Friday, October 1 - extubation

So, after the overly eventful Thursday, my last few days at Kijabe hospital arrived.  I would work a regular day Friday, be on call Saturday and Sunday, and then finish with two regular work days on Monday and Tuesday.  I arrived Friday and went to the ICU to check on the child we had intubated on Thursday.  He was doing "well" on the ventilator, meaning that oxygen was going in adequately, carbon dioxide was coming out adequately, and his lungs were not requiring high pressures to achieve this.  This is not truly good news because it means that his breathing problems from the day before were not caused by a lung problem, they were caused by a brain problem: his brain was not telling his diaphragm to breathe sufficiently.  On my examination, he would withdraw from pain but had very little else that was positive from neurologic standpoint.

We had talked with neurosurgery prior to intubation the day before, and they said they would give him a trial of a few hours on a ventilator to see if he would recover respiratory function.  We had decided to give him longer than a few hours and allowed him to spend the night on the ventilator in order to be certain that he was not going to recover adequate respiratory function.  After another round of discussions with Dr. Letchford (ICU/med/peds), Dr. Lee (ICU), and Dr. Albright (neurosurgery), the consensus was that if the child was going to recover, he would have resumed spontaneous respirations and started to "overbreathe" the vent, which he had not done.  

The prognosis was discussed in depth with the parents and they were given the choice to transfer to Kenyatta Hospital in Nairobi for further ventilation care or he would need to be extubated and allowed to try to breathe on his own.  Kijabe Hospital did not have the resources to perform prolonged ventilatory care on a baby that would most likely never recover.  We advised the parents that if the child was extubated, he most likely would not breathe adequately and would likely pass away.  The parents decided against transfer for continued ventilation and chose extubation, with the understanding that the child would not be reintubated if he began to have respiratory failure again.  We extubated Friday afternoon to CPAP (continuous positive airway pressure) to give him the best chance to make it and the child initially did breathe some on his own with the assistance of CPAP.  Prior to extubation, the chaplain came up and we prayed with the family before stopping the ventilator.  At the end of the day he was still breathing spontaneously, though somewhat irregularly, and there was a glimmer of hope that he might make it.