Day 11 - ICU, 7pm

Transitioned to Trickle Feedings via NG Tube

   Bob's still receiving the TPN IV nutrients in his Central Line. But now they've added the trickle feedings to begin working his digestive system. A "vanilla shake" is trickled into his stomach via a pump that sends it through his NG tube. It is administered at 15ml per hour...that's only one tablespoon each hour.

 

Extubated!

    This morning's chest Xray looked remarkably better. Because the fluid was greatly diminished, they tried a breathing trial this morning, but Bob was unable to breathe well enough on his own. So they changed the vent from forced air to only pressure support and let it assist his own spontaneous breathing for six hours, and by this afternoon, Bob passed the second trial and was finally able to have the ventilator tube removed!
    He's still on nasal cannula oxygen, but extubation was a huge step towards advancing him to the next steps in his care. All pain meds are now being given through his NG tube, not his IV, so he will have longer periods of pain relief and hopefully less drowsiness and more lucidity.

I'll leave you with this:

(please pardon my vertical video - 

I'm running low on sleep and was quite overcome with emotion)

Day 10 ~ ICU, 7pm

Lung Fluid
   - This morning's chest Xray showed another increase in the fluid both at the base and the top of Bob's right lung. They pulled another sterile sputum specimen to culture for bacteria. He has had no spike in fever (still having a steady reactive fever at 38.3C/101F) so they really do not think it is pneumonia. They're pretty sure it is third-spacing fluid that is still lingering in the lung, and since he is already on high amounts of antibiotics, they're not going to change anything unless the sputum culture grows bacteria.

Third-Spacing Fluids
   - They gave him another round of diuretics (Lasix) today to try to remove more of the excess retained fluids. Along with the increased fluid in his lung, it is also still present in his abdomen and lower body, especially his calves and feet. If there isn't enough reduction in the chest fluid tomorrow after today's diuretic, they will run another course of the Albumin protein to try to pull some fluid back into the capillaries.

Extubation Attempts   
   - Tried two different spontaneous breathing trials today with the goal of weaning off the ventilator. First attempt in the morning led to almost immediate de-sats (drops in adequate oxygenation) and after a few minutes they reinstated the vent back to 35% forced air. 
   - During the second attempt in the afternoon, they moved him from forced air to pressure support only, and he did pretty well until this evening, when he began to have insufficient tidal volumes as pain began to increase. So they are putting him back on forced air tonight (35%) and will start over the trials again in the morning.

Wound-Vac Dressing Change
   - Today was Bob's first wound-vac sponge change that hasn't happened while he was unconscious in the OR.  Watching him experience that pain was indescribable. They finally added back his sedative IV drip (Versed) because his abdominal spasms wouldn't stop after the sponge dressing was removed and replaced. This vac-dressing will be changed every Mon, Wed & Fri, and it will take several weeks for his body to re-grow tissue and close the wound. (The wound itself measures 8" long x 3" wide x 1.5" deep. They refer to it as a defect. It's going to take a good while for his abdominal muscles to be covered and no longer exposed.)

Future Health Care
   There were a few discussions with me today about the path Bob's care will take once he leaves the ICU. He will likely go to a long-term hospital first (like Kindred) and then move to a skilled nursing facility/inpatient rehabilitation hospital (like Sea Pines) after. They've advised me his brain will have to relearn to coordinate his body's muscles, since he has been immobile and under duress (high fevers, blood infection, multiple operations) for this extended period. Some of the initial goals will be:
   * Transitioning from IV nutrition (TPN) to slow-trickle tube feedings through the NG tube, then to full meal feedings via the NG, and then finally to oral ingestion. This transition process could take up to 2 weeks, and might even include him having to relearn how to swallow.
   * Strengthening atrophied muscles with physical and occupational therapy. This doesn't just include gross motor skills like sitting up, standing or walking, it starts with him becoming strong enough to simply hold a pencil, or move a utensil from a plate to his mouth, etc. Right now he struggles to lift up and hold his head from the pillow for more than a minute at a time. Small steps, but at least he's heading in the right direction.
   * Improving pain management: Once Bob's at an inpatient rehab facility, he'll have to be able to take oral pain medications that will last longer periods of time (4 to 6 hours). This morning, his IV pain meds were decreased ever so slightly (Fentanyl drip went down from 250 to 200). But the more awake and less sedated Bob becomes, the more pain he feels. So today they had to return to supplementing the Fentanyl with Dilaudid once an hour, which is a short-term control and can't be a long-term solution.

It's so relieving that Bob is able to open his eyes 
and look at us again when we talk to him.

"We Miss You, Bob!"

What an awesome and thoughtful idea. 

The Aeronix family really must miss Bob, because there's a big photo poster on the wall across from his bed in his ICU room letting him know!

Thank you ~ you guys are great.

