here is the letter from Dr. H on 10/20

[Guest guest]

Dear Mrs. ,

So what happened between 3 and 9pm? Perhaps did she have a sever drop and

was on the rebound?

YES, for sure!!

I just put her up to bed so I guess we will see what happens. I just wish I

understood the problem we have days of low and now this.

You did the right thing to call for advice, to wait until her BS was down to

start her as you did and to establish that your Accu Check was working

correctly. I will be interested to know what her BS’s were during the night.

I

think that it is important to have some D10W ¼ NS at home so that you can

connect her up to it during the day if she is not eating. Better yet, Dr. Chen

could help you decide whether you need to slow the rate and increase the

number of hours she is fed during the day when she is in one of her non feeding

episodes. It was these non eating episodes combined with her BS instability

that prompted my suggestion that she NOT be cycled down to night feeding alone.

Dr. Spigland has explained to me that from a surgeon’s stand point, placing

the J-tube must be separated from the revision of the Nissen and the

repositioning of the G-tube because the former is a ‘dirty’ and the later

two are ’

clean’ procedure. She has also explained her technique for placing a J-tube

and the tube she uses designed to minimize problems. As a result our new plan

will be as follows:

1. We will get Madison back to normal. [i suggest spreading her TPN

back to continuous.]

2. Mrs. and Dr. Spigland will schedule the procedure at Cornell.

3. When we are set on a date, Dr. Chen and I will speak our Cornell

colleagues in the PICU, Endo and GI about what we want to happen.

4. She will be admitted to Dr. Spigland’s Surgical Service 48 hrs

before the procedure to roll down her TPN to a concentration of D10 and

establish

a stable blood sugar on it.

5. Because of her prior problems after anesthesia both at Cornell and

MSSM, Dr. Spigland and I will work with anesthesia from both services to work

out what she should and should not get in terms of anesthesia related

medication.

6. After surgery she will go to the ICU where her TPN will be moved

back up from D10 to D20 while she is awaiting initiation of J-feeding.

7. PICU, GI, ENDO and I will work together to carefully taper TPN as we

increase J-tube feeding. [if establishing J-feeding and stopping TPN is

taking a prolonged time AND she is completely stable from a surgical

standpoint,

she could be transferred to MSSM, making it easier for me to do this.]

8. When she is no longer on TPN, a protocol must be established to

maintain the inject-a-port for venous access. I need it to do an OGTT and it

will be very handy for access during the prolonged upper GI surgery.

9. After the J-tube tract has healed, she can return for the upper GI

surgery.

If this is acceptable to all involved we should proceed. If not, let me

know and I shall revise the plan. I shall be away from 11/4 to 11/13 so it

should not be scheduled during that time.

Dr. H

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