Monday, December 26, 2011

First Day on the 3rd ECMO Circuit

After a very stressful morning, Jude had a relatively uneventful day today.

As I indicated in a post early this morning, Jude had a large clot in his ECMO circuit, which prompted it to stop working completely; consequently, Jude had to be put on a new circuit altogether.

While Jude is on ECMO, his blood leaves his jugular through a venous cannula (a very large catheter), oxygen is added and carbon dioxide is removed in an oxygenator component, then the oxygen-rich blood is returned to Jude through an arterial cannula in his carotid artery. However, as Jude's blood passes through the tubing of the ECMO circuit, his body thinks that it (the tubing) is a foreign object, so his immune system responds accordingly, and one of the things that can happen with that response is clotting in the circuit. A certain amount of clotting in the ECMO circuit is to be expected, particularly as a circuit ages; however, as clots form, there is always a certain risk that small clots could pass from the circuit into Jude's body or that clots could stop the circuit from working. The latter of these scenarios is what played out this morning. A large clot that had formed in a part of the tubing dislodged and clogged the oxygenator, thus stopping the circuit from working.

When the ECMO circuit stopped, Jude was quickly taken off bypass and his ventilator settings were adjusted to give him additional support until he could be hooked up to a new circuit. We thank God that Jude weathered this transition relatively well: His vital signs were reportedly stable, and his arterial blood gas analyses while he was off ECMO weren't fantastic, but they could have been worse. Once Jude was on the new circuit and things settled down a little bit, Rose and I were allowed to go back into the NICU to see him and talk with his doctors and nurses.

As the day wore on, we eventually met with several of Jude's doctors, including two attending neonatologists and his pediatric surgeon, and a tentative plan for this week began to take shape:

The overarching goal in the short term is to get Jude off the ECMO circuit. To that end, his doctors and nurses will attempt to "dry him out" by removing extra fluid from his body and challenge his lungs in order to get them expanded and working better.

Jude has had a longer-than-usual course on ECMO, and he's had a lot of unforeseen setbacks that have prolonged his time on bypass. We're thankful that such technology exists, because it saved Jude's life when he would have certainly died otherwise; however, as Jude's pediatric surgeon put it this morning, because of the risks and problems associated with ECMO at this point in Jude's care, it is becoming a "death machine" to him, and it's now imperative to relieve him of it as soon as possible.

At some point tomorrow -- possibly in the late morning or midday hours, unless things change -- Jude's surgeon will insert a drain (chest tube) on the right side of his torso, which will hopefully drain fluid that has accumulated in the pleural space alongside his right lung. By relieving the pleural effusion on that right lung, the hope is that it will allow for the expansion of that lung and the increase of its function. Although Jude also has pleural effusion on his left lung, the doctors won't be addressing that directly at this time. Jude's left lung is significantly smaller than his right lung anyways, so it's more important to relieve the pressure on his right lung at the moment in order to get it inflated and working. Insertion of the drain is risky since Jude is on a blood thinner, and it's a more invasive procedure than the surgeons would like to do, but its potential benefit in helping usher Jude off ECMO now outweighs the risks.

The attending neonatologist who was on duty today also indicated that, if it may be helpful in getting Jude off ECMO, he might give him some doses of a steroid called dexamethasone. This drug could conceivably provide some short term improvement in Jude's lung function, so it's something that might be used if needed.

As of this writing, Jude is relatively stable, and we're hoping that the Lord will keep him that way through the night. His lungs have largely "whited out" again on his latest chest x-ray, but we expected that as one of the consequences of his body's inflammatory response to the presence of the new ECMO circuit.

Going into tomorrow, please join us in praying for the successful insertion of the drain on Jude's right lung and that the Lord will protect him from complications such as bleeding. The surgeons will use an ultrasound to find the best possible entry point for the drain so that it will minimize the risk of bleeding. Please pray that the ultrasound tech and the surgeons will be equipped with all that they need to take care of this with no problems.

Also, please pray with us for the safe but swift removal of fluid from Jude's body and for an increase in his lung function over the next few days. It is absolutely critical that Jude's lungs expand and begin working in order for him to come off bypass. Please pray that the NICU staff will be adept in helping facilitate this through the various means at their disposal.

As we have seen already, being on ECMO has risks, and although Jude must come off of bypass as soon as possible, it's extremely important that his circuit work correctly while he is being supported by it. Please pray with us that Jude's ECMO circuit and all of the other technology being utilized in his care remain free of malfunctions or complications.

And, as always, please pray with us that God would simply, yet miraculously, heal Jude of the things that are threatening his life.

Today we are thankful that the Lord brought Jude through the shock of another serious incident, and we're thus thankful that we had another day with our son. We thank God for several of the many mercies He has afforded us in our time with Jude: The opportunity to hold his hand, to touch his head, to read to him, to speak loving words to him. Rose and I also got to enjoy a belated Christmas gathering this afternoon with some of her family from Florence, and for that we also give thanks. The love of Christ continues to surround us during this time, and in no small part we feel it through the messages, tangible support, and prayers offered up by others for our family. There are those of you who don't know us, or who are perhaps only acquainted with us, and yet you pray for us. We thank God for you as well, as we are deeply touched and comforted as you continue to point us to Jesus.

We believe wholeheartedly that the Lord knows what He's doing, and we trust Him and pray that His will be done in our lives, but we also approach His throne confidently as we ask for healing, knowing that He can do it. Out of nothing, He creates. When it seems there's no way forward, He blazes a trail. When we are dried up and have no resources left, He provides.

    Behold, I am doing a new thing;
        now it springs forth, do you not perceive it?
    I will make a way in the wilderness
        and rivers in the desert.
(Isaiah 43:19)

    In his hand is the life of every living thing
        and the breath of all mankind.
(Job 12:10)

1 comment:

  1. Praying for a good day for Jude. For the chest tube to be inserted without incident and to help in drying him out and for all the technology at the doctors disposal to work. I know how scary these days are. Dakota got off of ECMO in a rather dramatic fashion. She was more than 7 weeks early, but a fairly large 5 lbs 3 ounces so when she started crashing on her second day of life, the surgeon made the call to put her on ECMO and saved her life. However after a couple of days the tube in her neck shifted since she was so small compared to the tube - the nurse had to hold her in all kinds of weird positions just to get the flow the surgeon had ordered on the ECMO machine. Thank god Dakota was tolerant of being touched! My heart was beating a million miles per minute - I went into the pumping room and for the first time just broke down in tears from the stress. The alarms kept going off saying that the machine couldn't get the flow. They kept shifting her and trying ... through all this her sats remained good and her blood gasses remained good so when the surgeons came by they said she's showing us she's done with it - let's get her off. The nurse finally got to sit down, they turned the flow down and we went from there. Many prayers that it is Jude's time to get off and that everything works perfectly. Thinking of you all!
    Mom to Dakota 12-25-2008
    RCDH survivor