Day 9 ~ ICU, 9:30pm

Progress
   - Today Bob began to respond to simple commands (wiggle your toes, squeeze my hand) and he also would open his eyes whenever someone approached him and spoke loudly to him. His awakening is slow following yesterday's surgery, but he's gradually coming around. He can't stay awake or alert for very long yet. 
   - He is now spontaneously breathing 9 breaths per minute on his own, while the ventilator is assisting with the rest. He is back down to 35% oxygen, and hopefully tomorrow they'll be able to dial back the vent even more. Everyone wants him off the ventilator as soon as possible, but they aren't pushing him too quickly and want to do things right the first time around to avoid any backtracking.
  - They did remove the Arterial IV line from his left wrist, and one of the veinous IV lines from the back of his hand. They'll continue to keep the Central Line in his jugular for all of his IV medications and TPN (IV nutrition) as well as the other two IV's he still has.

Concerns

  - Although his heart rate was very good most of the morning (around 100bpm) he again became tachycardic this afternoon and remained so this evening (115-120bpm).
  - His blood sugar was 217 at noon, and 292 at 6pm. It is not being adequately controlled by his body, and they pulled blood for labs today to see if his TPN (IV nutrition) needs to be adjusted.
  - His third-spacing fluid retention was returning, especially in his feet, legs and abdomen, as well as more fluid collecting in both the base and the upper portion of his right lung. They started him on aggressive levels of Lasix today, and thankfully his urine output tripled by this evening. They don't want that belly getting tight. And they don't want to hear "rattling" in his right lung like they did today.
  - Tonight they added another antibiotic to his cocktail, this latest one is Mycamine. So they took away the Vancomycin, but he's back on 3 antibiotics again (Maxipeme, Mycamine and Flagyl). He's been feverish on and off all day (101-102F), so they're concerned about infection creeping up.
  - Pain control was very difficult today. Although they removed his sedation (Versed & Clozapine) they are still giving him the maximum Fentanyl IV drip (250mg) and are now also giving him IV Dilaudid once an hour.

If any of you know me very well, I have never been a rollercoaster rider, especially the ones that go upside down and do loop-de-loops. This rollercoaster ride is worse than anything I've ever ridden at Cedar Point or Six Flags. I'll be glad to leave this theme park and never come back!

This is a bag of Bob's TPN. I think it looks like Gatorade, 

but apparently some people say it makes them think of something else...

😝

Day 9 ~ ICU, 10am

Ventilator
   Vent is back up from 35% to 40% this morning. Today they're going to do a "Spontaneous Breathing Trial" to see if they can begin the weaning process, but as of yet, they're still letting Bob rest. They have, however, discontinued all of his sedatives! He is still receiving the maximum amount of Fentanyl IV for pain management, which is keeping him very drowsy.

Dehiscence
   When a wound ruptures or is separated along a surgical incision line, it's called dehiscence. Right now, that is a concern of the surgeon's, because Bob's layer of muscle that he sewed together yesterday is under stress this morning due to post surgical swelling; Bob's abdomen is very tight. 

   It's a delicate balance they're striving for now, because leaving the ventilator in too long could increase lung fluid, leading to pneumonia and coughing, which would likely cause dehiscence. But weaning Bob off the ventilator too soon could also be problematic, as it will permit Bob to have a greater range of motion and could lead to accidentally pulling abdominal muscle apart. So many what-ifs and if-then scenarios.
   Because they also don't want to chance any coughing that might stem from Bob swallowing, they're waiting another 24 hours before trying to give him any liquids, which will still be passed through Bob's NG tube. Giving the muscle tissue as much time to knit together without any abdominal tearing is the goal.

Antibiotics
   They removed the powerful Vancomycin last night. Today they've added another antibiotic, Maxipeme. They're continuing with the Flagyl for the fungal infection.

Post-Surgery Vitals/Stats
 - Fever: Overnight, 38.6C/101.5F; this morning, 38.1C/100.5F.

 - Blood pressure: Maintaining average of 115/65 without any medical intervention.

 - Heart Rate: Overnight was a bit tachycardic at 115-120bpm. This morning it is down to 100 (normal is 80bpm).

 Resting with a fan running to help keep his fever at bay.

Day 8 ~ Followup Surgery (Operation #4), 9pm

Surgery #4 completed

  Bob's fourth (and hopefully last!) surgery finally took place today, lasting from 3 to 5pm. We had to wait for clearance from the respiratory therapist, since fluid was in the bases of both Bob's lungs this morning. Amazing how much can change in the human body in just 10 or 12 hours; we went from clear lungs yesterday to "junky" lungs today. 
  Biggest news is that the surgeon did reattach the small and large intestines together in today's procedure! Again, he removed a few inches from each end before they were rejoined. He is cautious, because there was still a substantial amount of swelling in the intestinal tissue, but he feels this step was necessary to get Bob moving in the right direction. He was also able to close the abdominal muscle layers, but Bob's skin and underlying (subcutaneous) tissue will remain open, with his body literally healing from the inside out. He now has a wound-vac dressing (covering a 9 to 10 inch vertical opening) that will need to be changed every other day. How long this vacuum dressing will remain depends on how long it takes Bob's body to heal and close.

