[nu2LVNnowwhat]

Hi, Ive been an LVN for a few months now and I work for a home health Peds. agency.

I've been given a new pt. 8 yrs. old, CP, central line and a Gtube. I'm going to school with him and it's been great. I just love the little guy and his classmates.

Question, His mom tells me they're going to start weaning him off the central line. That last time they did this his co2 levels increased and he ended up in a coma.

I'm not allowed to do anything with his central line (his mother refused an RN)

I'm a little worried-what should I be looking for? other than the obvious, of course.

[Jolie]

I'm a little confused by your information.

Is his central line being used for parenteral nutrition? If so, then I assume the plan will be to gradually increase his feedings (oral and/or g-tube), while slowly weaning his IV fluids. I don't understand how that would relate to elevated paCO2 though. Increased CO2 levels result in respiratory acidosis, and are usually related to poor ventilation due to chronic lung disease, pneumonia, muscle weakness, and neuromuscular diseases. I don't get the connection to his central line.

[nu2LVNnowwhat]

I've had him for 2 weeks. He's new to the agency and there isn't much history. All I know is what mom told me, that "They're going to start weaning him off the TPN again but slower than last time because last time his co2 levels went up and he ended up in a coma." She says they couldn't find out why but it wasn't the first time.

The first week was at home, my job was pretty much babysitting. Conversations with mom turned to schooling -I have a special needs child too- and she decided she'd prefer a nurse for school instead of home. She's never had a HH nurse before and didn't really want one. No one ever told her she could have a nurse go to school with him.

He eats (PO) like a horse but has almost no small intestines left. The central line is for TPN and the Gtube is for Pediasure. He's being weaned off the Gtube as soon as he can suck down (and tolerate) 4 cans of Pediasure a day...HOOORAY!!!!! Gtube can go bye-bye.

Problem is the tolerate part. He hates the taste and medicaid won't pop for strawberry or chocolate flavor so mom says, but I'm going to check that out myself. I've got exp. with those (deleted bad words).

[janfrn]

I'm going to have to think on this one. I'm not really making the connection to the TPN and CO2 levels, unless he's a chronic aspirator, as so many of these kids are. Let me think...

[kristenncrn]

Hmmm....

Primary metabolic alkalosis leading to compensatory respiratory acidosis? Could the metabolic alkalosis be caused by HCO3 loss from the GI problems? TPN could correct pre-emptively the issue... and then once he is off? I don't know - that is perplexing.

And as far as symptoms - headache, especially at night or first thing in the morning. Change in LOC, confusion, anxiety, tachy, sometimes tremor...

Anything I've forgotten, I'm sure the other folks here who are smarter than me will remember!

[janfrn]

I was thinking along those lines too. I've looked after chronically ill children before who have ongoing problems with acidosis (often with short gut, as this little guy has), who have a bicarb supplement given orally or per GT to maintain their pH in the normal range. The chronic aspiration picture still may apply and depending on how severe his CP is, he may also have ineffective respiratory effort, and thus not blowing off his CO2 properly.

Can't say I blame the little gaffer for not liking Pediasure. That stuff is vile! If Medicaid won't pay for the other flavors (which don't cost any more than the vanilla!) maybe Mom could be adding a tablespoon or so of strawberry or chocolate syrup to it. He might like that better. If he's quite spastic, the extra calories won't be a problem.