Fluid Rollercoaster or Waterslide?

This post has been updated at the bottom

There are three kinds of men. The one that learns by reading. The few who learn by observation. The rest of them have to pee on the electric fence for themselves. -- Will Rogers

Today I have felt like each of the men described in the quote above. In our last post we mentioned the desire to get more fluid out of Andrew and dry him out. We have read as much as we can put our hands on and know this is the right thing to do. After observing his lack of progress and eventual transition to renal failure, we became more convinced than ever that the only fluid we were moving was that in his blood. We started requesting that the fluid they were removing from his ECMO circuit (hemofiltering) and the diuretic drugs be stopped. After an entire night of asking and begging that they stop trying to dry him out, he looked horrible. His eyes were so sunken that the lids would not close on their own when he slept and we had to put in eye drops. His blood chemistry was also starting to look bad as were the numbers that tell you how his kidneys are doing. After a few more hours, I lost my ability to control myself. If you took the other issues off the table and looked only at his fluid levels, kidney failure is what most people would expect. At the beginning of the last trial off ECMO the attending stated we should be "looking at the patient and not the numbers". After an entire night of beating the fellow to death asking her to end this, that same attending had not been there to look at the patient. Needless to say, I said MANY mean things that I should not have... I should feel bad about this but it is how I felt and I was tired of being ignored. So, ten to twelve hours later, the team rounded and decided to stop the diuretics but continue the hemofiltering but at a lower rate. This was a good, albeit late, first step but at that point we would take what we could get.

A consult with the pediatric nephrologist was requested along with a renal echo to look for clots in the kidneys. The nephrologist on call was Dr. Wigfall. I can not begin to explain the relief I felt when I saw him enter the room. This is a man that is very active in the Medical School and I have had a little contact the with over the years. His attention to detail is exactly what we needed to solve our dehydration induced renal failure. His conclusion is that we were too aggressive with the hemofiltering and probably created a situation where the kidneys were not working because there was nothing for them to do with the current lack of vascular fluid. This was great news because shortly after this, hemofiltering from the ECMO machine was stopped and some fluid was given to replace the huge vascular loss. It took several hours for the changes in Andrew's appearance to return to their current almost "normal" state.

Andrew also developed some oozing from his ECMO cannulas. The team made several attempts to control the bleeding but ultimately had to call in the cardiothoracic surgery fellow to do some stitches. This seemed to work well, for the few minutes we were still there anyway.

The really GREAT news is that we are just getting home and Andrew is starting to pee again. Up to this point he has only put out 3 cc's of urine all day. When we left the hospital at a little after 11pm, he had produced almost 22 cc's. He is still relatively inactive and looks like he has no energy left at all but we are excited about the small amount of urine we see now.

The plan for tonight/ tomorrow is to start weaning him down on the ECMO flows. They are planning a VERY slow wean so I feel much better about this than any of the other trials. I have to wonder if it would not be better for him to be more stable...

The other news we have to report is that Harley (our roommate) passed away in her mothers arms this afternoon. As she was unable to get a heart for transplant, it does remind me of why I am an organ donor.

EDIT: Since I posted this, five hours has passed. In that time they did try to cut the flows from Andrew's ECMO which also lowered his urine output. They have returned to full flow again but his kidney chemistry numbers are looking worse. Nephrology has been consulted again. I am also excited about a new attending in the PCICU since all his renal issues started at the same time the last attending took over and started pulling fluid off.