Big Changes
The next 24 hours could hold many changes for Bob, but the biggest modifications they're shooting for will be: 
  - Remove ventilator: They are beginning to wean him off the ventilator, starting tonight. The quicker his body breathes all on its own, the less his chances are of coming down with pneumonia. Based on the fluid findings in his lungs this morning, the sooner he is vent-free, the better.
   With the ventilator being removed, the sedatives and paralytics will no longer be administered, either. Even with a Fentanyl drip (which he's had since last Thurs), there is going to be a lot of pain over the next several days.
  - Stop Vancomycin: Based on the Infectious Disease doctor's orders, tonight they discontinued the strongest antibiotic Bob has been receiving. This was concerning to me, because we know he's still fighting the blood infection. But it does make sense: The stronger the antibiotic, the more damage it does to the body's own natural flora while it is killing off infection. In Bob's case, a fungal infection has started growing in his abdominal tissue. They have been giving him Flagyl (an anti-fungal) as part of his antibiotic cocktail to try to prevent this, but the Vancomycin was mightier at killing the flora than the Flagyl was at protecting it. So they've removed the strongest antibiotic, but still may add back a lesser powerful one over the next day or two.
    Have I mentioned that the culture also found E-Coli in Bob's wound? Yes, that bacteria exists everywhere in our environment, but if your immune system is compromised because you have sepsis and mega-antibiotics are killing any natural defenses your body may use to fight e-coli, that disgusting bacteria will find a nice spot to settle in and grow. They're confident that the e-coli is no longer a threat, so I'm going to trust them.
   - Transition from most IV access: Specifically, they want to remove the access to Bob's jugular vein via the Central Line. He has had 8 ports traveling into his circulatory system via that large vessel; he even has the line sutured directly into the jugular because they knew it would be used to administer many medications over several days. They can't transition him to oral medications yet, because he still cannot take in anything by mouth, but they will start giving him injections or using just a standard IV line in his hand instead (he actually has 4 IV sites right now, in addition to the Central Line and the Arterial Line). With most of these intravenous accesses removed, he'll have a little more freedom to move his head, hands and arms. For now, he'll stay on TPN (IV nutrition).

   The hopes are that these changes are going to take place quickly. Of course, they'll continue to monitor him for any increase in fever (he is still at 38.6°C/101°F), any drastic drop in blood pressure, or any sign at all that the infection is strengthening. Hopefully he'll be free from the paralytics and the sedatives tomorrow and I'll be hearing his scratchy voice tell me how he can't believe this happened. Good thing I have photographic evidence. 😃

Back into his room in the ICU after operation #4

(hopefully one of the last pictures of him with the ventilator)

Day 8 ~ ICU, 12noon

Cha-cha

  A very good friend told me this morning that Bob's illness is going to be like dancing the Cha-Cha. One step back, a couple steps forward, then another step back again...but overall, still moving forward across the dance floor. And that is exactly what it's like, especially today.

  They had decreased some sedation yesterday, but had to increase it back last night. Bob was experiencing too much pain and became extremely agitated. His blood pressure is holding well, though, even with the added sedation medications.

  Surgery was on the schedule for 12:45pm, but it looks like it will happen later today, if he goes down to the OR at all.

  A chest x-ray this morning shows some "junkiness", in the right lung especially, and the respiratory therapist heard some coarseness at the base of both lungs. They've reassured me that, with the ventilator's assistance, his air is still moving very well.

  His fever has remained at 38.6°C/101°F throughout the night and all this morning.

  The ICU critical care doctor just told me: "He's not out of the woods yet; his blood is still infected and his body is still fighting."

  As soon as I know more, I'll try to get the blog updated, but for right now, today's 12:45 trip to the operating room is in a holding pattern.

Gotta get these hands back to typing on a keyboard!

Day 7 ~ ICU, 10pm

Revised Surgery Plans

  This Sunday evening the surgeon met with me and revised some of the upcoming surgical plans. Tomorrow (Monday) Bob is on the OR schedule for 12:45pm. The goal in this operation is to re-attach the two intestine ends, and to also be able to close just the muscle and fascia layers, not the skin and underlying tissues. The actual steps that can be completed in tomorrow's surgery still depend on the degree of the swelling that remains in Bob's abdomen.
  However, the surgeon does not want Bob to have yet another surgery after tomorrow's, so instead of closing the skin and underlying layers in an operation, the wound will be left open and then covered with a type of vacuum dressing that will slowly encourage the skin to close on its own. Bob's incision is very large, and this final process of wound care will take quite a while. This is all just a plan right now and there aren't any confirmed arrangements yet, other than Bob will definitely be back in the OR tomorrow afternoon, starting at 12:45pm.

Third-Spacing
  The excess fluids that have been filling the "third spaces" in Bob's body are finally beginning to be expelled! The Flexbumin (diuretic) and the TPN (IV liquid nutrients) have been pulling the fluid into the vessels and sending it along to his kidneys, which have started to perform great! Yesterday (Sat), over the entire day, his total urine output wasn't even 650ml. Between 10am and 4pm today, Bob's kidneys had already processed double that amount! Less edema means less abdominal pressure, easier BP regulation, slower heartbeat, and faster healing.

