PICU, Day #16 – Countdown begins…

This morning was a rough one for me.  I only got 3 hours sleep since I did not get a room at the Ronald McDonald House last night (fortunately, I did tonight!).  Also, their “plan of care” for Hannah’s sedation wean for an extubation trial Thursday morning that was created a couple of days ago seemed to be not working.

It started this morning with rounds.  Since it is a new month, that means a new rotation of residents and our third attending since being in the PICU.  Our fellow introduced Hannah as the “sedation nightmare.”   Their plan was the same as it was since Dr. Roy was here a couple of days ago — to wean Hannah from the narcotics (Versed and fentanyl) and streamline the rest of her sedation meds (pentobarb, chloral hydrate, clonidine patch, rocuronian – the paralytic, etc).

Well, the plan of care was to wean down the Versed and fentanyl IV drips and use them as-needed.  Well, as-needed turned out to be 15 or 20 times combined.  Hannah’s sedation flow sheet still easily was onto the second page.  It was not helping.

Also, when Hannah gets agitated or awake, she is not consolable.  She does not even respond to me talking or touching her.  These meds have made her so delirious it seems like that nothing that me or the nurses do has any effect.   The nurses (who have been incredibly fantastic!) even try getting gas out of her tummy by suctioning it out through her NG tube, repositioning her every which way (except on her tummy which she would love but can’t with the vent), and putting on music.  They have really gone above and beyond what I could have ever expected.

So when today’s nurse called the fellow to say “this is just not working,” the fellow (who also has been really good with us) made a comment that they were going to continue the “plan of care,” and think that they need to ‘nurse’ her more — hold her down, comfort her, etc.   I saw the look on the nurse’s face because it was exactly what I was thinking — it is NOT the nurses that are the problem.

Thinking I was getting angry because I was exhausted from lack of sleep, I went up to the RMHouse for a quick shower because it was all I could do but at least be here to help them with Hannah.   I sent Dr. Roy and my friend Cristina an email about what was going on, mostly venting, because I just could not figure out how this was going to work for extubation on Thursday morning.

So I came downstairs and talked to our nurses.  I started getting upset.  I could not wrap my mind around how she was going to get a fair chance and extubation in less than 48 hours.   So I asked the nurse who I could talk to, and she got the attending.

I shared my concerns with the attending, and the nurse corroborated what I was saying.  The attending actually agreed that this was not working and made some real changes to the plan of care (totally weaning fentanyl and Versed, even as needed, and removing the clonidine patch) and putting Hannah on a phenobarb IV drip and continue using rocuronium (the paralytic), chloral hydrate, and the Ativan/methadone (to help wean off the narcotics).    Then, I BELIEVE 24 hours before, they will be adding the Precedex and only be on Ativan and methadone as well…I think…

Though she still needs a lot of sedation, it really seems that since that change this afternoon, she seems as if she has less agitation episodes.  Of course, it has only been a few hours.   But the goal is to get her on all these short-acting sedation meds and off the narcotic and long-lasting ones so once they are ready to extubate, she should be much less sedated.

Thursday morning seems to be extubation time — my guess is after rounds, probably around 11 am or noon.