Thursday, June 23, 2016
June 23, 2016
We got the results of Zeke's VCUG yesterday. His bladder is refluxing up into his kidneys (vesicoureteral reflux). They expected this, and because he's on dialysis and his kidneys aren't very functional anyway (he's making urine, but not filtering toxins), it's not a huge deal. They also confirmed that there was a fistula, or connection, between his bladder and the lower portion of his large intestine, and it's coming out through the mucus fistula. The test also showed that there was no urine flow through the lower part of his urethra, which we already knew, since they haven't been able to insert a regular foley catheter. The urologist said that when general surgery went in to reattach Zeke's intestines, he'd be there at the same time. He plans to try to open whatever blockage is in the urethra and insert a foley catheter at that time. If that's not successful, he'll likely perform a vesicostomy (similar to a colostomy, only it's an opening from the bladder to the skin, instead of the bowel). He will also go in and close the opening in the bladder and seal it off from the bowel. We're still not sure when they plan to do any of these procedures. At some point in the night, he lost his superpubic catheter, so we're not really sure what the plan is. The urologist tried to reinsert it shortly -after they realized it came out with no success. He also tried to insert a foley catheter this morning, but that also didn't work. They're ok with just letting his bladder drain through his mucus fistula into the bag for now, until they figure out what to do next.
He's still having a larger than normal amount of secretions in his tube, and is needing suction often. Not as much today as yesterday, but still more than they'd like. His blood gasses haven't been amazing, so they're not weaning his rate on the vent or trying to extubate until he's more stable. He's still at a rate of 30rpm, with pressure at 20/5 and his Oxygen support is between 25-30%. Because of the increase in secretions, they sent a sample to be tested for respiratory viruses on Tuesday afternoon. The results they got back yesterday were negative, which is good. They started him on a low dose of Ampicillin to be on the safe side.
He had a rough night last night. They were able to get him back on the dialysis pump with no issues yesterday afternoon, but on night shift they were having a lot of issues trying to get the lines to flow. They had to disconnect him several times to flush or tpa the lines, and the machine ended up clotting. They had to take him off for the rest of the night, and restarted the machine with new blood early this afternoon. It was running fine at first, but this evening it started having issues with the line pressure again. His dialysis catheter/lines are extremely touchy and positional, and it's been pretty frustrating for his nurses to try to keep them in a good place to keep the machine running.
He's still doing well off the dopamine. His blood pressures have been pretty high - means occasionally as low as 50's, but usually between 60's-90's. His pump is set to I=O.
He was extremely agitated last night, even after several doses of Fentanyl (and they increased his dose as well). They started him back on a low dose (1mcg) of Fentanyl in his IV today to try to give him some relief. It has helped some, but he's also needed prn doses as well.
He's having less secretions today, and hasn't needed to be suctioned nearly as much as the last few days. With all of the issues he's had with the pump, as well as being out on a 'field trip' yesterday for his VCUG, being poked with the catheter, and needing lots of suction, we're not pushing for extubation at this point. We'd rather wait until he's more stable and has a better chance of staying extubated.
We've had a rough couple of days, but he's still doing well.