Perry remained on the Phenylephrine HCl (NeoSynephrine) IV drip to keep his pressure elevated. His glucose level was 206 @ ~1222a so received insulin @ 1227a. BP 102/57, heart rate 99/min, oxygen saturation @ 100% & temperature @ 37 degrees C (98.6 degrees F). He did not spike any additional temperatures throughout the night. His assigned day shift nurse was Rachel RN who took over his care from Josh RN. Rachel is assigned only to Perry today so he was able to receive one on one nursing care. In preparation for his bronchoscopy his formula feeding was stopped @ 7a. His hemoglobin went from 8.3 yesterday to 6.4 with a hematocrit @ 19.8 with this morning’s lab results & his white blood cell count had gone from 6,000 to 17,000 (indicative of infection). Two units of packed red blood cells were ordered & started. At 0830a, Dr. Chiedozie Udeh, Intensivist, was in to see Perry. We discussed that Perry is septic with exact source of infection still pending; condition changes that had been occurring prior to yesterday that I had continued to alert other physicians, nurses & his RTs; his treatments since yesterday; today's plans for bronchoscopy that is scheduled for 2p; & the plan for repeat chest CT scan on Monday with possible removal of the L pigtail chest tube catheter pending those CT results. I also mentioned that Neurologist had stated to me on 11/6 that he planned to wean Perry off of the Valproic acid, Depakene, & although I have mentioned such to several physicians & RNs that has yet to be done. He was also made aware that Janelle Romond APN with Psychiatry had ordered for Seroquel to be discontinued. Discussion also occurred that his IV & dialysis access sites would need to be removed as they have been in place since 8/24 & could be a source of his infection. Kathy Hogan APN from the Bronchoscopy Suites called to inform the staff that Perry's bronchoscopy for today had been cancelled. Dr. Udeh left immediately to call Kathy Hogan APN to find out who had cancelled it & why.
At 0920, Rachel RN attempted to place a large gauge peripheral IV without success. At 0935, Jay RN inserted peripheral IV accesses to his R forearm & L forearm. At 0945, Dr. Turowski, Pulmonologist, had also contacted the Drs from Bronchoscopy Suites who had rounded this morning & cancelled the procedure as Perry had been receiving vasopressors, was septic anemic, & hypotensive (low blood pressure). Their decision was overruled with more input & discussion from both Dr. Udeh & Dr. Turowski. Since biopsies are taken from each lung during today's bronchoscopy, his heparin had been held & a medication known as DDAVP was ordered. DDAVP is synthetic hormone used to control the amount of urine the kidneys make. Normally, the amount of urine you make is controlled by a hormone called vasopressin. In persons with acute and chronic renal failure, less vasopressin is made & since Perry has not had dialysis since Tuesday he has even less vasopressin in his system. Vasopressin’s other function is to constrict blood vessels which then increases blood pressure & is essential to control bleeding. Due to the low level of his kidney function at present, his platelets (help to clot blood) are down too. Hence, with all of the above, DDAVP is crucial.
At 950a, Dr. Udeh assessed his abdomen as I had informed him that I've noticed that his abdomen has been becoming more & more distended over the last few days & that he has complained of lower chest/upper abdominal discomfort with capping & has been experiencing intermittent bouts of nausea. He plans to order a KUB abdominal x-ray. He informed me that he looked over the notes & Valproic acid was recommended to be weaned & so he wrote the order for the Valproic acid (Depakene) to be decreased to 125 mg & will write additional orders for the rest of weaning schedule so it does not get overlooked. At 1017a, his temperature was 36.7 degrees C (98.06 degrees F) & the 2nd unit of blood was started.
The Nephrologist agreed that the perm cath & Hohn line (access sites currently in his R femoral/thigh) need to be pulled & his lab values & toxin levels are stable enough that he does not have to have dialysis today especially with his low BPs. They would like to give him a chance to be line free until all culture results are back & have an access placed on Monday if at all possible. If he needs dialysis tomorrow she will have a temporary access line placed as waiting for the blood culture results. I asked that the procedure be scheduled with Interventional Radiology (IR) so it's “on the books” NOW & then if needs to be changed or canceled at least we are not “waiting” to be scheduled & putting him more at risk. She agreed with plan & will contact IR now. Rachel RN asked her if a trialysis catheter could be inserted to prevent even more invasive procedures. A trialysis catheter has 3 different ports that will allow for: lab draws, medications & contrast media administration, & for dialysis.
