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!