Respiratory
  The fluid that was in the lowest lobe of Bob's right lung is no longer present. It was also a product of the third-spacing, and the respiratory therapist and I practically hugged when he could no longer hear any crackles today! There also wasn't any mucous at all when they suctioned his lungs, so that's even more good news.
  They've started to wean Bob from the ventilator (he will not miss that tube down his throat), and today they had him on the lowest percentage yet - he's down to 35%, and he had started at 100% after the emergency surgery. They hope to wean him completely off the vent by Tuesday or Wednesday of next week, which will be one to two days after tomorrow's surgery.

Vitals/Stats

 - Fever: His temp was at 38.6C/101.5F all day today. Hopes are that a few more days on the antibiotics will help that fever to come down even more. He is still receiving the antibiotic cocktail of Flagyl once an hour, and Vancomycin every two hours, both via IV. 

 - Blood pressure: Dropped just a little bit today. It was averaging 100/55, but they did increase his Versed (sedative) slightly so that he could get some rest this afternoon in preparation for facing another operation tomorrow. He was alert for several hours this morning, so it was good he had some nice deep naps this afternoon and evening.

 - Heart Rate: His pulse has been steadily slowing down, and was only in the mid-to-high 90s for most of the day today. Less fluids in his body means his heart can relax a little!
 - Blood Sugar: The TPN is helping to get his nutrients back into balance. His blood sugar was only 115 today.

  Aside from getting the news that Bob will be facing a very long healing time for his incision and the wound care associated with managing the vacuum dressings, today revealed several very positive trends. What a relief! Hard to believe those terrible events of Thursday & Friday were just two days ago, and Bob's already come so far.
  Thank you to everyone for your continued well wishes, kind thoughts and prayers.

Bob snoozed as I sat and addressed Christmas cards today in the ICU.

Day 7 ~ ICU, 10am

Morning after Surgery #3

  It's been about 18 hours since Bob's third operation. He's doing much better than he was after the emergency surgery - they say his sepsis finally seems to be under control. This morning has been a bustle of activity. He received a "bath", clean bedding and a new gown, and had oral care and lotion application. Unfortunately, a lot of this movement was painful, but I can only imagine he feels better now that those things have been done.

Alert

  Bob's the most alert he's been in several days. They're slowly trying to reduce the amount of sedatives he is receiving, so his brain remains active and is not asleep all of the time. This morning he made his hand in the shape of holding a glass, so I asked him if he was thirsty and he nodded yes. I told him he couldn't have anything with the ventilator tube down his throat, and he let me know with his eyes he's not at all happy about that. I know he's so frustrated - I'm happy to see he's still stubborn Bob! I wish I could place a damp sponge around his mouth, but the risk of aspiration is too great.

  The downside of his alertness is that he's experiencing much more pain. And so much of what they have to do for his care is painful:

    *Of course he has to remain on his back, so they tip his body from side to side every two hours to avoid pressure sores. They do this by inserting a long wedge under his right shoulder and ribcage, then remove it and reposition it beneath his left shoulder and ribcage 2 hours later. This causes intense spasms in his abdomen, and sometimes I see tears trickle out of the corners of his eyes when it happens. He holds up one finger, asking them to wait, so they try to do it in stages with about 30 seconds in between each move.

   *Periodically the respiratory therapist has to top-off the cuff that holds the breathing tube in place by filling it back up with saline, and as the air-leak is sealed, it makes Bob feel like he's choking or being strangled. It's a natural reaction to fight back that feeling, and his body tries to cough, which again makes his abdomen spasm, leading to more pain. Since he's got at least two more surgeries in front of him, they're not going to wean him off the ventilator yet, so every time they suction out his tube or have to refill the cuff, he tries to cough and the battle continues. Good oxygenation is priority over the pain, but it still hurts to see him hurt so much.

Concern

  Bob's albumin levels are low. Albumin is a protein that the liver makes to pull fluid into blood vessels and away from areas in the body where fluid shouldn't be - like in the lungs. Since Bob's body already has too much fluid in the tissues, low albumin makes the situation worse. To combat this, they have started giving him a diuretic, Flexbumin. They are also starting TPN (total parenteral nutrition) which is supplying all of the nutrients Bob's body needs by bypassing the digestive system and dripping a specifically combined nutrient solution directly into a vein. TPN will begin tonight.

Cultures

  They sent off blood cultures the night of his emergency surgery (Thurs) and after 48 hours the results came back inconclusive (they sent off two identical samples; one sample grew, but the other one didn't). To be sure there was no accidental contamination, they took two more samples and sent them off again last night. Since the infection is responding so well to the antibiotic cocktail they're using, the results of the blood cultures are not as nearly crucial as they could have been.

  They also sent off a mucous specimen pulled from the base of his right lung, and that has come back negative. So there isn't a pneumonia infection right now - the fluid in his lung is most likely from the third-spacing and the focus now is to get his body to reabsorb/eliminate the extra fluid, which is being addressed with TPN and medications.

Vitals/Stats

 - Fever: This morning's temp is 38.6C/101.5F. Still feverish, but that's to be expected after the infection and the surgeries. They're using acetaminophen and cooling fans to try to keep it from climbing.

 - Blood pressure: Maintaining an average of 115/60. They are no longer giving him pressor medications since his body's keeping a high enough BP on its own. When they have to turn him or work on his ventilator, they first give him an extra push of his sedatives, which does cause his BP to drop, but usually only for a few minutes.

