I've got a lot of ground to cover today, so this might get a little long (not that that's a surprise to any long time readers). First up - as I wrote yesterday, we were able to remove the LA line earlier this morning. The picture above is from yesterday, and you can see the LA line as it is the one crossing over her left hand with the two green stickers on it. This line allowed us to monitor her heart closely in the immediate post op period, but we don't really need it any more.
Lillian's first post op ultrasound also looked really good and combined with the results of her OR ultrasound is encouraging so far. We've scheduled a new ultrasound for Sunday, so she is already at the every other day ultrasound, which normally happens at least a week after transplant.
Taking the LA line out was only the beginning though. She had to have another IV added in her right arm. The reason for adding this IV was so that we could give Lillian immune globulin, an anti rejection treatment that must be given slowly and can conflict with other medicines, so we needed to establish a new IV route for it. To recap, this means that she has a PICC line in her leg, an IV in her right hand and a arterial line in her left as well as another IV in her neck. Almost out of extremities at this point. To recap everything that's a continuous infusion, here's the pumps above in counterclockwise order: Morphine, Milrinone (she'll be on this for about another week), Lidocaine (to help regulate her heart's electrical activity), a flush, Potassium Chloride (to make up for the fact that she's NPO), Furosemide (Lasix, a diuretic), the CVL (central venous line) maintenance fluids, the aerterial flush and the CVL flush. There are two more pumps on top on either side, both of which are serving as med lines. That's a total of 11 pumps.
The next plan of action for Lillian was to remove the last two drainage tubes as they weren't draining and weren't needed any more. We did need to leave them in for a while after removing the LA line to make sure that didn't cause any bleeding, but the LA removal went fine so we went ahead and removed the drainage tubes. It's a bit hard to see the two that are left in the picture above, but there's one poking out over the purple blanket, and another one just to the left of that under the blanket (more obvious in the picture up above).
For the record, the white and red tags are for a 12 point ECG, which we're leaving on even though it's not hooked up in case we need to put it back on. The white patches above her belly button and below her incision are the spots where the drainage tubes were. You might notice that there's an NG tube coming out of her right nostril. Since she's NPO at the moment, she's building up quite the collection of stomach bile, and that is draining it out.
As with the LA line, once the drainage tubes were removed, we had to wait several hours before removing anything else to make sure that the last removals went smoothly. When we were sure that they did, it was time to extubate. First the NG tube was pulled, and then the breathing tubes in her nose. With the removal of those, we also took off the large oxygen sensors for her renal and brain function. With that, Lillian had her face back! Take a second and look at the pictures of her earlier in the post from yesterday with everything in, then with the LA line removed, then with the drainage tubes removed, and finally, with her breathing tubes and oxygen monitors gone.
Almost back to normal at this point. We still have 3 extra IVs from before the surgery as well as the pacer wires, but she made fantastic progress today already. At the same time though, she also doesn't currently have any drainage tubes as has been extubated. So far the extubation looks to be going very well. She's had one episode where she stopped breathing, but we turned off her Morphine and Ativan, which has prevented her from having any more episodes of apnea and she's tolerated having them off extremely well. We're hopeful this continues as at this point it looks like we've avoided a morphine dependency. However, because she's had slightly lower SpO2 saturations, she's been put back on a cannula just to be safe.
On a couple of other fronts, Lillian is still having the rhythm issues in her heart, so we continue to have to manage that. She is still on the external pacemaker, and we are giving her Lidocaine to help with the electrical issues. We spoke with an electrophysiologist earlier, who was concerned with her rhythm; specifically the lack of coordination between the top and bottom portions of her heart. Lillian's heart does something very curious though. When we have the pacemaker turned up past her own heart beat, the top and bottom halves of her heart are coordinated and the top communicates with the bottom. Without the pacing though, there is no communication. Since the communication pathways are there, we would expect them to communicate with or without pacing. We still have hope that the rhythm issues will resolve themselves on their own, but if they don't there's always the chance that she'll have to have a pacemaker. Since she's had such a good recovery so far, having to take that route wouldn't surprise me.
|Eyes finally open, although she's extremely drugged.|
|I know I post the pumps a lot... but they make for good pictures.|