Chest Closed and WARNING.....photo at bottom of page

So I really wanted to get a photo up for people.  And I figured now that his chest is closed it would be the right time.  But I thought it would be nice for me to bury it at the bottom of this post.  So if you aren't feeling like seeing it, that is okay and just don't scroll all the way down.  Just to prep you though, he has his vent in and you can just start to see the top of the chest tubes.  His incision is covered with bandages and he is looking pretty darn fabulous, in my opinion. 

Okay.  On to the big news of the day.

You didn't misread that up above.  His chest is CLOSED!  Hooray!  We were actually starting to think it might not happen today but then, suddenly, the surgical team was free due to a cancelled surgery and they made him their priority.  This really needed to happen today, as far as I was concerned, because he was desperately trying to wake up. 

Jason and I went to bed and when I came down at 6 this morning, Hans told me T had opened his eyes and been a little agitated. 

Geez.  Ya THINK??? 

So began the peaks and valleys of pain management.  Over the next 3 hours, he would wake up, bite his breathing tube, and move around and they would give him bolus doses of versed and he would calm down. He had a set schedule of versed every 2 hours, but he was waking and panicking a bit much more often than that.  In addition to this, his LAP had gone up into the mid 20s again, so Megan, the NP drew a bit more blood out of the chest tubes and it dropped a smidge. 

***I interrupt this blog post to show off my newest cardiac knowledge***

LAP, or Left Arterial Pressures

In a healthy heart, the blood flows, unrestricted, from the lungs into the left and right atria via the pulmonary veins.  Next, it goes through the mitral valve into the left ventricle and finally, it gets pushed out to the body through the aorta. 

Typically you would expect to see LAPs in the single digits.  But several things can occur that will cause that number to go up.  Tiernan has a probably combination of the following:

1. Surgery is an "insult" to the heart. (really, that's what they call it.) So the ventricles get stiff and don't get rid of all the blood on each pump.  (Ejection)  So when the Atrium is trying to send it's full volume into the Ventricle, there isn't room for it all.

2. The Mitral Valve is still a tad on the small side and may have some mild regurgitation (backflow) which causes the LA to have to work harder to get the blood through the valve.

3.There is still a fluid overload in the tissues from when The Kidneys were on strike. This makes the heart less efficient in it's pumping and therefore the LAP goes up.

 

***Resume regularly scheduled blog post***

 

Dr. Cisco and NP Megan both feel okay about his LAP being a bit higher because the above factors are all likely.  Also, now that we are several days post op, there just isn't the concern that a higher pressure could blow sutures.  (It's AMAZING how quickly the heart can begin to heal.)

 

More on the LAPs later.

 

Back to the Pain Management Plan.

We want to avoid peaks and valleys.  That's too stressful.  And so they started a drip of Versed to keep him steadily infused.  So now he has a combo of precedex and versed (low anxiety) and  fentanyl and Tylenol (for pain).  This should keep him nice and comfy.

 

The team is extremely pleased with all his peeing.  He is still puffy, but not anywhere near where he was. 

 

At one point during the day, his nurse thought there might be something a little wonky with his rhythms.  So they ordered an EKG and thankfully found that everything is still normal normal NORMAL!  WOOHOO!

 

Just after that, they came into do the chest closure and he tolerated that like a rockstar.  In fact, he surprised them all by not doing as expected (shocking, right?) and lowering his LAPs!  That is the opposite of how this usually works.  So fun to see him finally not following rules in a positive way.  So now, they are creeping back up between 17 and 19. Still a bit high, but lower than it was and NOT unexpected.

 

The other big news of the day was that he started breathing above the vent.  This means he was initiating breaths in between the ones the vent was doing.  This is a really important step toward extubation.  They are expecting Wednesday might be a good day for that.  In the meantime, his upper left lung was a bit collapsed, but they are not overly concerned.  They will keep an eye on it over the next few days. 

 

Tonight they also were finally able to start some nutrition...albeit IV nutrition.  TPN and Lipids are on board, which means he will need some Lasix again. 

 

So the plan for the night is to keep him nicely sedated and calm.  He is breathing above the vent as I type this, so the deeper anesthesia from the surgery seems to be wearing off, which is good. 

 

I am undecided how my night will play out.  I am not too eager for him to wake up and not see me or Jason.  So I think we will be taking it in shifts from this point onward.  It's totally worth it to see those eyes though. 

 

IF you don't want to see the photo, then stop scrolling at this point.  To see my brave boy, keep on going

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Almost there...

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