Sandra Kim

Weaning again

Yesterday they had her weaning again at a pressure of 15 and today she was at 12.  The reason she stumbled recently seems to be that her fluid level was getting too high.  I noticed on Monday that her peak pressures were a bit high (upper 30's) and her heart rate quite low (lower 80's).  I think the higher peak pressures were just causing her to have to work too hard.  In the past when she had lower fluid levels her pressures would be down in the teens but her heart rate could be almost problematic in the 120's.  But that is where she does best with the weaning - the low pressures make it easier for her.  So they started working on lowering her fluid level again.  On Monday I saw her weight was just below 50kg and today it was just below 48.  And her peak pressures were lower and heart rate higher (although she was also sitting in the chair this time which always increases her heart rate).  She did great all day yesterday and I'm hopeful that will be the case again today.

In any case, I'm hopeful that she doesn't have any other problems and although she continues to be very sensitive to fluid levels that as long as they can walk that line properly she'll start to make good progress again with the weaning.  -Willem

still stumbling a bit

Yesterday they had her weaning at pressure of 8 and she ran out of steam again in the early afternoon.  Today she only made it a little while before they had to stop weaning.  She has had no fevers and minimal secretions so they don't see any reason for it other than her just getting physically tired.  The doctor hadn't done rounds yet when I was there this morning but the nurse thought they might try increasing pressure and trying again.  -Willem

weaning progress

Sandra has been progressing well overall with weaning.  She was down to pressure support of 6 yesterday but started looking strained after 5 or 6 hours and her oxygen saturation started going down so they stopped.  They had her at 8 today and she also started having trouble so they had to stop early again.  They plan to keep her at 8 for a few days and then move foreward again.  Overall I think she's doing well.  -Willem

weaning again

I was surprised to find out just now that they have her weaning again already today and she's doing well with it.  In regard to the lab results they found a urinary count that was off.  I talked to Dr. Karen again and she suspects the cause to continue to be fungal in the urinary tract.  They gave Sandra andi-fungal meds which Karen said she responded to.  She has a low grade fever now but appears comfortable and "isn't really sick" like before, Karen says.  She seems very determined to figure out what's going on and was looking through the records and saw from a previous belly scan or xray "possible kidney stone".  She said that if she indeed does have a kidney stone that it would explain the recurring, hard to eliminate fungal infection.  So she's scheduled a CAT scan for the morning to find out for sure.  If she does have a kidney stone they would likely continue to give her anti-fungal at low dosage for now and eventually pulverize it with ultrasound. 

I'm happy that Dr. Karen is so determined to figure this out and happily surprised that this doesn't appear to be stopping the weaning process at the moment.  Fingers crossed!  -Willem

fever

Well that was short lived.  She spiked a 103 fever this morning and her heartrate was in the 150's.  they gave her fluid and by the afternoon when we were there it was down to 100 and 120.  They took all the cultures and are  holding off on antibiotics until the results come back unless they can't keep the fever down but so far they have been able to.  An odd thing is that her white blood cell count is normal. 

weaning again

On Saturday they got her started weaning again.  Over the past week they have been trying to get her in shape for it, mostly balancing her fluid level.  Too high and her lungs are too stiff, too low and her blood pressure drops too low and heart rate too high.  Eunhae and I were there around 5 last night and she had been going strong since 7:30 in the morning.  Pressure support was at the highest of 20, but it's a great start.  She was working hard.  Her face was all red and hot and they had a cold wet cloth on her forehead.  (Still no fever - on Wed they said her white blood cell count is also normal at 8, which is great news).  She was awake most of the time that we visited.  Her expression never changed much but she looks serious and determined and like she's in the middle of a workout.  She would look at Eunhae or myself when we talked to her and would pucker up her lips for a kiss and that's about it.  She could barely move her right arm and it was very shaky.   When they have her fluid level relatively low you can really see how skinny she is.  Her hands and arm are feather light and really just skin and bones.  They look like they belong to someone who is starving - although I know it's from lack of use rather than lack of nutrition.

She has been tearing up when I leave after visiting lately.  No change in expression.  You might think she barely sees you or doesn't understand what you're saying until then.  She's very heavily sedated.  But she understands, at least mostly.  This time a big tear came down her cheek as we were leaving.  I'm really worried another infection will come and block her before they get her completely weaned off the vent.   Dr. Karen told me the UtI she had is very nasty and hard to get rid of completely and may come back.  It set her back 3 weeks last time.  We just need a window without infection now.  Maybe just a few weeks.  I so hope this is it.  -Willem

no weaning today

Sandra's stomach is distended and she wasn't tolerating the tube feeding yesterday so they did an abdominal x-ray.  They got results today and said it's nothing to worry about, as it is only gas buildup which they are treating.  (The nurse didn't know the cause, so that part is a mystery to me, anyway).  She also had shortness of breath this morning - the nurse didn't know why and I didn't talk to the RT - and becasue of this, or possibly due to this and the abdominal issue, they didn't attempt to wean today.  -Willem

better understanding of recent setback

Today I talked to Karen, a infectious medicine doctor to try to better understand what's been going on since Sandra got the urinary tract infection almost a month ago.  The basic summary is that the UTI was difficult to get rid of and it took the first 3 weeks or so and several changes in medication before it seemed to be eradicated.  Then about a week ago she got a second infection in the lungs.  They never cultured the lung infection but with all the scar tissue in her lungs they don't always expect to be able to as it can be sort of hiding out in an area they don't reach.  It sounds like they just culture her spewdum anyway.  They have been treating it with a mix of antibiotics including a mist of tobermiacin which the ventilator sprays into her air, with the theory that it can reach areas where she doesn't have good blood flow/dead tissue in her lungs.  In any case, she has been doing well the past few days, they removed the cooling blanket a few days ago and they have been letting her rest.  The lung infection seems to have responded to the treatment.  Probably she is now strong enough to start the weaning process again, which they will start to attempt in the next few days. 

Assuming the infections really are taken care of potentially things could go pretty quickly.  I mentioned to Dr. Karen that i was hopeful that in a month or so after starting the weaning process that she could be off the ventilator and her reply was that she would expect it to go more quickly, like a few weeks.  She said this was based on how well she was doing with it prior to the UTI and because she shouldn't have completely lost the gains from back then.  She confirmed that if we get to that point they will drastically lessen the sedation and one by one they will start removing the lines and cathedor drastically lowering the chance of infection and thus she will be in a very much safer situation, as we have anticipated.  So close.  But that's what I said a month ago.  Anyway - hoping for the best, at least to start making progress again soon.  -Willem

fever

This morning she had a 102.5 temp so they did all the cultures and put her on 2 new antibiotics which the nurse said were pretty broad spectrum and should cover her for almost anything.  Otherwise her vitals are good, she's making good urine and seems comfortable.  But no attempts at weaning.  Her tempurature was down to 101 this evening.  Sometime tomorrow we should know if anything grows out of the cultures indicating a new infection.  -Willem