Forward and Back

Andrew had a great morning, and was already at minimal ventilator settings when we arrived. He was getting twelve breaths per minute at 29% oxygen, and they had even increased his feedings to 4cc per hour. He was resting comfortably and saturating well; when awake, he was smiling and looking around. He's gained some weight, and is now at 5.2kg (11 pounds, 7 ounces); he's also 22 3/4 inches long. The only minor annoyance today was a tiny bit of baby acne...he has a tiny rash (complete with pimples) where the CPAP tubes were rubbing on his face, just below his eyes. They didn't want to put him on anything for it (like topical hydrocortisone) because he's already on so much...but it wasn't a big deal at all.

Then, about twenty minutes before we got kicked out for shift change at 6:30pm, I noticed that there was some water in his vent tube. It wasn't going down his throat, but was collecting in the larger tubes next to his head. The nurse was in the middle of getting some new lines ready (they have to replace the plastic tubing on most of his IVs daily) but said she would take care of it when she was done. Apparently there was more water than either of us knew, because as soon as she went over to switch the IV tubing and empty his vent tubes, the water made it up the smaller tube and into Andrew's mouth.

I don't know how much actual water made it in, though I don't think it was an extremely large amount. However, it was just enough to cause some other problems. First, it blocked his breathing tube so he started to desaturate a bit. Then it made him cough, which caused him to bear down...he may have also been trying to go to the bathroom at the same time. The nurse suctioned him through the tube, trying to get some of the water out. We can only guess at exactly what happened next, but we think some combination of coughing, clamping down, being suctioned, and not being able to breathe well stimulated caused him to "vagal himself." I had heard this phrase bantered about the NICU before, but I had always heard "that kid bageled himself," which didn't mean a whole lot to me. In reality, it refers to an unhealthy stimulation (pinch, tweak) of the vagus nerve, which transmits between the brain and several important organs (lungs, stomach, heart, etc). This stimulation caused him to drop his heart rate, lower his saturation, and vomit...all at the same time.

It was a scary few minutes, but he was quickly under control. His heart rate came back up on its own before it got low enough that CPR had to be involved, and the process was extended because his pulse oximeter (measuring his oxygen saturation) couldn't get a signal. Even though his color was normal again (he showed a hint of blue for a second), they gave him manual breaths ("bagged him"), suctioned him again (carefully), and propped him up on his side in case he vomited again. He was stable before we had to leave, and has only gotten better since, but it wasn't a great last impression on our way out the door.

For now, they've canceled the sprint they had just planned for tonight and postponed his feedings until tomorrow. Assuming he has a calm night (and there's NO reason to think that he wouldn't), they'll re-evaluate in the morning and probably restart everything. His numbers are already back down to where they were this morning, so it's just a matter of getting his food turned back on and starting the sprints. I don't think this is a major setback....just another indication of how fragile he is, how important breathing is for all of us, and how hard it is to breathe underwater.