James is having surgery tomorrow to fix his heart murmur (more technically, to ligate or close his PDA). As we may have mentioned before, this is a fairly common surgery for preemies. Any surgery has risks, but this procedure has an excellent safety record, and the surgeons at UNC are very experienced with it. The pediatric anesthesiology team that will be treating him is also very experienced. So of course it's scary to have our little baby having surgery, but the expectation is that he will come through it fine.
The surgery is scheduled for 11 AM, but the nurses warned us that surgeries often do not start on time. So don't worry or be surprised if we don't post any updates until tomorrow evening or night.
We were hoping that we wouldn't have to put him through the surgery, and if he hadn't had the second episode of necrotizing enterocolitis (NEC), the decision most likely would have been to not do it. (My understanding is that this surgery is more typically done on babies who are having respiratory problems, because the heart murmur changes the pattern of blood flow to the lungs. Although James still needs some breathing support, he hasn't needed a lot of supplementary oxygen, and he's basically been on pace with Matthew, whose murmur was closed by the drug treatment. So they wouldn't have done the ligation for respiratory reasons.)
But the doctors now think that the murmur is preventing James from getting adequate perfusion (basically, oxygenation) to his intestines, and that this may be contributing to the development of NEC in his case. The suggestive evidence for this is that 1) for the current bout of NEC, the bowel problems are not resolving as quickly as they usually see, and 2) in the kidney ultrasounds, it appears that there is some backflow of blood, so that the kidneys are getting perfused for one part of the circulatory cycle (when the heart is contracting), but not during the other part of the cycle (when the heart is relaxing). In essence, then, those organs are only getting part of the oxygen they need. As I mentioned in the last post, the kidneys themselves aren't a particular concern, but they don't have good ways of measuring intestinal perfusion yet, so they're using this as a proxy. An additional factor is that when they did the most recent echocardiogram, they saw a very slight increase in size in the left side of the heart, which indicates that the PDA may be causing his heart to have to work harder. Taken together, this suggests that the surgery may really help take stress off of some of his body systems by getting his circulation back to a more normal pattern.
This surgery used to be the standard of care, and relatively routinely done for all preemies who had a PDA. It still is in some hospitals, but now there has been some research questioning the benefit of the surgery. In particular, it is not always as effective at helping respiratory problems as people expected it would be, and it also appears to increase risk for some kinds of later problems (developmental delay or disability). (At the moment, this association with later problems is just a correlation -- they don't have an explanation for why it might happen.) As it happens, two of the leading experts who are advocating not doing PDA ligations are here at UNC. We spent a long time talking with one of them a couple of weeks ago. (He wasn't even "on duty" at the time, yet he took an hour or so out of his day to discuss all this research with us -- the doctors here are awesome.)
Certainly having this counterpoint makes the decision to have the surgery more difficult, but on the other hand, we know that the other doctors on the faculty are very aware of this research, and two of them (plus the cardiologist) have recommended doing the surgery nonetheless. The two who made this recommendation are the doctor who was in charge during the last rotation, and the doctor who is in charge for the current rotation. Neither one of these doctors has any wish to put a baby though an unnecessary procedure, but both of them believe that it is the right course of action in this case. We have come to agree with them. Most importantly, we want to do all we can to have him avoid getting NEC again. (He's come through it twice, but it's a serious disease that can be fatal.) Obviously the PDA surgery is not a guarantee of that, but the doctors think it will help. And although it may slightly increase James's risk for other problems down the road, he already has risk factors for those problems, and we just have to hope for the best.
The surgery is scheduled for 11 AM, but the nurses warned us that surgeries often do not start on time. So don't worry or be surprised if we don't post any updates until tomorrow evening or night.
We were hoping that we wouldn't have to put him through the surgery, and if he hadn't had the second episode of necrotizing enterocolitis (NEC), the decision most likely would have been to not do it. (My understanding is that this surgery is more typically done on babies who are having respiratory problems, because the heart murmur changes the pattern of blood flow to the lungs. Although James still needs some breathing support, he hasn't needed a lot of supplementary oxygen, and he's basically been on pace with Matthew, whose murmur was closed by the drug treatment. So they wouldn't have done the ligation for respiratory reasons.)
But the doctors now think that the murmur is preventing James from getting adequate perfusion (basically, oxygenation) to his intestines, and that this may be contributing to the development of NEC in his case. The suggestive evidence for this is that 1) for the current bout of NEC, the bowel problems are not resolving as quickly as they usually see, and 2) in the kidney ultrasounds, it appears that there is some backflow of blood, so that the kidneys are getting perfused for one part of the circulatory cycle (when the heart is contracting), but not during the other part of the cycle (when the heart is relaxing). In essence, then, those organs are only getting part of the oxygen they need. As I mentioned in the last post, the kidneys themselves aren't a particular concern, but they don't have good ways of measuring intestinal perfusion yet, so they're using this as a proxy. An additional factor is that when they did the most recent echocardiogram, they saw a very slight increase in size in the left side of the heart, which indicates that the PDA may be causing his heart to have to work harder. Taken together, this suggests that the surgery may really help take stress off of some of his body systems by getting his circulation back to a more normal pattern.
This surgery used to be the standard of care, and relatively routinely done for all preemies who had a PDA. It still is in some hospitals, but now there has been some research questioning the benefit of the surgery. In particular, it is not always as effective at helping respiratory problems as people expected it would be, and it also appears to increase risk for some kinds of later problems (developmental delay or disability). (At the moment, this association with later problems is just a correlation -- they don't have an explanation for why it might happen.) As it happens, two of the leading experts who are advocating not doing PDA ligations are here at UNC. We spent a long time talking with one of them a couple of weeks ago. (He wasn't even "on duty" at the time, yet he took an hour or so out of his day to discuss all this research with us -- the doctors here are awesome.)
Certainly having this counterpoint makes the decision to have the surgery more difficult, but on the other hand, we know that the other doctors on the faculty are very aware of this research, and two of them (plus the cardiologist) have recommended doing the surgery nonetheless. The two who made this recommendation are the doctor who was in charge during the last rotation, and the doctor who is in charge for the current rotation. Neither one of these doctors has any wish to put a baby though an unnecessary procedure, but both of them believe that it is the right course of action in this case. We have come to agree with them. Most importantly, we want to do all we can to have him avoid getting NEC again. (He's come through it twice, but it's a serious disease that can be fatal.) Obviously the PDA surgery is not a guarantee of that, but the doctors think it will help. And although it may slightly increase James's risk for other problems down the road, he already has risk factors for those problems, and we just have to hope for the best.
3 comments:
We are sending special prayers for James tonight - for a perfect surgical outcome, speedy and complete recovery, and strength for you guys.
R
I thought I already left a post but I must have clicked to fast and missed a step!
Anyways, as I said, we are still praying and believing!
Love Ann
We'll be thinking of him, and you, today.
Post a Comment