Withdrawal, Headaches, PRN's & Setbacks

Friday & Saturday have been rough for Mr.Steele. His medical team rounded on him Friday morning, they were really happy with his progress. The plan was to remove the chest tubes and his central line, then move him upstairs to the floor. Just before 11am, Steele started going into withdrawal from the narcotic regimens that he has been on all week. He was doing very well weaning the IV drips of Versed and Morphine, but still needing PRN's (when needed) to rescue him from getting upset. These rescues are done with Versed and Morphine which calm him down, but increase the demand for needing them for pain management.

Going through these withdrawal episodes are extremely stressful for everyone involved. In addition to withdrawal, Steele is dealing with massive headaches due to his newly formed circulation and surgical pain from his chest being opened up. A lot of moving parts to manage. The withdrawal went on for about 1/2 hour, he received both the PRN's and finally calmed down. During this time one of his chest tubes that allows fluid to drain off your thoracic cavity after surgery had this milky fluid in it. The normal fluids that drain through the tubes are blood and other fluids that gather in the abdomen. This new fluid is called Chylothorax or "Chyle". Chyle contains high amounts of triglycerides (fat) which are essential for his recovery and overall health. The Attending MD was notified right away to come and have a look at what was happening. A sample of the fluid is sent to the lab as confirmation, but it was very obvious to the nursing staff and MD that it was in fact Chyle.

This changed everything. This first thing is to take him off breast milk and move to a low fat formula with a high caloric volume. It may seem counter intuitive, but the thinking is minimize the amount of fat and let the lymph fluid from the thoracic duct repair itself for up to 6 weeks. As you can imagine, Rachel and I were upset about this plan. The breast milk has antibodies to fight off infections, and provide essential nutrients for his growth. Steele does not respond well to sudden changes, his history has proved it. Rachel discussed other options with the Fellow MD, one of which included going back to breast milk if he was not handling the new nutrition. Additionally, his chest tubes and central line would not be removed. Pretty major setback, but his overall heart function was doing just fine.

Steele had an extremely rough Friday night, his night nurse kept giving him rescue PRN's of morphine and versed, but he burns through those very quickly, in about 1 hour. He was vomiting from the sudden change in nutrition and his feeds were turned down from 40 ml/hr to 5ml/hr. So, he was getting stacked with narcotics, food was not staying down, and he was up all night. Rachel arrived at 6:30am to discover that Steele was a train wreck. His fluid levels were really low, and we know that his vital signs are much better when he is fluid positive. He was starving, had headaches, and going through withdrawal. The plan was not working for him.

Rachel had a long discussion with the hospitalist about changing his feeds back to breast milk.  Steele was crying and writihing in pain most of the day today (Saturday), and after many PRNs of morphine, versed, and ativan, there was still no relief.  The team also gave him medications for gas, motrin for headaches, increased doses of ativan and morphine, but to no avail.  After exhausting all other options, the Attending MD decided to start a new drip, precedex.  Precedex is sedative that is often used in combinations with other sedatives and does not interfere with respiration.  Steele was on a precedex drip long ago when he was very sick, and withdrawal from the precedex was a nightmare.  Rachel reminded the attending about the problems Steele had withdrawing from the precedex, but seeing as that was the only option left, it would be added to the medical regime anyway.  The central line would need to stay in because of the new drip, and chest tubes will stay in because if the Chyle continues to drain, there will have to be another intervention. This means we are still not able to hold Steele, which is unfortunate, because holding him is usually a very helpful tool for calming and soothing him.

Rachel deserves all the credit for his care and advocacy these last two days, I'm so thankful that she has the working knowledge to effectively communicate strategies with the medical forces in the CVICU. All the tinkering with his medications, nutrition and pain management do not work well with Mr.Steele.

This also means our transition out of the hospital will be delayed for an undetermined amount of time. Please send Mr.Steele your positive thoughts and prayers. Thank you all for the kind messages and continued support.