Jan 27, 2012

Blood Culture Negative!

I will try to recount the day.  (Much is medically complex.) 

Manny slept well.  The nurse got the hint. (Yay).

The day nurse today was one we'd had before and let's just say that by the end of the day, she'd shared some pretty personal information.  I got to bless her, speak into her life, hug her, comfort her. 

The Infectious Diseases doc came in and was pretty certain that this blood culture was either a contaminant or a transient infection.  The second set of cultures drawn were NOT positive!  (Yay)  This is incredibly great news. 

He suggested a plan ... and the plan made sense, but didn't take into account the whole overall situation.  So we took his plan under advisement but knew that Cartaya would have his own say about the whole thing. 

Finally Cartaya came in and he and I talked for quite a while about the pros and cons, the risks/benefits of all the options we have.  Eventually the head of the IV team (Stephanie) came in and she was in on the conversation. 

The bottom line is ... Manny's situation is unique.  To treat him, you have to deal with a lot of "gray" areas.  We all basically make this up as we go.  And today was no different. 

By the end, we settled on a very strange solution.  I'll try to explain. 

In most cases, the right thing to do would have been to pull the PICC line and put in a broviac.  (That was the Infectious Diseases doc's suggestion.)  But for Manny, there is a real possibility that he could run out of veins.  And THEN what?  So we have to protect every vein like it's gold.  We can't just go pulling lines. 

So ... since this line wasn't infected, we could still use that vein.  BUT, since the line was out of place, it had to be repositioned.  To do that, you have to go in and rewire it.  Basically, they put a wire in where the current line is, pull the old line out and the reinsert a whole new PICC line.  So it's a clean, new line but in the same vein. 

Now to the next problem .. his HORRIBLE skin rash (allergic reaction to the dressing/bandages).  There is even some skin break down where there is the clamp (stat lock) that holds the line in place (making sure it doesn't go in or out).  This arm is a MESS.  (It wasn't.) 

So we decided to suture the PICC line in place instead of using a stat lock.  This is basically unheard of.  But it's what we needed to give the arm some much needed break from the stat lock. 

It worked!  Dan and the kids arrived just as we were headed down to the procedure so they waited with me in the waiting room. 

When we got back to the room, we noticed that his bandage was completely pulled away from the site and his whole PICC line was completely exposed (A MAJOR MAJOR problem and a potential source of infection .. this field is supposed to stay completely sterile).  The nurse immediately put tegaderm on it to help until Stephanie could arrive. 

Once she got here, we noticed there was some leakage around the PICC site.  (Not good news ... could mean that there is a compromise in the PICC line.)  The whole bandage had to be changed ... which involves an alcohol based cleaning solution.  Imagine THAT on open wounds about 3 inches by 4 inches wide!  (Poor baby).   Something we have to keep an eye on.  If it keeps leaking, the PICC will have to be removed. 

About 8pm he fell asleep.  We're putting oxygen directly on his arm to try to keep it dry and see if the parts that are exposed can start to heal.  We have to keep an eye on this too. If the skin doesn't heal, we have to remove the PICC. 

Finally, there is one spot that looks like it MIGHT be phlebitis.  (But it also could just be rash.)  It's possible that the old PICC had curled around and was sending the TPN back up the vein.  (There was a lot of biofilm on the PICC ... and when there is that, it sometimes does that.)  It's complicated ... but the bottom line is - we have to keep an eye on this as well.  If it's phlebitis, we have to remove the PICC. 

So as you see, there's a lot of great news ... but also a lot of things we have to keep our eye on. 

If all these are under control tomorrow, we go home!

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