Wednesday, April 22, 2009

Extensive damage: particularly to brain and kidneys

The initial insult caused massive oxygen deprivation to all of Lachlan's organs: lungs, heart, kidneys, liver, gut, and brain. Unfortunately this badly damaged most of them, far beyond what you would normally see for a premature baby.

His lungs were initially doing poorly and like any premature baby delivered without steroids in an emergency, needed artificial surfactant to stay open. Four days later he is still on a mechanical ventilator, although it looks like he won't have to stay on it. He is taking many breaths on his own and is often down to atmospheric oxygen concentration.

We don't know a lot about his gut and liver. The later isn't doing it's job but the doctors don't seem too concerned. He won't be fed by mouth for at least a week because they figure he wouldn't be able to process the food yet. They are freezing Juliet's milk for when he's able to eat it.

Fortunately his heart appears to be normal.

In general his levels need a lot of balancing. He gets sugar, calcium, potassium, lipids and other basic compounds intravenously. For a while they were very concerned about his blood pH which was too high and causing cell damage. His kidneys are very bloated and doing very very poorly. There's a chance that they won't make it, but we recently heard the specialist is now cautiously optimistic for which we are very glad. If they don't pull through he would be on dialysis for a least a year until he could possibly get a transplant. He would only be considered for one if he
didn't have multiple organ failure. We're not yet certain if that would be the case.

Low clotting factors, hemoglobin, etc. have lead to numerous, repeated blood, platelet and plasma transfusions. These and the other fluids have left him very bloated as his non-functioning kidneys and liver have left him holding fluid. This in turn means they cannot give him as many fluids and transfusions as he needs. He has started peeing so we're optimistic that he'll void the excess fluids. It's a step by step process whereby a small improvement in one area allows treatment of another.

Unfortunately the much needed transfusions had another adverse (but expected for cases like Lachlan's) effect. After blood loss and partial brain shutdown, a new influx of blood causes an infant's brain to fire uncontrollably in the form of seizures. In themselves seizures aren't bad. However the uncontrolled, rhythmical firings increase in size and damage the brain. Frequent and severe seizures can cause serious brain damage. Lachlan was showing signs of seizures at Alta Bates: raised heart rate, lowered oxygen intake, lip smacking and posturing (a certain stretching of arms and legs). Baby seizures are much more subtle to spot than adult seizures. They gave him an EEG Fri afternoon which showed no seizure. However repeated suspect behavior lead them to transfer him to the Oakland Childrens' Hospital neonatal ICU Sat, where he is now. There they have neurologists with experience with babies. They have run EEGs on Lachlan almost everyday. With anti-seizure medicine which knocks him out, they seem to have his seizures under control. This should be protecting his brain from damage from seizures.

An ultrasound on his brain Mon showed recent bleeding (after his transfusions). It seemed localized, although they found a blood clot in one of his brain's ventricles. Pressure buildup from blocked fluid making it's way to his spine will cause the ventricle to dilate, forcing the surrounding brain tissue in turn to atrophy. This news was heartbreaking: an earlier ultrasound of Lachlan's brain showed no bleeding (we now realize there was no blood to bleed, but the damage was probably there) and the seizure treatments seemed to be working. We were encouraged by the possibility of surgery to alleviate the problem however. Treatment would relieve the pressure with a catheter or shunting the clot to his abdomen for reabsorption.

An MRI was scheduled for Tue morning; EEGs and ultrasounds of babies' brains only show one picture each. The former is restricted to seeing damage to lower order brain function. We felt optimistic that the MRI wouldn't show too much more brain damage.

The preliminary MRI results are bad. Bleeding has happened all over his brain (not detected by ultrasound) and there is a lot of swelling, much like what we see externally due to his fluid retention. The neonatologist said his brain has suffered "quite extensive damage". We will find out more, including a better idea about his prognosis and treament (if any) tomorrow in a "family meeting" with the neurologist, neonatalogist and social worker 3pm today Wed.