Tuesday afternoon Dr. Patel did the angiogram and confirmed that the EKOS had broken up the clot. In nineteen hours the clot was completely dissolved. Lucy was removed from the machine and we were prepared to move forward with extubating. This would entail allowing the paralytic medication to run it's course through her body and her breathing to resume. The ventilator setting would be decreased as Lucy started to initiate breaths. Eventually the vent would be just support as Lucy would breath on her own.
As we waited, Lucy urine output began to decrease and her plural effusion began to increase.
Fontan patients do better extubated because the positive pressure from the ventilation interferes with the blood flow through the Fontan. With excess liquid around her lungs, they were unsure that she could handle extubation. A chest tube was place on left side to help remove excess fluid.
However, her kidneys were having trouble recovering. The team brought the nephrologist back in to consult on her kidneys. What we have learned is there are three things that impacted her kidney:
1. Dye used in the angiogram, which was necessary
2. Antibiotics to get ahead of a fever and ensure she stay healthy
3. Low blood pressure.
If you can remember, way back when Lucy was an itty bitty, prior to our first discharge we were having trouble with digesting bolus feeds. This was due to her vital organs needing the best oxygenated blood and the stomach was that last to get good blood. This is some of the same now, except her low blood pressure is the problem. It is not allowing good profusion to the kidneys to get the adequate blood flow they need to recover and function correctly. Our first line of defense is to flush out the dye used in the angiogram and second would be to adjust medication to increase blood pressure. After rounds, the word dialysis was floated by as a last resort to help the kidneys. At first it sounded like we were days away from this. Dr. Nater did everything we could to rid Lucy's body of fluid, even placing a third chest tube, but around 6 pm she came into the room to tell us they were going to start dialysis. CRRT (continuous renal replacement therapy) is used to treat critically ill patients who develop acute kidney injury. The blood is removed from the body, waste is filtered, then replacement fluid is added and returned to the body. To start we were only filtering but as Lucy is able to handle we will slowly start to remove fluid to help with the effusions.
Our plan for the next few days is to slowly remove as much fluid as we can from her body. Once we get to a point where we can successfully extubate, we will bring her off sedation and take out the breathing tube. My hope is that can be done by this weekend. The dialysis has thrown a curve ball at our dosing of pain and sedation, so we continue to manage and increase as she shows signs of waking up or pain. I believe we will also be on dialysis for another two days. While we are seeing the creatinine normalize, her kidneys still need time. Following that we will start to look at chest tube drainage and then finally move on to revisiting fenestration. Luckily we are showing no signs of impact to her heart.
I have asked if we should be concerned about her recovery and their response was that they feel she will make a full recovery, but it will be very slow. I have a feeling we will be here through the end of June and into July.
Our plan for the next few days is to slowly remove as much fluid as we can from her body. Once we get to a point where we can successfully extubate, we will bring her off sedation and take out the breathing tube. My hope is that can be done by this weekend. The dialysis has thrown a curve ball at our dosing of pain and sedation, so we continue to manage and increase as she shows signs of waking up or pain. I believe we will also be on dialysis for another two days. While we are seeing the creatinine normalize, her kidneys still need time. Following that we will start to look at chest tube drainage and then finally move on to revisiting fenestration. Luckily we are showing no signs of impact to her heart.
I have asked if we should be concerned about her recovery and their response was that they feel she will make a full recovery, but it will be very slow. I have a feeling we will be here through the end of June and into July.
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