He came out of surgery breathing on his own on the spontaneous setting on the ventilator. This setting allowed him to do most of the breathing work on his own, even though he was also at 100% oxygen (whereas room air is considered 21%).
Sadly, his sats, never as high as we wanted to begin with (well, specifically after surgery) dropped dramatically into the 50s in the middle of the night, proving he wasn't ready to breathe on his own.
The most acute patients are in rooms directly outside the attending's office. And Job had a steady stream of medical personnel in his room all night.
After his desat, his team decided to take him off of the spontaneous setting on the ventilator and increase his vecuronium (muscle relaxant) significantly, as well as his dilaudid (narcotic).
Job's heart function following surgery was and is still depressed (so he's on milrinone and was on epinephrine to help his "squeeze") and last night he didn't have the ability to work as hard as he needed to in order to maintain his sats. The idea was that if completely muscle relaxed (so his body isn't "wasting" energy), with the ventilator turned on to full capacity, Job could rest and recover a bit more and maybe his sats could recover too. And as of this afternoon it seems to have worked!
You and I only have to get used to switching our circulation once: from fetal to, well, typical. But Job will have to adjust to five different circulations: fetal to typical, typical to Norwood, Norwood to Glenn and someday Glenn to Fontan.
This is a very big adjustment for him and his little body was struggling to keep up with the work of breathing on depressed heart function, as mentioned, in addition to the normal complications of recovering from the trauma of surgery.
One such issue is his positive fluid balance. His little lungs can't function correctly with the excess fluid in them, so he needs help getting rid of that fluid through diuretics, namely lasix (item one). We need Job to have a negative fluid balance (that is, we need him to pee!) before we can move forward.
Job's hematocrit (concentration of red blood cells) was low as of this morning and so he received a transfusion (item two). In very basic terms, this means he received more red blood cells. This helps his capillary leaks heal (which helps his fluid balance) and it gives his hemoglobin a better ability to carry more oxygen around to his tissues. This made a big difference for him as he recovered from rhino a few weeks ago and the mention of it this morning made me hopeful for a similar result. I was afraid to get too excited, because of course recovering from rhino and from surgery are very different animals, but the crit infusion seems have been one of several factors in Job's turn around. SV kids (single ventricle) often respond well to crit infusions. In Job's case, it likely helped him come off of his blood pressure meds (vaso and epi).
As mentioned, in the middle of the night, Job's hard work caught up to him and he needed to do less work. His vecuronium (muscle relaxant) gave him that break, but now that he's a few more hours post-op he will be weened off of his vec so that his body can begin to breathe on his own again (item three).
I mentioned Job's new Glenn circulation and the big change that it is for his body (but I really do need to write out WHAT the Glenn is... Maybe tomorrow's project?) but in contrast to any other cardiac surgery, it is important for Glenn patients to get off the ventilator as quickly as possible. This is because the Glenn now sends passive blood flow to Job's lungs. And his lungs need the negative pressure of his diaphragm (or in his case, only the right side of his diaphragm) pulling his lungs down to better receive his passive flow. The positive pressure of the vent, pushing air into his lungs, makes it too hard for the blood to optimally drain through Glenn (that is, from his SVC to PA). The ventilator, however, provides positive pressure on his lungs and therefore Glenn patients do much better extubated (item four).
And of course, we want Job's blood pressure to remain stable as this is a primary indication of his heart function (item five). Stable blood pressure helps his profusion too, bumping his sats higher.
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