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Controlled Coma

Journal, Blood - 10/04/2009

01:00 AM
We are running out of medical ways to control his intra-cranial pressure. We are unsure what is actually going on inside his head, but we cannot take a "field trip" to get a Head CT because it is too risky, and in any event there is no reward because low coagulation numbers prevent us from putting in a vent or operating.

Those ICP numbers are hovering in the mid 20's (they should be under 20). Hopefully the bleeding stopped, and this is just edema that is still peaking. His sodium levels are maxed, and the lung ventilator pressures are high 43/8. His CO2 levels are high but they cannot speed up the ventilator to blow it off because he has a pneumo-thorax (air pocket outside his lungs) and also extensive sub-cutaneous emphysema (crackly lumpy air swelling under his skin) up and down his side, shoulder, chest, and neck. There was talk about switching to an occilator (another method of ventilation) but one of the doctors pointed out to me the high ventilation pressure would substitute the ICP in the equation calculating cerebral perfusion (oxygenation of the brain). Basically higher lung pressures would increase "downstream pressure" (central venous pressure) against his mean arterial blood pressure - lowering his cerebral perfusion. His head oxygen saturation monitor reads 64, and we don't want it going lower.

So his lungs are maxed. His alveoli are very sick. They need high pressures to "pop open" and stay that way. His oxygen level is at 100 which in itself is damaging to the lungs. Everytime they try to suction, or change filter, or do any little adjustment and the Peep (positive end-expiratory pressure) falls for a few seconds, the alveoli all "de-recruit" ...and it takes a long time for them to open back up. Meanwhile his oxygen levels sink. I don't think they even want to try the occilator because of the huge risk in just switching equipment.

And every time his breathing is disrupted, his CO2 levels rise which dilates the brain vessels and causes his ICP to jump up. It is a viscious cycle that hasn't been improving.

Sedation has been growing more tricky, and that is causing ICP spikes from time to time. So we decided to put him into a coma using Pentobarbital. He got 1.5x loading dose and finally dropped ICP to 20. I'm not sure if this is going to allow us to drop other sedatives or not ...will ask on rounds tomorrow.

We started weaning the dexamethasone (I'm worried about it choking out his T-cells)
...but with his lungs right on the edge I did a bit of poking around tonight and found this study:
The effects of vitamin E and dexamethasone on inflammation of acute lung injury and expression of myosin light chain kinase
"...the inflammation and hemorrhage in the 2 treatment groups were significantly improved ...attenuation of pulmonary edema and inflammation..."

We checked with the attending doctor to be sure Vit E wouldn't compromise critical care, and then gave him a subdural dose (also swabbed his lips with it - it made a great mouth care).

I've also been trying periodical tummy/intestinal healing herbal doses but to be honest, the more sedatives we put on board the slower things are going to go and I'm not sure we are getting far. I started to look up studies on stomach absorption as opposed to intestinal, but there is a limit to my energy at 1:45 AM. I suppose if I really want to get something into his blood I can use the subdural method (now that he is in a coma) or the suppository method ...but while everyone else is worrying more about his brain and lungs ... one of my main purposes is to heal and protect his gut from progressive injury because we need that in the weeks to come. So I'd rather not take shortcuts ...it would be nice to get things to make the trip from top to bottom. Not sure if that is possible.

07:25 AM
On 100% oxygen (vent settings maxed). Can't turn it down even for a little, his stats drop to the 80's and take a long time to come back.
Sub-Q air on both sides, necks, chest, arms, poor little guy is blowing up like a balloon.
Heart: 91, BP: 121, Oxygen: 93, CO2: 37, ICP: 27 CPP: 75
Head saturation: 69, Renal saturation: 68, Arterial Blood Gasses: pO2 67.4, pC02 59.0
Blood Sodium maxed 167, and sedation maxed (pentabarb coma), intracranial pressures hanging in the low 30's

11:00 AM
The drug Pentobarbitol is so nasty that it ruined one of the lumens of his Picc line.
Suction this morning, and a couple of deep bagged breaths managed to re-recruit enough to get a jump in perfusion/ventilation, which instantly lowered his ICP (intra-cranial pressure) so we weaned his vent settings a point.
However his ICP is again in the mid 20's even though his respiratory stats remain up.

The doctors agree that Jaymun's situation is so critical, and his margins of being able to handle toxicity so small that even if he somehow miraculously makes it through this crisis (we are at a wall with all options exhausted)
...he still has rising leukemia to face, and it is doubtful he would survive a month of chemo let alone radiation and another transplant.
Our goal has been to just get him home for a time, but even that goal looks unachievable.
They advised that if Jaymun gets to the point where his heart stops then CPR is probably pointless
...we are going to leave that situation in God's hands ...if his heart stops no CPR will be performed.

9:30 PM
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