Moving Forward

Andrew's having a really good night so far. He's on high settings, but they didn't really see much reason to tax him unnecessarily, so it's okay that they're taking it slow. The current priority is getting his stomach surgery, which has now been scheduled for Tuesday morning. That should allow him to get up to full feed volumes without worrying about aspiration. Without that worry, they'll be able to focus on his ventilation and trying to get him back to minimal settings for extubation.

He's definitely on pretty high settings, but he seems very comfortable and has been getting good test results again. It's almost unfortunate that he's doing so well on extra support....we'd much rather have him doing this well on minimal support as he was last week....but there's a lot that's been stacked against him recently. The problem could stem from any or all of the following:

• Infection. They've restarted his antibiotics, two of which had been discontinued, just to rule out the possibility of infection. His white blood cell count and blood protein count don't really point to an active infection, nor does his behavior, but it's best to be careful.
• Micro-aspiration. Since he hasn't obviously spit up in the last week or so, they've slowly been increasing his feeds. They were up to 20cc per hour, which is more than double where he has been. This introduces the concern that he may be spitting up small amounts that never make it out his mouth, but are instead inhaled in tiny amounts. Since he's getting the stomach surgery on Tuesday that should prevent any future reflux, they decided to play it safe and take him back down to 8cc per hour. He's responded well to the change, but it's difficult to pin the improvement to anything specific.
• Self-induced distress. Andrew is definitely much stronger than he was a few weeks ago. He's shown that by moving his arms and legs much more, but he's also been able to get upset in a more dramatic fashion. He's once again able to clamp down when upset, preventing good airflow and causing himself problems. Since he's been a little more uncomfortable recently (for various reasons), he's making things worse by getting upset about it. They've upped his Ativan and Methadone dosage to compensate for his increased size, and are being a bit freer with as-needed doses of stronger medications.

Whatever the reason, there's no reason to push him too hard right now, since he'll be well-sedated for the surgery on Tuesday. After that, they'll start to wean his settings back down.....if the problem was micro-aspiration, he should respond much better post-fundoplication.

I'm getting back to work today and tomorrow, and next week is already looking crowded for both of us. The fires are still threatening areas in northeastern and southeastern San Diego, but the western edges seem to be well under control. There will be challenges during the next windstorm, the first rain, and the rest of the fire season, but we were very lucky that the weather decided to cooperate.