new day. New complication

light at the end of the tunnel

2nd biopsy

Ananya had her 2nd biopsy. The biopsy showed no rejection which is good news.

Awaiting biopsy results

Ananya just had her biopsy. Its always disconcerting to let her go for these procedures - I hope she and I never get used to it. The results will be back this evening. Her output from the abdominal drain (JP drain) is the same - it just fills more slowly. I don't know what that means. She's only getting 6 hours of IV fluids now - and gets 50% of what she puts out in the JP drain back in the form of albumin. I continue to hope the longer our stay here extends.. that no other complications develop - like line infections, pneumonias, kidney failure etc. Normally the central lines stay in ~ 3 weeks...we're nearing that mark without an endpoint in sight. Boy, I can't wait to get out of here, and stay out...

Still hoping for a drought

Ananya has been on steroids for 6 days now. She seems so much better than the girl who last thursday had a belly the size of africa and was lying in bed listless, not even able to turn her head from one side to the other. Her belly has shrunk a significant amount, one of the drains in her belly stopped draining, and she's eating, laughing and playing with us. (The steroids make her a little cranky).
That's the good news. Unfortunately the amount of fluid out of her abdomen (the ascites) while diminished is still significant. Enough for the transplant docs to think she may not be responding completely to the steroids, and that there may still be some rejection left to go after. So she's scheduled for a liver biopsy tommorrow to see. If there's rejection - she'll get a t-cell antibody treatment - thymoglobulin or OKT3. Both have reasonable side effects so I hope the biopsy looks good, and that by tommorrow the ascites has reduced to nothing. I know, I know - wishful thinking.

Interestingly it was briefly mentioned to us that Ananya being of Indian origin may have something to do with the rejection she's had. One of the tranpslant docs. looked back at the last 4 transplants done here which involved a caucasian donor and indian recipient. All of them had rejection to a significant degree. 4's a pretty small number but interesting none the less.

So here's to hoping Ananya's belly dries up soon..

New Attending, New Plan

So Starting monday we got a new attending surgeon. What are attendings? Attendings are the senior most physicians in charge of you or your loved one's care. They are the - in the words of our eloquent president - 'The Deciders'. All decisions are supposed to be run by them before anything happens, because they are responsible for your care. There are typically residents, fellows, physician assistants, nurse practitioners as part of the team - but all of them are acting on the attendings behalf.

So the center Ananya had a liver transplant at has 4 pediatric transplant surgeons. Each of the four take turns taking care of the patients in the intensive care unit and on the regular floors. Every week a different attending is on 'service' taking primary care of patients.

This rotating model of service is what you find at a lot of hospitals. So If I see Dr. Jones who is part of a 5 physician group - and I happen to get admitted to the hospital for a pneumonia - I may not necessarily see Dr. Jones - I'll see the physician who's turn it is that particular week to see the hospital patients for the group.

A system that makes sense, right? Well a little side effect if you have the misfortune of being in the hospital long enough is that each particular physician may have a different plan for you. So for example, on Sunday Ananya was thought to be in need of more fluid to jumpstart the kidneys. On Monday, the new attending makes a plan to take fluid off to jumpstart the kidneys. I think it can be a little disconcerting for patients and families when plans shift 180 degrees - b/c it suggest uncertainty among the physicians taking care of you, and that someone's wrong. Of course the standard answer I think we as physicians would give if queried about why the plan is so different than our colleagues (we seldom are asked) is to say that the patients clinical status changes on a day to day basis. So Ananya could have had too little fluid on Sunday, and have too much fluid on Monday - so everyone's right. And so everyone's happy that the patients attempt at clearing the mist has been thwarted.

Anyhow, the new transplant surgeon had a bevy of new ideas - Ananya needed lasix to get fluid off, and we should get an x-ray to follow some fluid that was noted in the lungs. I questioned him to make sure I understood why he thought lasix would help - (a diuretic) - b/c if she didn't have enough fluid - a diuretic would make kidney function worse. Ultimately he said the prograf causes the kidney to clamp down, and that little kids, unlike adults just didn't have the capacity to deal with a lot of fluid. So while you or I could pee out 5 extra liters of fluid babies kidneys need a little help. So fine, I accepted. The X-ray was a harder sell There is good data to suggest cumulative radiation dose in kids will result in a higher rate of cancer later on. Now one x-ray is like a drop of water in terms of radiation dose - but I'm thinking of total aggregate dose she may get in the next 5 years - so I absolutely refuse to have her get studies which won't change the teams management. The attending said he just wanted to follow the lung fluid that was noted prior. I didn't need an x-ray to tell me her lungs had less fluid - she had gone from needing 2 liters of oxygen and saturating 93% to being a 100% on no oxygen. In addition her lung exam certainly ruled out a significant effusion. But I was interested to see whether the right upper lobe of her lung that had been collapsed after intubation was now open - so I agreed to the x-ray.

The x-ray result came back first- the lung fields looked great - no fluid...but the right upper lobe was still collapsed. Bummer. So more chest PT, and some breathing treatments to try to break up junk that may still be in there. After ananya got the lasix she peed like she hadn't peed in a while, and it lasted well after the lasix effect should have passed - the labs the next day did show an improved creatinine from .4 down to .3. Yay!

Ananya's mood improves!

Oh I almost forgot - Ananya is returning to the baby I remember. Happy, cheerful, playful, wilful - which is great to see. For a while she was this listless baby that just layed there and stared. She's still v. deconditioned which surprises the surgeons a little I think. Prior to the transplant she was walking with help, now she won't really even sit up on her own. Her legs are also much skinnier than they were before - so she's going to need some major physical therapy. But honestly, I am surprised at how backward Ishani went functionally. Hopefully it won't take her too long to physically return to herself as well. As a parent - its hard to be patient. Once we get out of the hospital, I'll edit some of these posts with pictures..