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*December 29th 2014* Sabrina is in tremendous pain today, She is slightly communicative and responsive and she winces with the slightest touch or movement, Her parents discussed this with the team and a plan was put in place to address that pain, Her abdomen has become very swollen, She has an open abdomen with a wound-vac in place and a divided intestine, (Not in continuity), Surgery has talked to the parents about putting a stoma in place and possibly closing the abdomen, This should help with the abdomen swelling and pain as well as getting Sabrina's small intestines working again, So an ileostomy will be done today, Also Sabrina is having a difficult time weaning off her ventilator and ECMO support and they are concerned that there may be more mucous plugging in her airway's, therefore they will do another bronchoscope, Surgery began the procedure by removing the vac-pac (Negative pressure dressing) and washing out her abdomen, There was a small amount of blood clot underneath the dressing noted, Then surgery visualized the small intestine and identified an appropriate location on the right anterior abdominal wall for the stoma, They removed her skin and dissected down through the fascia of the anterior abdominal wall,, Then pulled her small bowel up through the abdominal and ensured there was no twisting or kinking of her distal small bowel, Then secured her small bowel to her anterior abdominal wall in 3 separate locations using Vicryl suture's, Then opened her intestines externally and matured the stoma using Vicryl placed in 4 separate locations, Then they ensured adequate hemostasis and ensured thet her ascending colon was very near the fascia opening of her end ileostomy, They then placed the vac-pac(Negative pressure dressing back on Sabrina's abdominal wall, There were no known complications noted.
They then performed the bronchoscopy , they placed the bronchoscope down the left and right side of the main-stem bronchus they clearly visualized that there was no evidence of significant mucous, Then withdrew the brochoscope without causing any bleeding.
They then performed the bronchoscopy , they placed the bronchoscope down the left and right side of the main-stem bronchus they clearly visualized that there was no evidence of significant mucous, Then withdrew the brochoscope without causing any bleeding.
*December 30th 2014* Sabrina has been on ECMO 9 days now and it is very important to try and wean her off before blood clot's and fibrous strands start forming in the tubing and filters of the ECMO curcuit, If they have to build a new circuit it will set Sabrina back immensely and despite all the horrible and intense treatment's she has gone through she is making slight progress in many area's, Sabrina had her first trial off ECMO this morning and she immediately desaturated (low blood oxygen concentration) and increased WOB (the effort required to inspire air into the lungs), They changed her vent over to conventional mode/assist control and tried again at 8:00pm, Under huge stress and completely terrified, Sabrina was able to tolerate 30 minutes off the ECMO circuit, However again having increased WOB, And through the night she had increased PIP's (Peak inspiratory pressure).
*December 31st 2014* Sabrina is resting her lung's today, There is growing concern about drainage from her right femoral site(where they removed her VA ECMO cannula's) So dressing was removed inspected, The area was cleaned and a new dressing placed.
Critical care problems list
*January 1st 2015* Sabrina is on day 11 of ECMO on the same circuit, She had another trial off this morning but was not successful due to O2 requirement and CO2 retention, (failed in 10 minutes.) The doctors want to give her 48 hrs of rest vent settings before attempting another trial off unless her needs for FiO2 decrease significantly, Sabrina has a large volume of bloody drainage from around the now nonfunctional abdominal wound-vac, She is now needing another surgery, They removed the wound-vac and cleaned up an immediate return of fresh blood, They packed her ostomy with lap pads to isolate it from the abdominal cavity, They then irrigated a blood clot out of the abdomen and identified a pumping bleeder from a cut edge of left rectus, This was controlled with suture ligature, They then controlled minor scattered additional areas of oozing with electrocautery, Sabrina's gallbladder was noted to be tense and distended, Her liver tense and swollen, No infection or abscesse's were seen, They placed new ostomy appliances and controlled oozing at the base with fibrillar surgicel, They placed a new wound-vacuum dressing on her that had suction with a good seal. Her postoperative Diagnoses was; Arterial bleeding from pumping vessel in abdominal wall left rectus muscle and moderate intrabdominal hematoma; Tense edema of liver and gallbladder; Mild/moderate edema bowel, She lost about 300 cc of blood (most of which was already in her abdomen before surgery), This was sweet Sabrina's first day of 2015.
*January 2nd 2015* *Day 12 ECMO*, Sabrina is on rest vent settings in hopes of being able to wean off ECMO before the circuit needs to be changed, There are clots in the oxygenator as well as connection sites on the venous side of ECMO cannulas, If she cannot wean off before they need to change the circuit it will be a huge setback, She also has an acute kidney injury so CRRT (Continuous renal replacement therapy) was initiated, They hooked up a dialysis machine and tapped it into the ECMO circuitry.
