Need info on Pediatric Cardiac ICU's

Pediatric Critical Care Columnist · Dec 29, 2006

Hi Steve. Welcome to the fascinating world of peds critical care. I work in a unit exactly as you describe. I love the work, and would be totally happy if the working environment was better, but that's not the work's fault so I won't belabour it.

Our unit is based in the University of Alberta's Stollery Children's Centre. On paper we have 16 beds, but we often have 18 or 19 patients; we average about 850 admissions per year and have a mortality rate of 2.6%. About 2/3 of our patients are kids with congenital heart defects; our catchment area for CHD covers all of western Canada from the Manitoba-Ontario border to the Pacific, and from the 49th Parallel to the Arctic Circle. Having said that, we have also treated children from every other province in Canada and from a number of other countries as well, due to our world-renowned cardiovascular surgery program and the reputation of our PICU. We also have the only Canadian pediatric extracorporeal life support program west of Toronto. Recently we became the North American training facility for the Berlin heart, an external four-chamber pulsatile artificial heart. The remainder of our patient population are kids who have other transplants, respiratory illnesses, hematologic or oncologic crises, trauma, dialysis, neurosurgical procedures and metabolic disorders.

Our typical assignment is 1:1, although very stable transfer-ready kids may be 2:1. The CV procedures we do range from simple PDA ligation to the Norwood-Glenn-Fontan series, arterial switch, total anomalous pulmonary venous return repair and heart transplantation. Our patients are often on multiple vasoactive infusions such as epinephrine, norepinephrine, vasopressin, milrinone and sodium nitroprusside; I've run all five of those in the same patient at the same time. We don't use a lot of dopamine or nitroglycerin, and I've only seen phenylephrine used once in more than four years. We use a variety of anaesthetic and sedative drugs both as infusions and for bolus administration. Our current ECLS patient was on 350 mcg/kg/hr morphine and 12 mcg/kg/min midazolam plus frequent PRNs the other night, and I fully expect him to be on a ketamine infusion when I go back.

As a senior staff member, I may or may not have an assignment. When I do, I generally have one of the sickest or I'm admitting a kid back from the CVOR, so it's really nice when I get a stable, extubated-and-waiting-for-a-floor-bed kiddy. When I don't have an assignment then I'm the code nurse and resource for all the other nurses on my shift. Those days are often much busier than the days when I have a really sick kid.

We have a routine we follow with all our patients. At the beginning of the shift we do a head-to-toe assessment, equipment and safety checks, document our assessment and draw up a work list. We do q4h ABGs on all our patients as a rule, so the first one is at 8 o'clock. All our transplants have a ton of meds due at 8 as well, so they can be really busy. We reassess head-to-toe every four hours, and document vital signs, ins and outs and ventilator settings hourly. We haven't yet moved to computerized charting but that's coming. In between we do basic nursing care and treat any urgent concerns like hypotension, which is a very common thing for CV patients. It's important to be flexible and to be able to think on your feet, because one minute everything will be on cruise-control and the next the kid is trying to die. Organization helps; if you can have your routine stuff done a little early then it doesn't end up being hours late... if you know what I mean.

I spend a lot of time talking when the parents are at the bedside. They need a lot of reassurance and explanation so they can understand what's going on. I encourage them to be involved in their child's care to the extent possbile while keeping safety on top. It's important to be honest with them and to admit when you don't have the answer to a question, because trust is essential. So the more you know the easier it is to build trust and cooperation.

It's a really rewarding area to work in and the kids are so precious. I can't see myself anywhere else. At least for now. I hope I've hit the high points for you. Let me know if there's anything else I can tell you about.

SteveNNP, MSN, NP · Dec 29, 2006

wow! Thanks for the great reply! You seem to be very passionate about your job! I really think I'd like to make the switch someday once I find the right unit.... BTW, Why was that kid on epi/vaso/primacor AND Nipride? Wouldn't it work against the others? or was it for coronary artery vasodilation? Do you ever deal with Swans, CVP's etc??

Pediatric Critical Care Columnist · Dec 30, 2006

We routinely transduce our central lines, even the tunnelled long-term ones some call Broviacs. Central venous pressure is an important indicator of fluid volume status and right heart function, so we like to have a number (even if it's not exactly accurate as with the Broviac because of the compliant tubing) that we can follow trends with. Our cardiac patients also come out of the OR with a left atrial line (most of them anyway) that gives us similar information about left heart function. And occasionally we have a right atrial line too, but rarely. However, we do not use Swans for any reason. There are many studies out there in the adult population that have demonstrated that Swans do nothing to improve morbidity or mortality or shorten length of stay, and some studies have actually shown they are associated with MORE complications and sequelae.

As for your other question... yeah, Nipride antagonizes inotropes. It's our drug of choice for controlling blood pressure in the post-op cardiac patient because of its potent effect and short half life. It's easy to titrate and wears off quickly, witht he added benefit of improving coronary perfusion. We'll use epi to improve stroke volume and cardiac output as well as for peripheral vasoconstriction. Norepi has more of a vasoconstrictive effect so we'll add it to epi if we need to keep increasing the rate to maintain cardiac output and BP so as to limit the myocardial irritability that epi at higher doses will cause. Milrinone improves contractility, but can cause arrhythmias and hypotension, so we have a maximum dose we go to (0.75 mcg/kg/min), and sometimes we stop it altogether. Vasopressin will be added when we need to continually amp up our other pressors so as to limit their adverse effects. We need a good blood pressure to maintain end-organ prefusion, but not TOO good. So our goal arterial BP will be a bit lower than normal for age, say systolics between 65 and 80 for a six month old, or 75 to 90 for a five year old. A BP too high will put stress on the suture lines within the heart and cause them to pull away... catastrophic. And we can only give so much fluid (we use a lot of 5% albumin) to prop up BP without actually compromising cardiac function (and ticking the surgeon off!!), so drugs are our friends. Dumping a bunch of fluid into a stiff heart with dilated ventricles is a waste of time. I know, clear as mud...

We need more good people in PICU, so when you're ready I'm sure you'll be snatched up in a second.