Whew!

Oh man, this is stressful. They extubated Andrew around noon, and I've spent the last two hours holding his hand, patting the blanket (for the vibration), and doing everything I can to keep him calm. He's been waking up and crying every couple of minutes, and probably with good reason. Putting a baby as big as him on CPAP is difficult, and they've been focused on mechanical issues the entire time.

Most of the issue is because the little nasal prongs are too small for his nose, and it creates a leak. He's supposed to be getting air pressures of 22 (breathing in) and 8 (breathing out). Instead, it's closer to 10 and 6. They don't have bigger prongs or a mask that will work with this ventilator, so they're attempting to make it more efficient. They tried him laying down, they tried him sitting up, they tried putting a blanket under his back to lift his neck. They tried holding the prongs in manually (obviously not a long-term solution), plugging his mouth (part of the leak) with a pacifier tied to a blanket, and even putting a little chin-strap on him to keep his mouth closed.

They've also tried at least four different vent settings. I don't even know what SIMV, CMV, CPAP, and VIVE stand for, but I do know that they don't help a leaky nasal prong. The ventilator alarm goes off once every couple minutes (Leak Detected!), and his normal alarms go off every time his blood pressure spikes. He's gotten three doses of Ativan, one of Methadone, and one of morphine...he's still not happy.

They tried him with a rate (10 breaths per minute) and without a rate...he seems to like it better without. When he gets upset, he fights against the vent, shutting down his airway. They took a blood gas after an hour and a half, which was (very predictably) not great. His oxygen was fantastic (172...the best it's ever been), but his CO2 was high (104) and his pH was low. I don't know how bad they'll let his pH/CO2 get, but probably not a whole lot worse. Fortunately, I feel like the issue is almost entirely mechanical, and not really his fault. If they have to reintubate, we'll need to make sure that they have a better strategy next time.

I've been kicked out for medical rounds (2-3:30), so we'll see how he's doing when I get back. I can't be there 24/7, so hopefully they can keep him relatively calm without my help. Almost the entire time, there were two respiratory therapists, a nurse, an occasional doctor, and I...all in a tiny room. The nurse and RTs seem to think he'll do really well if they can get things figured out...they're happy with how he's recovering from his snits. I think the doctor might have an itchy reintubation finger, so I can't guarantee he'll still be tube-free when I go back in. It's going to be a matter of finding a long-term solution to the leak and his attitude, which I think would improve if he were more comfortable.

This would be the point where we need to sit back, take a deep breath, and let the professionals do their job. I might be able to calm him down, but the doctors, nurses, and Andrew himself will really decide if he can stay off the vent.