Friday, March 7, 2008

March 7, 2008

We traveled back to Fort Worth today. We are staying in the Ronald McDonald House, which is a few blocks from the hospital. A big thank you goes out to my sister, Karen, and her husband, Steve, and their daughter, Natalie, for coming to the hospital to babysit Racheal while we went into the NICU.

Rylie and Reese both had echocardiograms and it showed that both of them have a Patent Ductus Ateriosis (PDA). See yesterday's post for descriptions of PDA and its problems. They are going to be started on IV Indocin, which will hopefully cause the Ductus Arteriosis to close. The Indocin causes a decrease in prostaglandin production, which is resposible for keeping the ductus arteriosis patent. Hopefully, the decrease in the prostaglandin production will cause the ductus to close. If the Indocin does not work, they can repeat the dosing, but there is little hope that a second dose will be any more effective than the first dose.

If the Indocin does not work, there are two options. The first option is to do nothing, and wait to see what happens. The second option is to do surgery to manually close the ductus arteriosis. The doctor feels that as long as the babies are stable there is no need to do the surgery; he prefers to provide whatever oxygen support is necessary for the babies to be stable, and just wait for the ductus to close itself. This could take days; it could take weeks; or, it can even take months. As long as the babies are stable, there is no reason to do the surgery.

There is a down side to giving the babies Indocin. Prostaglandin production is necessary in order to maintain adequate blood flow to the stomach and intestines; prostaglandin production affects blood flow to the kidneys. Indocin decreases prostaglandin production and therefore, it alters the blood flow to the gut and the kidneys. As a result, Rylie and Reese have had their feedings decreased to a minimal amount, and an IV has been restarted for fluid support.

I spoke with Dr. Riley and asked about a PICC line for Rylie and Reese. Dr. Riley prefers to use regular IVs unless the PICC line is absolutely necessary. PICC lines come with a greatly increased risk of infection in newborns, and especially in premature newborns. Babies have very little reserve capacity, and any infection can take a baby from stable to unstable in a very short period of time. Another problem with a PICC line, is any insertion site for a PICC line would mean that the site could not be used for any other IV or other line. So, if the babies needed a surgery, in say 2 or 3 weeks, that would be one IV site that would not be available for the surgery.

Now for some specifics; Rylie is doing well. He is still on CPAP at 21% FiO2, and maintains blood oxygenation above 94% all the time. He is able to tolerate being off of his CPAP for short periods of time, but still needs CPAP for now. Hopefully, the Indocin will cause closure of the PDA and his ability to oxygenate will improve and he will no longer need the CPAP.

Reese was attempted to be weaned off the CPAP last night. The plan was for her to be off the CPAP for 6 hours and then back on the CPAP for 6 hours, and cycle in that fashion. When she was taken off the CPAP, she did well for about 3 hours, and then she started to have problems with a low heart rate and low blood oxygenation. They put her back on the CPAP and everything was okay. Because of her inability to stay off the CPAP, Dr. Riley listened to her heart again and he heard a murmur, and that prompted him to get the echocardiogram that showed the PDA.

Ryan has been extubated (he has been taken off of the ventilator and his breathing tube has been remove), and he is back on CPAP. I asked Dr. Riley what he thought about the thick material that was being suctioned from his tube. Dr. Riley seems to think that this represents gastric reflux and aspiration. Even though Ryan had a tube down his throat and into his trachea, the tube did not have a cuff on it, so it was possible for any reflux, or spit up, to seep around the edge of the tube and get into the lungs. So his feedings have been changed so that he gets his feedings over several hours, instead of as a single bolus. This seems to have stopped the spitting up, and hopefully, will prevent further aspiration, and allow him to heal. Dr. Riley says that he heard a soft murmur on Ryan a few days ago, but was unable to hear any murmur today, so he does not think that Ryan has a PDA. Ryan in now back on CPAP and is doing well. Most of the time his FiO2 is at 21% (the same as room air), but whenever he gets active or needs care from the nurses, his blood oxygenation starts to drop and his FiO2 has to be increased for a short period of time. If he does not have a PDA, and if he can gets his feedings without further aspirations, he should get better.

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