NICU Night #61 - 8 Weeks Old: Freaky Father's Day

Sunday, June 20, 2010

Our thanks for Sunday going out to the Barnetts for attending our ward and helping so much with the kids.

We were all so tired.  The kids didn't wake up until after 8am and Trevy wouldn't let me do her hair.  Normally I would fight for at least a combing through on Sunday, but not on 5 broken hours of sleep.  (Gotta love pumping!  But I'm not going to complain because I can pump!)

We made it through church and then, thanks to Bridgette, all three kids went down for a nap.  Landon has been fighting me so hard.  If he's not utterly exhausted, he will just keep climbing out of his crib.  Yes, I do wait by the door and keep putting him back in but, after an hour or more, it's time to pump again and I'm too tired ro stick with it.  Just feeling so blessed when someone else is here who is willing to do the deed.  He racked out in minutes for Bridgette.  I think he just knows she's not going to quit like mom.  Thank you so much, Bridge!

I'd like to say I took a nap, but this one time I decided that I would let the unpleasantness of my kitchen win out.  Dirty pots and pans do not pleasant countertop decor make.  Happy to say I did get it all cleaned up before anyone woke up, so I was feeling pretty good all around.  But, once again, that was relatively short-lived.

At 6:42pm, the talking caller ID announced that we were getting another phone call from the hospital.  Timmy had been doing so well so I told myself to just stay calm.  It was Dr. Tsai calling to inform me that Timmy had been extremely irritable for the past couple of hours and they weren't sure why.  She was thinking that it might be an infection so they had taken a urine sample and drawn blood for cultures and gone ahead and started him on Vancomycin and Cefotaxime, broad spectrum antibiotics.  The urine sample had shown a white blood cell count of 12, which is high but not necessarily indicative of infection though it could be the result of a UTI.  The blood cultures would be monitored for 48 hours before anything was determined.

Dr. Tsai said she just wanted to make us aware, nothing we needed to run in for.  But when my cell phone rang less than an hour later at 7:25pm and it was Krista, one of the nurse practitioners, I decided we needed to really get going on bedtime so I could head over to our little man.  Krista also didn't want to freak me out, just tell me that Timmy's CBC was low and he was quite pale so they were starting another blood transfusion (his third since birth).  The other positive to that was that the extra blood should help with any infection.  Okay.  I hated that he was having yet another 40+ mls of blood pumped into him yet again but if he really needed it...

I was finally able to get into the NICU around 9:45pm and was honestly freaked out by what I saw.  Jenny was Timmy's nurse again and she was patting him pretty firmly.  He was all burritoed up, looking very much asleep, but his heart rate was down into the 70s.  It is normally in the 130-140 range with some random dips down into the 90s that always pop right back up.  It was terrifying to see his heart rate that low and then even more so to have Dr. Forrester, the resident on for the night, and Krista both tell me that no one knew why his heart rate had dropped.  They were researching like mad.  Dr. Tsai had already gone home for the evening and was researching from afar.

Oddly, but reassuringly, Timmy's O2 sats remained very high, mostly at 99 or 100 but occasionally 1-2 percentage points lower. 

We would rub Timmy's chest and back vigorously when his heart rate hit the 70s and he would come back up, usually into the 100-somethings, not above 110 for the most part.  At one point, Krista wanted to see what Timmy's O2 sats would do if we left him in the 70s for a minute or so.  Crazy enough, nothing!  Which is a huge relief.  Obviously, having his heart stop beating would be the absolute worst case scenario, but having his O2 sats ride low for a prolonged period of time resulting in cell death and tissue damage would be quite devastating as well so there was a significant comfort in the fact that he was able to maintain his O2 concentration on minimal ventilator settings in spite of a bradycardic heart rate.  Unfortunately, Timmy wasn't able to bring himself out of the 70s without stimulation.  Not really surprising as Timmy had also been given Morphine and Atavan earlier due to his inconsolability and the thinking that he might be septic (having an infection that had gone into the bloodstream and become generalized).

Timmy went through this for a couple of hours and then his heart rate evened out into the 130-140s for another hour or so and we all breathed a little easier.  Around 10:30, we got the call from Dr. Tsai that she found what she was looking for - an article she remembered reading at some point from back in the 1980s where four case studies had shown infants experiencing intermittent bradycardic episodes after being given increased doses of Dexamethazone, the steroid Timmy was on to help his airways heal and strengthen in preparation for extubation on Monday.  He had received them q. 12 on Wednesday and q. 12 on Thursday for his Thursday afternoon attempt at extubating and then Dr. Parry had ordered another round after seeing Timmy on Saturday.  The steroids build so it was most likely that Timmy had hit his critical threshhold after, essentially, his 7th dose at 8am fully entered his system.  The final dose for his second course was discontinued. 

Timmy's blood gases for the night looked great and cultures were still looking negative at 12 hours out. 

I lasted until the 2am cares (Timmy weighed 4 lbs. 15 oz.) and then had to turn Timmy over to Jenny.  I felt guilty not to be able to stay awake and watch for bradys with her and help her get Timmy's heartrate back up.  At the same time, I was very relieved that she was there.  Melissa had come in also prior to Dr. Tsai's finding the article and we were all racking our brains to come up with anything to explain Timmy's bradys.  She came back around 4am or so (I just remember seeing her and thinking how nice it was to have two of Timmy's primaries there and I would love to talk to them but I was too tired to hold any sort of rational conversation so I turned to my other side in the chair and falling asleep again).  She and Jenny stayed by Timmy all night (thanks, Axel, for being such a calm, stellar neighbor Sunday night!).

It did seem like Timmy was doing a little better with each intermittent episode of bradying.  By around 2-3am, he was starting to help pull his heartrate back up from the 70s.  Jenny had also posed the theory that maybe the blood from the transfusion (given this time through his broviac line instead of a peripheral IV) was tickling his AV (atrioventricular) node.  We aren't entirely certain that it was the steroids that caused the bradys, but it seems the most likely source.  One more indicator in favor of the steroids was Timmy's elevated blood pressure, which can also correlate to steroid use.

That was the first night I stayed at the hospital since discharge.  My least favorite part of the NICU experience is feeling like Timmy is making significant progress - his feeds weren't affected at all, thank goodness - and that there may just be a glimmer of light and then walking in and fearing that things could suddenly go very very wrong.

So grateful they didn't.  After Cassie arrived (I learned she's Axel's primary and that's how we get to benefit from having her so often), Timmy's heartrate landed in the 70s a few times off an on, but much less frequently the when I had arrived the night before and he was no longer requiring stimulation to get his heartrate back up.  Huge relief.

I did get to meet Dr. Taylor, the pedo surgery resident, and he wasn't too impressed with what had happened overnight, saying that we would not be able to schedule Timmy's surgery for reanastomosis until after his medical issues were taken care of.  I understand that.  At the same time, very ready for his intestines to be reconnected.  I had already written off the extubation for the day ad now I figured I could just add the surgery to the list.  But I was wrong on both counts.