At ~1035a, the KUB X-ray was taken. Rachel was not comfortable that despite Perry having received almost 1½ units of blood that his BP was 89/54 & with the removal of the perm cath & Hohn line he would then only have the 2 peripheral IV lines leaving him without a central line. In the event he would need more vasopressor medications (Neosynephrine) to help constrict his blood vessels & raise his blood pressure should it remain low &/or bottom out, he would need a central line. A central line is an IV that feeds into a larger vein known as the vena cava that goes directly to the heart. She discussed with Dr. Anandamurthy & he discussed further with Dr. Udeh. It was decided that Dr. Anandamurthy will place a temporary trialysis catheter.
At ~1130a, I went to the Family Waiting Room Lounge so that Dr. Anandamurthy could remove the perm cath & Hohn line from his R femoral & place a trialysis catheter into his L femoral vein in his upper thigh/groin area. While waiting, Janelle Romond APN came out to talk to me, & I was able to vent many of my own thoughts & feelings. The J5 CVICUs were sponsoring a bake sale in order to raise funds for their “Christmas Adopt a Family” project so Janelle treated us both to a taco, pop, & some baked items as I had left my purse in Perry’s room as I was not expecting to be in the waiting room for ~2 hours. It took a bit of time to remove the tunneled catheter with the need for an additional incision to be made to free the catheter. Perry tolerated the procedures well with Dilaudid having been given. He was also given Vancomycin 1 gram IV antibiotic. Perry slept with the need for frequent oral & trach suctioning of thick yellow cream colored mucus secretions. He nodded subtly that he was understanding what was happening otherwise remained asleep. The 2p bronchoscopy scheduled time was delayed until 4p. At ~315p, the anesthesiology team from the Bronchoscopy Suites came for Perry, & he was removed off of the vent & bagged with an ambu bag while being transported to the Bronchoscopy Suites accompanied by Rachel RN & me. I was escorted to a hallway seating area while Perry was transported into the Bronchoscopy Suite @ ~345p.
At ~545p, Dr. Mehta, Pulmonologist, shook my hand & hugged me as he informed me that a lot of thick pus was removed out of both lungs & that Perry had experienced continued bleeding & oozing after the lung biopsies were taken. Despite several intervention approaches such as iced saline lavage, he continued to bleed & ooze. After about 45 minutes, they were able to get the bleeding to stop with balloon inflation. Perry otherwise tolerated the procedure well & was stable upon discharge from the Bronchoscopy Suites. Dr. Mehta wants Perry to have a bronchoscopy done at least twice a week for a while in order to rid the excess pus & mucus lung secretions that he has not been able to cough out on his own due to thickness, weakness, diaphragm atrophy as well as secretions which cannot be reached via tracheal suction. He does not want Perry to cough or to be suctioned until tomorrow to avoid further bleeding from the biopsy sites, so they are going to keep him very well sedated with a fentanyl drip until tomorrow. Dr. Mehta prefers for Perry to have his next bronch shortly after dialysis in order to have a higher level of platelets & vasopressor so anticipate next bronch either Monday or Tuesday & then again most likely on Friday next week. Since he will not have to have biopsies taken for a while, the bronchs can be done in his ICU room at bedside & hopefully rid secretions & mucus plugs related to the pneumonia infection. Perry had already been transported back to the CVICU, so Dr. Mehta escorted me to the elevator & we discussed that we want to get him out of here alive, then he hugged me again, & said “God Bless” as I got onto the elevator. He is such a dear man & physician that has been a blessing to Team Perry.
Perry was able to very subtly nod as I kissed him upon my return to his bedside & shortly thereafter was started on the Fentanyl 2500 mcg/50 mL drip @ 50mcg/hr. He remained calmly & comfortably asleep throughout the remainder of the evening with his vital signs remaining stable. My parents plan to be en route as of tomorrow for additional support & get in a visit before the cold winds start to blow, the temperatures begin to drop, & the turkeys start to trot.