 - Heart Rate: His pulse is still slightly elevated, around 100-110 (normal is 80bpm), but it's probably going to stay this way as long as he is feverish and has the increased fluid levels in his body.  

This morning's numbers on the monitor are a happy sight!

Thank you!

  Thank you to everyone for your words of encouragement and offers to help. This process will have to be dealt with step-by-step, day-by-day. I hope to be able to get back with all of you to thank you each individually, but right now my schedule is still pretty uncertain, and I am staying with Bob for 10 to 12 hours at a time before I go home to sleep, shower and then return. 

  I want to be sure to thank Bob's coworkers (at Aeronix) who sent this beautiful floral bouquet and Get Well balloon. We received it at home the very next day after his initial surgery (Mon, 11/20) and when I got back to the house that night I sent Bob pictures of it - the arrangement is absolutely gorgeous and orange is his favorite color. I've been enjoying it each evening when I get home and try to decompress. 

  Since Bob is now in the ICU, and will be for several more days, he cannot have any visitors and nothing is allowed in his room at all, including flowers, plants, balloons, even stuffed animals. An atmosphere as germ-free as possible is the goal. However, he does have a huge bulletin board in the room, directly in his eyesight across from his bed, where cards can be hung. So for those who have asked, I'll gladly put up anything on his bulletin board that you'd like him to see.

  Once more, I must thank everybody for the outpouring of so much kindness, love and support. It's keeping me going and I tell Bob every day all of the people that are thinking of him.

Fondly,
Angela

Day 6 ~ Followup Surgery (Operation #3), 5pm

Blood
  Before Bob was cleared to have surgery #3, he received a unit of blood in the morning to bring up his hemoglobin. 

Surgery #3 completed

  Bob's third surgery was cleared to take place today, and it lasted from 4 to 5pm. The surgeon opened up Bob's abdominal cavity, flushed it out, but wasn't yet able to rejoin the two intestine ends, since they are still too swollen. So he left the wound open, and placed another wound-vac sponge to continue to drain his abdomen.
  The hopes are that they might be able to go back in again on Monday (11/27), and possibly reattach the intestine ends, but right now it is too soon to tell. After next Monday's operation, there may still need to be yet another surgery to hopefully close up the muscle and skin. 

This is going to be a LONG HAUL. A marathon, not a sprint.

Post-Surgery Vitals/Stats
 -Fever: Post surgery temp is only 38.1C/100.58F. Hoping it will remain in this range since the antibiotics that were started two days ago have been doing a good job fighting the infection.

 -Blood pressure: Maintaining 100/60. Even with the anesthesia, his BP hasn't been dropping; and no pressor medications being administered, either. This is very good news!

 -Heart Rate: His pulse is 100 (normal is 80bpm), which is only slightly elevated due to just having surgery again. 

 -Hemoglobin: Hemoglobin at 8.1 (normal is 13.5 - 17.5). This morning it was down to 6.6 before he received a unit of blood. This number is going UP, which is what we want!

 -Fluids: The third-spacing issue still exists. All of the extra fluids that have built up in the tissue in Bob's body have not yet been absorbed/removed. Much of this happened because of the sepsis - the body was defending using every method it had to try to rid itself of the infection. That is a large reason why the intestines were still too swollen and couldn't yet be joined back together in today's operation. The edema is still in all areas below his waist, and also beginning to show in his hands. This may take a while to handle and resolve.
 *Concern regarding the fluids - There continues to be some additional fluid collecting in the lowest lobe of Bob's right lung. This is the same side where Bob's ascending colon was removed, where his largest incision was, and where the greatest amount of fluid has also collected in his abdomen and flank. In an over-abundance of caution, they removed a sample of mucous from that area of his right lung and sent it off for culturing. So far, it doesn't look like pneumonia, but is rather more third-spacing fluid. The respiratory therapist comes in every two hours to suction the ventilator tube, to listen to Bob's lungs, and to check his oxygenation levels. They are very diligent about managing every aspect of Bob's condition, always.

 -Kidney Function: Urine output is still concentrated, but each time they have to go into his abdomen, the kidneys are going to "go to sleep" somewhat and remain sluggish. This is going to take some time to be resolved.
 -Blood Sugar: Latest level was only 133 - no insulin needed! This may increase after the insult of another surgery, but will be addressed with injected insulin as needed.

Back into his room in the ICU after operation #3

Day 6 ~ ICU, 6am

Surgery Update
  Right now, Bob is scheduled to go back into the OR at 4pm today. The purpose of this surgery is to go back into the abdomen again, flush everything once more, and possibly re-attach the small intestine back to the large intestine. If this reattachment can be done, they will also close the muscle wall, but will keep the fascia and skin layers open, with a sponge wound-vac on again until the final surgery, which could possibly be Monday. Today's surgery will depend on his vitals remaining stable.

Comfort

  They have finally been able to balance Bob's sedation and pain medications in such a way that he can rest and "ignore" the breathing tube and the pain, yet his blood pressure remains in a safe zone. He only had two times (midnight and 6am) where they had to re-administer the coma-inducing drugs. His pain medications are being given continuously via IV. 
  