**Sabrina has endured and fought through so many painful and terrifying procedures,surgeries and care's at this point and her fragile little body has taken a beating, Time is running out on the current ECMO circuit and The tension and fear is very high,** "A miracle is needed"
*January 2nd 2015* *Day 12 ECMO*, Sabrina is on rest vent settings in hopes of being able to wean off ECMO before the circuit needs to be changed, There are clots in the oxygenator as well as connection sites on the venous side of ECMO cannulas, If she cannot wean off before they need to change the circuit it will be a huge setback, She also has an acute kidney injury so CRRT (Continuous renal replacement therapy) was initiated, They hooked up a dialysis machine and tapped it into the ECMO circuitry.
**Sabrina has endured and fought through so many painful and terrifying procedures,surgeries and care's at this point and her fragile little body has taken a beating, Time is running out on the current ECMO circuit and The tension and fear is very high,** "A miracle is needed"
*January 3rd 2015* Sabrina after being on the dialysis (CRRT) machine for only 7-8 hours had something happen about 4:00am, The dialysis machine is thought to have pulled sedation and pain medication's from her body and cleared her mind a bit and although she was in a state of delirium, She woke up mad and in pain, It was without question the most she had moved or had reacted since being in the P.I.C.U. She raised both her arm's, lifted her head, opened both her eyes and was looking around the room, Sabrina was able to wean off ECMO with a successful clamp trial 4 hours later, The surgical team was called in to remove the ECMO cannulas in her jugular vein and put in a temporary dialysis catheter in the same location as well as wash out her abdomen and replace the wound-vac dressing the surgery went well with no complications noted, Sabrina was 13 days on ECMO and weaned off the day they were considering changing out her circuit, "Today a true Miracle was witnessed".
*January 4th-5th 2015* Sabrina has multiple wound cares done on her neck site where the ECMO cannulas were and the dialysis catheter is currently, also on her ostomy where it has been oozing, and so many other skin tears, She did not go on CRRT Dialysis due to adequate output, though an 11.5 french Dialysis catheter is in place and is currently heplocked.
*January 4th-5th 2015* Sabrina has multiple wound cares done on her neck site where the ECMO cannulas were and the dialysis catheter is currently, also on her ostomy where it has been oozing, and so many other skin tears, She did not go on CRRT Dialysis due to adequate output, though an 11.5 french Dialysis catheter is in place and is currently heplocked.
*January 6th 2015* Sabrina has had an open abdomen for 18 days now combined with right groin venoartrial ECMO as well as right neck venovenous ECMO , She has now been completely decannulated and has somewhat stabilized clinically, She is now ready for a abdominal wall closer, The surgeon proceeded to eviscerate the small bowel he identified multiple pockets of clear fluid inside the abdominal cavity and washed all of these pockets out, Then inspected her liver and it appeared congested but otherwise normal and healthy, Then was able to evaluate her gallbladder which appeared pink and healthy, There had been some concern that she may need a cholecystectomy (removal of her gallbladder), Given her dropping of total bilirubin as well as the appearance of her gallbladder they elected not to perform either a cholecystectomy or cholangiogram (Radiographic examination of the bile ducts), However given the need to eventually provide GI continuity they secured and stapled the end of the hartmann's pouch to the fascia at the site of her end ileostomy, Then washed out her abdomen with saline and closed the fascia with a series of running and interupted stitches, Then placed a negative pressure dressing the entire length of the incission that was approxiamatly 25 cm x 2 cm x 1 cm, connected to the wound-vac, Surgery went well with no complications noted.
*January 7th-8th 2015* Sabrina tries to rest when she can, She also is becoming more alert although still has some delirium, She has Lot's of wound cares done for her right neck,right groin and stoma/wound-vac area and skin tears.
*January 9th 2015* Sabrina gets her Dialysis catheter removed due to better output and lab test's, But not without showing P.I.C.U. team and surgeons they should always take precautions when doing procedures on her, They thought it would be a simple pull of the catheter and hold pressure on the vein for a few minutes till the bleeding stopped, Not so, The surgeon came up to Sabrina's room and pulled out the catheter applied pressure but it would not stop bleeding,They kept checking it periodically for well over an hour, They had no suture's ready and really didn't have the necessary instruments needed to close an open jugular vein, , Urgency set in quick, the operating room was notified and the nurses began gathering up and getting everything ready to go down to the O.R. which took a while in itself to do, The team was ready to go when another surgeon showed up, Had the other surgeon lift pressure off of her vein and it had slowed immensely in just a few minutes, from a gushing vein to Almost nothing,
"Another miracle witnessed today" (continue to next page)
