Friday, May 20, 2016
Friday, May 20
Ezekiel has had a fairly good day. He seems to be fairly stable where he's at, enough so that this morning they felt like he may be able to tolerate some changes to his treatment.
His urine output yesterday over 24 hours was 61cc's, and he was holding steady at I=O on the dialysis. He had gained 30g, but his abdominal circumference stayed the same (42cm). He hadn't had any major saturation or blood pressure dips or anything overnight.
Blood pressures have been consistently in the 30's to 50's (unless he's mad, and then it's higher), and they were able to wean his dopamine down to 7 overnight.
During rounds this morning, nephrology wanted to try removing 5ml/hr with dialysis, pending neonatal's opinion on Zeke's status. When the neonatal team came in, they decided that his blood pressures and blood counts were stable enough, and they agreed with nephrology. I suggested starting slowly, taking 5 for an hour, and leaving him I=O for four, to make sure he would tolerate it. I don't want to go back to the cycle of taking too much off, so he needs a saline bolus, which causes his hematocrit to drop, causing him to then need a blood transfusion, a vicious cycle, adding all of this extra fluid that wasn't being pulled off. I'd rather start slowly and work our way up if he's tolerating it. They agreed, and that's the plan with dialysis for now. He's done well all day, with no noticeable change in his vitals during the hours when he's having extra fluid removed. Maybe tomorrow we can do 1-3.
I also asked about restarting breastmilk feeds, and they agreed that it could be beneficial, especially since he hasn't had any issues. They wanted to start with 3ml in the og tube every three hours and see how he does with that. They did one feed this morning around 11am, and he tolerated it well. But after talking to Gary and discussing it with the nurse and NP, since he's still on one of the meds prescribed by surgery to help with his colostomy, they need to talk to the surgeon who has been following Zeke, to make sure his digestion is ok and his colostomy is working well before doing any more. Surgery usually rounds early in the morning, so hopefully we'll have an answer either way when neonatal rounds tomorrow.
The swelling in his chest and extremities seems to be down, but his abdomen looked a bit more swollen in front this afternoon/evening, vs out to the sides. He had an abdominal ultrasound this afternoon, and it looked like there was about the same amount of 'free fluid' in his abdomen that was there during the last scan, so it's good that he's not accumulating more.
He has needed a few extra doses of Fentanyl, mostly around fluid change and when anyone's been touching him for long periods of time. He hasn't needed a saline bolus since Tuesday 5/17, and hasn't needed a transfusion since Mondday 5/16. The Epogen (erythropoietin) seems to be working to help him make his own red blood cells, so his hematocrit is staying stable without needing extra blood products, despite the dialysis.
His vent settings are down, due to having good blood gasses all day. He's down to a rate of 70rpm, with the same pressure settings (27/4). He's been up and down on his oxygen intake today - mostly between 95-100% - but right now he's getting 97% and satting in the mid-high 90's. I wouldn't be surprised if he's been weaned down more when I come back in the morning.