Tag Archives: patent ductus arteriosis

the eric update – day 44: almost closed pda. bugs? and more bugs?

day 44: do not reuse

i think eric is enjoying dragging out the drama of doubling his birthweight. he was up 10 grams today, topping the scales at 1270 grams or 2 pounds 12.8 ounces.

we finally received word on his patent ductus arteriosis and it’s almost amusing – it’s not closed, but it’s not open wide enough to warrant additional measures to try to close it. although everyone seemed quite confident that it would close on its own, it’s still slightly disconcerting to not be able to give a definitive answer to the innumerable questions regarding the status of the hole in his heart. i didn’t follow up as rigorously as i might normally as to why they weren’t going to pursue another round off indomethacin simply because everyone seemed so confident that the hole wasn’t big enough to have any physiological consequences and that it would close on its own accord.

day 44: tubes in tent

unfortunately, i don’t have any good an answers as to what may or may not be the source of his sepsis ( if, in fact, he does have a blood infection ). remember, they caught a gram negative bug in a blood sample that was being used to determine if he had a yeast infection. they’ve been having trouble determining the exact type of bug in the sample because, as a person from “infectious diseases” said today – “fungus is funky”. in other words, they are trying to grow enough of the bacteria to allow identification in a media that was meant to grow fungus and it’s not working well. all you armchair microbiologists in the crowd could perhaps speculate as to why they can’t transfer the small amount of the bacteria they did find into a more suitable media. then again, i might have some of the details confused so it might not be worth your effort. luckily they haven’t found any bugs growing in any other samples they’ve drawn, so all this might be much ado about nothing.

we also received the results from another round of “trach aspirate” tests, which indicate if he has anything growing in his trachea ( being intubated on the vent greatly increases the chances that strange bugs will grow in his trachea ). six days ago, they discovered small amounts of enterobacter and klebsiella growing in his trachea and today they said the bugs were still there, despite being on antibiotics for nine days. the staff seem to not be overly concerned about the bugs sticking around for now. things might be different if they are still there after they finish the antibiotic regime, which will last for about 6 six more days.

oh. and his arm was quite red around the entry point of his IV line, which would strongly indicate that a superficial bacterial infection was starting. they moved the line and applied a topical antibiotic which will hopefully prevent any further complications.

i was joking with the nurses that i didn’t have any of these problems with bugs when i was a 26 weeker, 32 years ago, and that one couldn’t help wonder whether or not eric IV had the misfortune of finding himself in a “dirty” unit ( really, it was all in good humor ). aside from being continually astounded that i survived the ordeals of being a micropreemie in 1972 ( indeed, one nurse commented that when she started in the nicu at about that time, they would have never tried to save a 28 weeker, little less a 26 weeker ), the nurses all remind me that we can thank indiscriminate usage of antibiotics for causing all the “bug” problems that are seen in the modern nicu.

so think about the micropreemies the next time you jump for the medicine cabinet to grab an antibiotic for a minor ear infection.

the eric update – day 43: readin’, feedin’ and nicu noise.

day 43: creased palm

another day of quiet recovery, which is a good thing these days. slightly frustratingly, we still haven’t heard the results from the echocardiogram which will tell us if his patent ductus artierosis has closed, but his blood gasses are so good that i think everyone is assuming that it’s closed. also, they are apparently having trouble determining what the bug was that showed up in one of his blood samples and haven’t been able to find any more of it, so it’s likely that we’ll never know for now if it was contamination or is simply lurking in the background at undetectable levels while he’s on the antiobiotic regime. or maybe it’s gone for good.

day 43: feeding again!

they started eric’s breastmilk feedings again, which means that they are getting more confident that he’s recovering from his recent “troubles”.

technically, they aren’t really feedings as they are giving him such a small amount – only 1 cc every 3 hours, but it’s a start. rather than sending the food directly to his intestines via an “o.j.” ( oral to jejunum ) tube, they’ve decided to see if he’s can tolerate sending the milk directly to his stomach via his “o.g.” ( oral to gut ) tube. this is another small sign that they believe he’s getting stronger, despite his pneumonia.

day 43: ear clasp

the nicu is packed these days and when it gets packed it gets noisy. it’s a small nicu with only 15 beds, but it’s a small space and can get quite crowded when all the beds are filled, if all the babies have visitors. there’s and ebb and flow to visitors and during peak hours it the constant din of conversation and bells ringing can make it sound like a surreal cocktail party.

if you’re paying attention when it’s noisy, you’ll notice eric sending little signs that things are getting too loud, such as grasping his ear tightly in an attempt to block out the sound. subtle signal, no?

day 43: jonathan livingston seagull. I.

kris finished reading eric jonathan livingston seagull. he liked it a lot.

