing more oxygen.
most innocuously, he might simply be getting comfortable on the vent and getting lazy, taking fewer and shallower breaths. breathing takes a lot of work, and if the machine is going to do the heavy lifting, many micropreemies are more than happy to take a breather from breathing and require a little more oxygen to keep their blood gas levels at appropriate levels. while this might be partly the cause, he respiratory profile doesn't indicate that he's getting too lazy, so my guess is that it's only playing a minor role.
slightly more disconcertingly, he may also be developing a tracheal infection, which can irritate his mucous membranes and produce more slime and goo than normal; more slime and goo makes it more difficult to breath and increase the need for supplemental oxygen. he certainly seems to have more secretions than normal of late. and indeed, while we were discussing the potential for trach bugs, eric's latest labs came back and he was positive for enterobacter and klebsiella which are gram negative nosocomial bugs - in other words he got an infection from bugs that you find in the hospital. while it's not something that you want to see, it would be more remarkable if he didn't get a nosocomial infection from all the tubes entering various parts of his body. technically, the bugs have simply colonized and have not shown any evidence of becoming particularly invasive. simply put, they are just hanging out and slowly multiplying around his ET tube and don't seem too concerned with overtaking his system. it's very difficult to pummel colonized nosocomial bugs into complete submission so they are going to wait and see if eric's nascent immune system can keep them in check. i guess you could call this a developing story that could "get legs" and hit the front page soon.
perhaps even more problematic is the fact that eric could be developing a lung condition known as chronic pulmonary insufficiency of prematurity (cpip). essentially, this means his lungs are not growing fast enough to keep up with the oxygen requirements demanded by his growing body. cpip presents itself similar to bronchopulmonary dysplasia (bpd), but they are actually different enough to warrant different treatment strategies. this evening nurse practitioner dawn was not willing to say that he definately had cpip, but she said it wouldn't surpise her at all to see him get the official diagnosis over the coming weeks. the good news is that if he does have cpip, he will quite likely eventually regain normal lung function ( perhaps by year 2 ). the not-so-good news is that cpip could necessitate that he leave the nicu with an oxygen tank.
just in case you've started to miss the forest for the trees, the good news is that eric's overall clinical picture is improving.
and we're still getting postcards ( scroll down to the bottom of the link )!
8/11/2004 11:35:00 PM
3 comments
3 Comments:
E3,
Here's a little hope, and something to discuss with your drs. When Kyle was reventalated, a RT noticed that his secretions where picking up - so he ordered a Trach Aspirate. The tests showed 3 types of "bugs" colonized in his throat. He was given a round of antibiotics to kill of what could die. What remained was labeled as "Carrier Colonies". Kyle has MRSA, or a strain of Methicillin Resistant Staphylococcus aureus. Although he is immune to the strain that he carries, he will forever more be ushered into "Isolation rooms" when we visit Peds offices (or other offices where small infants will be at). The upside is that we don't have to wait in the waiting room... The downside, he contracted this while being in the NICU and being intubated (we where none too pleased).
In any event, he started having many of the symptons you mentioned: greater dependance on oxygen, etc, etc. They almost put a trach in, because unlike E4, Kyle was getting much worse on the vent (CO2 in the high 80's-90's). In desperation, I begged the drs to do something when the steroids didn't work. They extubated just to "See what would happen".
Well, with a little assistance of some Neb's to help clear up the secretions and re-open the airways, Kyle did significantly better off the vent from day 1. His CO2 dropped back to the 50's/60's, and he was carrying normal PH levels again.
Kyle does have moderate BPD, but what makes things a little worse is that being ventilated the second time, and getting infected caused reactive airway disease. Because of this, he is now refusing the bottle, due to his difficulties in swallowing (loves his pacifier though).
If there is any possibility that you feel they are being overly cautious - discuss reative airway disease with your Neo. This is NOT something you want E4 to develop.
PS. I think your guy is doing great - I wouldn't worry about O2 at home, just yet :)
By 
, at
9:52 PM
thanks katra. did he ever get sepsis from the mrsa? i'm not sure if you can get sepsis and still be considered immune. i guess i'm wondering if the bugs were ever found anywhere else besides his throat.
we've talked with them a little bit about reactive airway disease and it's certianly something that nobody wants to see, but since his pneumonia diagnosis, i don't think there's a chance of him getting off the vent soon.
on the upside, cpip is looking less likely since his increased need for supplemental oxygen was likely due to the pneumonia and pda.
We really lucked out, and he didn't get sepsis (this time). Most likely because he was so much older when he got MRSA (and the other buggies). He did however get pneumonia, but the colony localized in the throat and didn't fully infiltrate the lungs. Most likely due to catching it so quickly. The pneumonia was causing such a build up of secretions that they where suctioning him every other hour... Which of course, only causes more (sigh, and eye roll inserted here). Within a couple of weeks, he was doing much better. Part of the reason he didn't get so bad with the MRSA - he had already been treated for staph when he was first born (even though he didn't have it), because I had it from carrying Konner's placenta 4.5 days until Kyle's birth. Apparently, that treatment helped him to develop a resistence to the bug, and made him more elidgable for "Carrier" status.
He did get sepsis when he was smaller, due to a PICC line infection. Normal, everyday skin bacteria infiltrated his line and caused a horrible infection. They caught, a day and a half after we complained of him being too lathargic (bad nurse that day - she wasn't allowed near Kyle after ignoring us). He ended up on the vent, which was so diheartening, as he had only been on the canula for a few days. 5 days later he was extubated thanks to a sharp round of 2 steroids (Vaco & Gentamyacin), 1 week after that he was off CPAP.
As you are already aware, it's a major setback everytime something like this happens, but in time they recover. I still expect that E4 will fare far better than Kyle, because Kyle was intubated the first 5 weeks of his life... RDS/BPD had already developed by the time he was E4's age.
Oh, I should add, MRSA is typically only seen in Nursing homes and the elderly!!! Nice that it's in the NICU! I've read that about 20% of the population has it. It's spread by nasal secretions - which GROSSES me out to think who did what that caused him to get that!
Katra & little Kyle
By , at
11:41 AM
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