Lung Infection and Narcotics

When we arrived Saturday morning, Roscoe was not the calm, happy baby that we'd come to expect over the past few days. The baby we found was the fragile, unstable baby who came to UCSF roughly a month ago. It was like the bad kind of time travel where you go back to see yourself during your awkward middle school years, but are powerless to prevent yourself from getting the ultra-wedgie that haunted your social status through high school.

Roscoe's heart rate had stayed relatively high through the night, and when we arrived it stayed over 190 for several hours. It took several narcotic adjustments to bring him down. Even then, his oxygen saturations were very touchy with breathing support bumped all the way to 100% oxygen (it had been down to 50%). The slightest change caused Roscoe's saturations to drop significantly. He was manually ventilated for an hour or two over the course of various spells throughout the day as he struggled to maintain adequate oxygen in his bloodstream.

During one of his periods of instability, the team struggled to get an x-ray taken of his lungs to see if anything had changed. Luckily they were able to briefly leave the room to take the x-ray. They almost zapped it with the respiratory therapist still in the room. The result is shown below:

On the left is an x-ray from Friday and on the right is the x-ray from Saturday. By comparing the two you can see two major differences (and "one is bigger" is not one of those differences). First, there was a large amount of air in his stomach, which is evident based on the lower right area of his stomach being transparent. They resolved this by venting the air from his stomach using his g-tube. Second there is a patch in his right lung (shown on the left side of the picture) which wasn't there Friday. This indicates a lung infection in the good lung and explained his instability. They immediately started antibiotics to counteract the infection.

Red arrow is lung infection

Blue arrow is air in stomach

All told, here are the narcotics and other treatments that Roscoe got today. It is a staggering list for such a small baby. The narcotics he was already regularly receiving were:

• Fentanyl (pain reliever)
• Midozolam (sedative)
• Dexmedetomidine (sedative)
• Bosentan (lung vessel growth)
• Tylenol (pain reliever)
• Pentabarb (sedative)
• Remodulin (lung vessel growth)
• Albuterol (lung expansion)
• Lasix (diuretic)
• Aldactone (diuretic)
• Nitric Oxide (lung vessel dilator)
• ... then all of the usual stuff like oxygen, potassium, IV nutrition, vitamins, etc.

New narcotics that they administered today for either specific circumstances or started as new constant drips were:

• Vecuronium (paralytic)
• Morphine (pain reliever)
• Zophran (nausea)
• Milrinone (vessel dilator)
• Piperacillin (antibiotics)
• Vancomycin (antibiotics)
• Dopamine (vessel constrictor, not given but connected to his IV)

Most of the day was very stressful, with Roscoe setting off alarms. Around 5pm he started showing more stability and a lower heart rate, and then around 8-9pm he seemed much more stable with oxygenation staying in the high 90's. By the time we left, we got to see his smile which we hadn't seen all day:

Roscoe's arterial line also went bad, but the lead doctor today inserted a new line into the artery in his left underarm. If you want to wriggle in your chair, think about someone inserting a needle into your armpit and leaving it there. The good part is that this freed Roscoe's right hand which had been taped for the past week. It was a little queasy watching them remove the line, because right when they thought it was loose they discovered it had been stitched to his hand for stability. Once they got it free and washed his hand clean, he was very happy to have both hands back:

His right arm is under a warming pad because the artery was agitated after removal

We are hoping that tonight will be a period of recovery which returns him to the good spirits and stable health that we've seen for the prior few days. The antibiotics should take effect within 24 hours, however if the lung infection persists then it would compromise the open heart surgery by jeopardizing his stability. If that's the case, his surgery would most likely be postponed.