“poor fletch. don’t believe what your eyes are telling you. all they show is limitation. look with your understanding, find out what you already know, and you’ll see the way to fly.”

day 43: jonathan livingston seagull. II.

the eric update – day 41: closed pda? a bigger diaper and growth curves.

day 41: the fuzz keeps growing

eric received his round of indomethacin to treat the recurrence of patent ductus arteriosis, but we won’t have any decisive answers as to whether or not the hole in his heart has closed until monday; there’s only a small number of people who are skilled in doing the diagnostic echocardiogram on micropreemies and, apparently, they don’t work on weekends. it’s actually a good sign that the nicu staff don’t feel the need to call the technicians in for an emergency procedure, since it means that they think that the hole has closed. eric’s blood gasses have improved and his need for supplemental oxygen has decreased to 22-24%, which is almost the same as room air. also, none of the nurses can hear the characteristic “murmur” that they’d expect to hear with pda, so everyone is fairly confident that the hole has closed quickly in response to the medicine. good news!

as for the sepsis, we won’t know anything definitive for quite some time. we’ll probably know tomorrow exactly which bug is causing the problems, but that knowledge won’t change his treatment protocol. as i stated yesterday, eric will be on antibiotics for a full 15 days in an attempt to beat the bug into submission. however, we learned today that it’s likely that they won’t get rid of it completely and they will probably change tactics after 15 days and move towards a protocol that involves giving him short, sharp bursts of antibiotics. it’s a delicate balance, as giving eric a continuous feed of antibiotics obliterates the good bugs along with the bad; and dampening his natural immune capability increases the chance of eric getting a systemic yeast infection, which is really, really difficult to get rid of and can cause all matter of ugly and unspeakable problems. so for now, all we can go is hope that he continues to respond as well as he has to the current protocol. the good news is that his overall immune system profile is excellent, so we can only hope that it stays that way.

day 41: mama takes over the weigh-in. I.

we haven’t been able to hold eric as he’s been back on the vent while he’s fighting pneumonia, but the nurses cleverly found a way to let kris sneak in a little touch time by letting her put him on the scales for his weigh-in. eric’s nicu nurses are so incredibly thoughtful and considerate that it really is impossible to imagine how to properly convey the gratitude we felt at the kind gesture.

also, we talked with his caregivers for quite some time about how long he’d be on the vent and the possibility that he’d suffer from the negative side effects that are known to accompany the vent, including respiratory distress syndrome. luckily, eric’s vent settings are at the lowest that they can be and, while nobody can predict the future, they don’t think he’ll suffer any adverse consequences from being on the vent.

day 41: mama takes over the weigh-in. II.

eric tipped the scales at 1170 grams which is just over 2 pounds 9 ounces. that’s right he gained just over 3 ounces, despite battling pneumonia and sepsis.

day 41: mama takes over the weigh-in. III.

they say that every baby excels in one area of development and eric seems to be doing great with gaining weight. some of the gain can be attributed to water retension, but i think much of it is real. speaking of weight gain, eric also graduated into a new, bigger diaper! his previous diaper was only appropriate for babies at or under 1200 grams, so he’s crossed quite a milestone.

day 41: a new, bigger diaper!

the new diaper looks amusingly large on him, but with any luck he’ll quickly grow into it.

day 41: growth curves

while we’re on the subject of gaining weight, it’s interesting to note that eric is following the “normal” gestational growth curve as if he were in the 10th percentile. in other words, if he were born today, his weight would be in the 10th percentile of all babies born. not bad for a guy who’s been out of womb for nearly 6 weeks.

the eric update – day 40: return of the patent ductus arteriosis. and sepsis.