Concern
  His body is still being plagued by the terrible diaphragm spasms, and he becomes more alert when they happen, responding to the pain they cause. The nurses tell me with all of his medications, he'll likely not remember the pain he feels when the spasms hit. The surgeon shared he thinks the spasms are being caused by two issues: 
 - the combination of the fluids filling his abdomen and even creeping up into the bottom of his right lung are putting pressure both above and below the diaphragm, and
 - during the surgeries both on Monday and Thursday, some direct irritation of the diaphragm muscle and its nerves definitely took place.
  If the spasms continue after today's 4pm surgery, they will change the amounts and frequency of the sedatives (Versed and the Compazine) he is receiving to try to quiet the diaphragm, as long as his blood pressure remains high enough.

Vitals/Stats
-Fever: Temp is down to 38.2C/100.8F this morning!
-Blood pressure: Averaging any where from 100/50 to 120/60. So much better than the low pressures he has had over the past few days.
-Heart Rate: His pulse is the best it has been in days - down to only 110 so far this morning (normal is around 80bpm). That is a direct result of the fever lowering and the blood pressure coming up high enough.
-Hemoglobin: Hemoglobin down to 6.6 (normal is 13.5 - 17.5). It was 8.8 before the second surgery, so it was already low when he had to go back to the OR Thursday night. They are giving him 1 unit of packed red blood cells this morning.

-WBC: White Blood Cell count is 5.54 (normal is 4.5). His count indicates he has an infection and that his immune system is working to destroy it, but it's not too high, it's expected, so that's a good thing.

-Fluids: They have been forcing a high amount of fluids to keep his blood pressure up enough that they can give him sedatives to combat his fighting the breathing tube and reduce some of his reacting to the high pain. Now his body is experiencing third-spacing, which is when too much fluid moves from inside the blood vessels into the interstitial or "third" space around the blood vessels, which is the nonfunctional area between cells. This fluid is causing edema in his abdomen and legs, so they are trying to cut back on the forced fluids while continuing to use BP medications to maintain a healthy blood pressure.
-Kidney Function: Unfortunately his urine output has dropped, even with the large amount of fluids he has received over the last 24 hours. They hope the kidneys have just become sluggish from all of the trauma to the abdomen, and are encouraged that there is still some urine output, even though it is concentrated.
-Blood Sugar: Latest level was 192. This will continue to remain high until his body is no longer under stress and his insulin levels will stop reacting incorrectly to the stress-hormones in his blood. They give him injected insulin (2 units) each time his reading is over 150, to combat this.

Working towards being stable enough for today's followup surgery

"Look ma, no bite guards!"

Day 5 ~ ICU

Concerns

  Bob had a very bad night (Thurs) after the emergency surgery. Today (Fri) has also been a very difficult day. His surgeon told us that Bob was going to get sick before he got better, due to the sepsis, and boy was he right!

Vitals/Stats
 -Fever: His temp was 39.5C/103F when he came out of the OR. Throughout the night it climbed to 40C(105F). This extremely high fever was mainly a result of his body responding to the full attack of the sepsis. Throughout the entire day, his temp only dropped to 38.9C(102F), but at least it was decreasing.

 -Blood pressure: Very, very low following the surgery. Averaging any where from only 55/35 to 80/45. This was a top priority, and large amounts of forced fluids were being pushed, and "pressors" were being given via IV - Bob received norepinephrine and a few other pressors to force his vessels to constrict, and his cardiac activity to increase, which in turn made his BP begin to slowly climb out of the extremely low danger zone.
 -Heart Rate: His pulse raced in the 150s before the surgery, due to the infection. After the operation, it continued to be tachycardic (beating too fast), around 125-130 (normal is 80bpm). This fast pace was because of the fever and the medications used to raise his blood pressure. Lowering this heart rate was also a priority, especially with Bob's cardiac history.

 -Oxygen/Ventilator: The Respiratory Therapist had a real challenge on his hands with Bob. Once out of the surgery, Bob INSISTED that the tube was going to come out of his throat. Even with an attached bite guard on it, he still tried to bite through the breathing tube! They wedged additional large bite splints between his top and bottom teeth on each side of his mouth that basically forced his mouth wide open, and then attached the guards to his face and chin. Frustrated by that roadblock, Bob then began trying to reach up to his mouth with his hands in an attempt to pull out the tube, so they placed splints on his elbows so he wouldn't be able to bend his arms. 

  To be honest, I was thrilled when I saw him doing this. That meant he was ticked off about the tube, and he was digging in his heels, determined to figure out a way to get the vent out of there, even while he was still sedated from emergency surgery! I was happy to see that fight from him. That's what he'll need to keep drawing on to get through this ordeal.

