Perry slept fairly well for the remainder of the night with intermittent position changes, adding/removing blankets for comfort, & oral/trach suction needed. The dialysis RN arrived ~0630a to begin machine set up for a 4 hour dialysis session. By that time, there had been ~300 mL of serous drainage from the pigtail chest tube catheter.
Dr. Kotloff rounded & reported that the L lung looked much better on this morning’s chest x-ray. He plans for Perry to have another Sniff test & an EMG. The Sniff test, also known as Diaphragm Fluoroscopy, had to be completed during his pre-transplant work-up, & Perry had passed it. As a person sniffs, a continuous x-ray beam is used to evaluate the function/movement of the diaphragms. A sniff activates & exaggerates the contraction (downward movement) of the diaphragms & allows the lungs to fill with air. As a person breathes out, the diaphragm relaxes & air is forced out of the lungs. An EMG stands for electromyography & evaluates the electrical activity produced by skeletal muscles & will provide information regarding the intactness of the phrenic nerves. Dr. Kotloff reiterated if the phrenic nerve is not intact then Perry may be able to be on BiPap via by mask & not have to be on vent all of the day. If intact then later down the line there is a possibility that he may be eligible to have a diaphragmatic pacer inserted. This is currently used only for patients who have spinal cord injuries whose phrenic nerves are intact so much discussion will need to occur if Perry would even be considered to have a diaphragmatic pacer(s) inserted. Medicare does NOT pay for such unless the person is a victim of a spinal cord injury & meets specific criteria. All of this is preliminary information & no matter what we have lots & lots of work ahead.
Dialysis ended @ ~1115 with 2.3 L of fluid instead of 2.5 L removed as his BP was becoming low. Upon my return after getting something for lunch, it was 78/47. He has continued to have low BPs throughout all of today with systolic BP 70-90 & diastolic BP 40-50 without complaints of dizziness. Since the purpose of dialysis was to remove fluid, they did not want to start him on IV fluids as such would be counterproductive to having had dialysis. I had forgot to inquire with the physician who completed the insertion of the pigtail chest tube catheter as to whether he sent drained secretions for culture so I am glad I remembered to ask this morning. Cindy RN did collect secretions for cultures as they had been ordered by Dr. Koval, Infectious Disease. Perry slept a majority of the day. He has been experiencing an increase in spasticity & myoclonus both yesterday & today. He became extremely frustrated with the shaking by the end of the evening & released some of his tension by pounding on his pillow as he has had excessive difficulty with his attempts to suction his oral secretions. His feeding rate has been gradually raised from 30 mL/hr to finally 60 mL/hr which is his baseline. No trach capping was completed today as he was either exhausted or asleep & with the lower BPs we did not want to jeopardize things further. There has been very scant additional drainage from the pigtail chest tube to present. He did his best to stay awake for the Cubs game & had to nap intermittently. He is aware that they lost to the New York Mets in Game 1. Peter RN did hold some of his medications a little longer so he would not be dozing almost immediately after received. He’s been soundly asleep since 930p. I plan to do the exact same in just a few minutes.