day 40: return of patent ductus arteriosis

eric seems to be having a tough time catching a break this week. the doctors determined today that the hole in his heart, called patent ductus arteriosis has returned after being closed a few days after his birth.

the hole can reopen due to stressors, such as pneumonia, so it’s more normal than not that it has reopened. he’s still a micropreemie, so his body thinks that the hole should be open as it would be in utero; whenever something stresses his system, his body forgets that it’s been tricked into thinking the hole should be closed and it opens. the treatment strategy will be the same this time as last time, as eric will get 3 treatments of indomethacin at 12 hour intervals ( dose one at time zero, dose two at time zero plux twelve hours, dose three at time zero plux twenty four hours ). after 24 hours he’ll get an echocardiogram to see if the medicine closed the hole. if the hole hasn’t closed after the first round of treatments, they’ll try a second round and then maybe a third. if it hasn’t closed by the third round of treatment, then he’ll need to be transported to a different hospital for heart surgery.

day 40: he's mad!  yay!

eric responded excellently to the indomethacin the last time we went through this and there’s no reason to expect that he won’t do as well this time, despite having pneumonia. however, it’s impossible to tell for sure before he gets the echocardiogram, late saturday or sunday. although his risk for brain hemorrhage is less with this incidence of pda than it was immediately after birth, it’s not zero and, unfortunately, indomethacin itself can increase the chance of a “bleeder”; so, hopefully it will close as quickly in response to medicine as it did last time, because as a general rule, the less holes one has in their heart the better.

it’s good to see him getting mad again. it’s a little tought to tell from the picture, but his face is turning bright red and he’s trying to push my hand off him. if he wasn’t intubated, he’d likely be testing his vocal cords.

last week he started getting less mad and we thought it was just because he was content. really, it was because he was getting sick. having enough energy to get mad means that he’s getting better.

and check out that double chin. that’s the micropreemie version of getting chubbby.

day 40:  eyelashes

lab results from today also indicated that eric officially has sepsis, or a bacterial blood infection. while running a test to determine if he had abnormal amounts of yeast growing in his blood ( he didn’t, which is good ), they were surprised to find that he had gram negative bugs growing in the culture. considering that just a few days ago, they found two gram negative bugs, enterobacter and klebsiella, growing in his trachea, one would tend to immediately suspect that one or both of them was the suspect bug in his blood. since the bugs were nosocomial, or hospital derived, there’s always the chance that things could get Real Bad, Real Fast; we had hoped that they they’d remain pleasantly colonized in his trachea and not go invading the rest of the system, but unfortunately it looks like the bugs had different plans.

the good news is that eric appears to be responding to the antibiotics that are being given to help him fight the bugs. initially, they were going to give him a 7 day “short course”, but now with the sepsis diagnosis, they are going to continue to give them to him for 14 days. if he continues to respond the way he has been, then this will all be an interesting sidenote, but if not, things could get very, very nasty.

if you’ve continued to read this far, it might be tough to keep a proper perspective, so i’ll summarize the summary. the pda is “normal” and if it closes quickly, there’s little risk of complications due to a “bleeder”. we’ll know within 24 to 36 hours if it has closed quickly. eric’s white blood differentials show that he’s responding well to the antiotic regime for the gram negative bugs that are doing their best to cause him great grief. if the antibiotics continue to work as well as they have been over then 14 days, he’ll probably come through just fine, but if not – well – things won’t be so fine.

despite everything, eric isn’t losing weight and, in fact, gained 5 grams for a grand total of 1080 grams or just over 2 pounds 6 ounces, which is quite a feat for somebody on intravenous fluids and spending all his energy on fighting infections.

the eric update: he’s no wimpy white boy

eric's home address

on a day that statistics will tell you will probably be a bad day, we received some great news! at noon, we found out that the hole caused by the patent ductus arteriosus (pda) had closed in response to the medicine they gave him over the previous 24 hours. so, at least for now, there doesn’t appear to be any reason for him to get transferred to a different facility for surgery. he also has a greatly reduced risk for a class IV “bleeder” ( our neonatologist’s term for a brain hemmorage ). one of the side-effects of pda is that it sends five times more blood to the brain than is actually necessary, which in turn stresses the brain vessels. he’s still at risk for a bleeder, but much less so.