  By the way, Bob spent much of Friday slowly manipulating those added mouth guards by pushing them with his tongue and chewing on them with his teeth. I think it was distracting his brain from the immense pain, the fever and the diaphragm spasms. Believe it or not, by the end of Friday, he had them more than halfway pushed out from his mouth! The ICU nurses said they had never seen another patient manage that, especially while under sedation. They've never had Bob for a patient. =)  

The blue, canoe-shaped ventilator bite guards in position 

when he first arrived from the OR

The bite guards after he spent all day Friday working them out

Day 4 ~ Emergency Surgery (Operation #2), 6-8pm

Caution: This post shares detailed information about Bob's second (emergency) surgery. No pictures, but lots of descriptions. If you think reading this will make you uncomfortable, you might want to pass on this post. =)

Emergency Surgery

  6pm: Bob is now stable enough to go down to the OR. His surgeon advises me (Angela) that Bob's condition is a "life threatening situation". He is septic (infection has moved from his abdominal cavity to his blood stream and will eventually infect all organ systems in the body without intervention) and also at high risk due to his cardiac history. He will be opening Bob's abdomen with a very large incision, and is unsure of what he will find or what exactly will be done.

  8pm: Bob has come out of the surgery and in ICU recovery. The surgery entailed a lot of work. Basically, there was a pinhole leak in the joint where the small intestine and the large intestine were joined together after the first 1/3 of Bob's large intestine was removed in Monday's surgery. This leak likely didn't happen until sometime Tuesday, and it was tiny enough that the full effect of the leaking wasn't apparent until Wed afternoon.

  The surgeon completely washed out Bob's abdomen. He then detached the intestines where they had been stapled together, and removed three more inches of small intestine from one end and three more inches of large intestine from the other end. He didn't re-join the intestine ends, but instead stapled them off completely from one another.

  Since the infection had not yet responded to antibiotics (too soon), the surgeon didn't close up Bob's abdomen. Instead, he packed it with a sponge that is connected to a vacuumed wound-vac, which will draw fluids out of his abdomen for the next 48 hours. Depending on how soon the infection gets under control and when Bob's vitals are stable, the surgeon will then go back in and do a followup surgery.

  This next following operation will be to again wash out the abdominal cavity, and possibly to also re-join the two intestine ends, depending on the condition of everything. He may also close up the muscle layer of the abdomen, but will likely wait to close the fascia and skin until another 48 hours passes. That will require another (and hopefully the last) surgery to accomplish. That will mean between Mon, 11/20 and Mon, 11/27, Bob will have had four surgeries in total.

Concerns

  This surgery was done under the worst of possible scenarios, since there was an active septic infection. The next day or two will be a struggle to balance Bob's vitals. He came back from the surgery on a ventilator (breathing tube down into his lungs), a central line in his neck with eight IV ports, an arterial line in his left arm, a bladder catheter, an NG tube through his nose into his stomach, a vacuum drain on the sponge over his open abdomen, two additional veinous IV's (one in the back of each hand), anti-clotting pressure cuffs filling on each calf, EKG and heart monitors, an internal temperature sensor, and pulse oximeters on his earlobe and fingertip.

  After his first 24 hours in the ICU post surgery, I'll update his vitals and his progress. Goal is to have him stable enough to tolerate the next surgery, which is tentatively going to be on Saturday (in 48 hours).

Day 4 ~ Leave Room 421 & move to ICU

Concerns

  Today is the hardest day so far. Bob continues to do worse throughout the morning and afternoon. His color is gray, he's unable to sit up, the pain is becoming unmanageable. His abdomen is distended, swollen and hard. His fever is slowly creeping higher. He isn't drinking, he has started to feel nauseated, and the painful hiccups are now non-stop, are interfering with his breathing, as well as increasing his pain. The surgeon has been texting with the nurse throughout the night and early morning, and is coming in to see him.

Timeline

 -10am: Surgeon examines Bob and immediately puts in an NG (naso-gastric) tube. This is a tube that is inserted into Bob's nose and goes all the way down to his stomach. Immediately fluids come up, and over 500ml are vacuumed out in the first 20 minutes! The doctor tells us he can't believe Bob hasn't been vomiting. He tells us Bob's not out of the woods yet, but he wants to give the NG tube some time to remove some fluids, with the hopes that will be the most intervention he'll have to do. 

Placement of the NG tube

In preparation for a likely emergency surgery, the surgeon then places the following orders:

  *An abdominal CAT scan

  *Placement of a continuous heart monitor

  *An EKG

  *A respiratory therapist to do an assessment, including an arterial blood sample to check for oxygen saturation in the blood

 -11am: Respiratory therapist listens to Bob's lungs, agrees there is some audible diffusion in the lower right lung. Takes artery blood sample. Increases O2 cannula from 3 to 5 units.

 -12noon: Blood sample shows lower O2 perfusion than they're comfortable with, so Bob is changed from nasal cannula to full mask with forced air. This calms him a little since he isn't working quite so hard to breathe, and he gets a little bit of rest. Heart monitor is placed and being tracked by cardiologist. EKG is ran and cardiologist clears for likely surgery. NG tube has now drained over 1,250ml out of his stomach and small intestine in just 2 hours.

Addition of heart monitor and full mask with forced air

 -1pm: Charge nurse accompanies Bob down to CAT scan, and it shows that the lower right abdomen (flank and pelvis) are filled with considerable amounts of fluid.

 -2pm: After reviewing all test results, surgeon orders Bob be moved to the ICU. He wants Bob's BP, heart rate, oxygen perfusion and fever to be aggressively managed and monitored, since surgery is likely.

 -2pm to 5pm: ICU works to get Bob's vitals as stable as possible. He is becoming septic, his fever is climbing, his BP dropping, his oxygen saturation unsatisfactory. He has a central line placed into his large vein in his neck (superior vena cava) and they are pumping him with medications to try to stabilize him for the surgery.

Day 3 ~ Room 421

Concerns

 -Oxygen: Today has been a rough day for Bob. Although he was doing well Tuesday after Monday's surgery, today (Wed) he's taken some steps backwards. His oxygen saturations kept dropping during the night, which indicates his blood isn't getting enough oxygen from his breathing. They've added a nasal cannula for oxygen. He has been using the spirometer exactly as his surgeon and the respiratory therapist instructed, but the concern is that pneumonia may still be settling in, so they want to do a chest Xray. Due to the lower oxygen sats, he is staying in the hospital at least one more day - hopefully going home on Thanksgiving!

 -Hiccups: The pesky hiccups are becoming more frequent and lasting for longer periods of time. In post-op, the surgeon shared that he had to remove a great deal of adhesions and scar tissue, so we're wondering if it's possible that the diaphragm was irritated in some way, causing it to spasm, leading to painful hiccups. Bob's being a trooper and riding them out, but they certainly increase his pain when they happen.

Timeline

 -12 noon: Taken down for chest Xray.

 -2pm: Returned from Xray. He was in intense pain, unable to even sit up. They began pushing Morphine IV and increased his Percocet from 7.5mg to 15mg.

 -4pm: The pain continued increasing, even with the morphine. He became very pale, and they kept him in bed, alternating heat packs with cold packs on his abdomen. Likely the increased pain was due to gas beginning to move through the intestines, which is a very good thing, but also extremely painful.

 -6pm: Chest Xray showed some diffusion in the very bottom of his right lung. They started keeping the head of his bed at 30degrees minimum, and increased the oxygen flow in his cannula from 2 to 3 units.

 -9pm: He continued to receive Morphine, Percocet and they also added acetaminophen, since he began to run a very low grade fever (about 100F).

 -11pm: Had his first bowel movement, which is one of the goals needed to complete before he could go home. Even with all the pain, this was a great milestone, so we still were pretty optimistic!

Vitals/Stats

 -Fever: Temp began climbing throughout the day, eventually reaching 38.4C/101F by the middle of the night.

 -Hemoglobin: Hemoglobin was 8.8 (normal is 13.5 - 17.5), which is expected after an extensive abdominal surgery.

 -WBC: White Blood Cell count was 4.8 (normal is 4.5). Only very slightly elevated, so nothing was concerning at this point.

 -Fluids: Since Monday's surgery, they had him on IV fluids (saline only) but after Tuesday night, he no longer needed them. So by Wednesday he was drinking sufficient quantities of water and chicken broth to have adequate urine output, and they disconnected the IV fluids.

 -Blood Sugar: Due to his body's increased stress, his sugar levels started climbing, hovering around 200. They continued giving him insulin accordingly.

Morphine, Percocet, Tylenol, heating packs, ice packs - 

nothing takes away the pain and his fever continues to rise.

Day 2 ~ Room 421

Achievements

  Today (Tues) Bob has accomplished some pretty big goals! He's been up and walking (three times, over 1,000 steps total), sitting in the chair, has been napping on and off, and even spending time on his phone, following football scores and catching up on emails and text messages. Pain is worse than yesterday (Mon), but with the local anesthetics worn off and the general anesthesia pretty much out of his system now, increased pain is to be expected. He's still managing pain pretty well with oral Percocet (7.5 mg) every 4 hours. Hopes are he'll be able to go home tomorrow (Wed). But first he needs to pass gas and have a bowel movement (to be sure the intestines are connected correctly and passing things properly), and we're hoping the walking is helping that.

 

Concerns

  Bob's diaphragm has begun to spasm. We would call them hiccups, but these are MEGA-hiccups, which are pulling on his abdominal muscles, causing terrible bouts of pain. They aren't continuous, but when they do happen, they are extremely painful. We've tried repositioning him in the bed, readjusting the angle of the head and foot of the bed, sitting him up in the chair, but nothing seems to be able to stop them. So when they happen, Bob takes deep breaths, pushes down on his stomach using a pillow, and rides them out until they stop.

Vitals/Stats

-Fever: Temp ranged 98F-99F. Normal for post-op.

-Hemoglobin: Hemoglobin was 8.8 (normal is 13.5 - 17.5), which was expected after an abdominal surgery. They began heparin injections, just as a preventative for blood clotting, due to the extensive surgery.

-WBC: White Blood Cell count was normal, no elevation concerns.

-Fluids: Since Monday's surgery, they kept him on IV fluids (saline only). Plans were to take him off fluids Wednesday, as long as his urine output remained satisfactory.

-Blood Sugar: His sugar levels were anywhere between 140-160 throughout Tuesday. Even though Bob is pre-diabetic, he's been managing well with diet and oral medication at home, so Bob's never had to take insulin before. But now while he's in the hospital, anytime the readings are over 150, they'll be giving him 2 units of insulin. So they started doing that.

Tues afternoon - Just finished 1,000+ steps!