speaking of brain hemmoraging, when our neonatologist was explaining the effects of pda, he took the opportunity to launch into a discussion of bleeders. it turns out there are four classes of them, with ‘class one’ being not visible with the naked eye and not typically associated with negative outcomes and ‘class four’ being visible through the scalp and often fatal. in what was one of the many conversations we’ve had over the past few days that can be quite disorienting, we found ourselves listening to him calmly tell us that he probably wouldn’t even bother telling us about class one or two bleeders, as he’d end up driving us insane with that much detail.

the machinery

there are many other physiological consequences of the ductus arteriosis closing , the most notable being that they can reduce the percentage of oxygen that he’s getting via the ventilator. we normally breath air that has 20 percent or so of oxygen. for the past few days, eric has been getting anywhere from 30-60% oxygen. after the duct closed, they were able to move towards a schedule of letting him breathe ambient air with occasional enrichments of oxygen. also, they have been actively managing his blood pressure with dopamine and his blood sugar with insulin and they’ve stopped both of those treatments. later in the day, they also told me that they stopped giving him antibiotics to reduce the risk of infection. these are all stupendously wonderful signs that he’s stabilizing and setting himself up for the long haul. of course, he’ll still have bad days and downturns, but things are looking positive.

as donna, eric’s nurse today, was giving me an update about the pda and how good things were looking she stopped and laughed, “you know – he’s not a wimpy white boy!” she went on to explain that, when compared to other races, white male micro-preemies ( a technical designation for preemies that are born less than 26 weeks in gestational age and weigh less than 1 pound 11 ounces ) typically get more sick, have more bad days and have longer hospital stays. “i’ve been doing this for over 20 years and i don’t think i’ve ever seen an explanation for it. but lil’ eric ain’t no wimpy white boy. and that should make you very happy.”

day 3: and yet, he moves.


unfortunately, kris is still not progressing as quickly as she’d like and she’s three days post delivery, which means perfectly natural post-partum emotions are beginning. a bad morning was made worse when the nurses told her they didn’t want to even try to see if she could make it down to see eric, given her current condition. she’s still at an increased risk for a seizure if she has too much sensory stimulation, so they want her to have another day of quiet rest.

her blood pressure is still dangerously elevated even after starting an additional blood pressure management medicine; her platelets has also been down throughout the day, while her liver function is elevated, all of which are trends in the wrong direction. it’s nerve-wracking to anticipate each new lab result and continually discover that she’s not only not stabilizing, but technically getting worse ( although thankfully she’s not in any pain ); however, the doctor reassured us that she’s not atypical for cases of severe preeclampsia such as she developed. he expects her to have another day or two of trending in the wrong direction, followed by a gradual normalization process. first her kidneys will start working more efficiently, followed by better liver function and finally her platelets will go back up. he said her kidneys are looking better, so we’ll patiently wait for the others to follow.

her doctor also gave us a little more information about the specifics of her case. about 10 percent of preeclampsia cases have similar etiologies and, as we discovered, if the baby isn’t delivered immediately it will die and the mom will quite likely die. to highlight the point, as a consequence of the disease process, kris’ placenta had become 30% calcified over a very short time ( possibly 24 hours ). had we waited even a short period of time to go to the ER, the placenta would have become completely calcified and eric would almost definately have died from a lack of oxygen. it’s also more likely than not that an undiagnosed underlying condition will be found that is known to amplify the effects of the preeclampsia ( essentially “causing” the severe “10 percenter” cases ); so, after everything settles down, they will start testing her to see if they can find the root cause.

day 3: kris gets solid food!

amidst all the disappointing lab results, kris is feeling better and making other important signs of progress. she’s started to regularly produce milk with a breast pump, which is getting stored down in the nicu ( neonatal intensive care unit ) for when eric is stable enough to start feeding. she also had her first solid food today, after days of nothing but an IV and the occasional juice. she happily enjoyed what would have otherwise been a bland cheese sandwich. and she also had her catheter removed! if you’ve ever had a catheter, you’ll understand why this made her very happy.

update: later in the evening kris finally got her first set of postive lab results and her blood pressure, while still high, seems to be gradually trending downward. her results are promising enough that they aren’t going to pester her every few hours over the night to draw blood and it looks like she might have a realistic chance of seeing eric some time tommorrow.