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Discussion

Berlin's and toddlers

Hello all! My units been doing Berlins only for about a year now and our previous patients have all been babies. Our current patient is two. Our unit does not send vads to step down and this pt is a total floor status kid. No iv meds, ng feeds,stable and was previously healthy and just wants to run and be a toddler. Thing is she's paired now because she's stable and while her mom never leaves and is pretty god about entertaining her there are just some days when she's in her room screaming because she's bored and we can't let her out of the stroller because she will just run off. Our child life is a joke, we can't get volunteers, pt/ot doesn't come for long or on weekends and if we're lucky we can get her out for a walk or two I the hall. Usednto take her outside but with her being paired and the recent spike in our acuity we can't scrounge up two vad trained RNs (per our policy) to get her out. What do you with these kids all day? Mom needs breaks too sometimes, she doesn't leave the hospital but showers and leaves to eat and kiddo just sits in her room screeching for attention if mom is gone. She's pretty good with her toys but it gets to a point I just feel bad that we have to confine her to the stroller and her room all day.

Also as a side question of interest, what do you do for dressing changes in this ave group? Sedation/no sedation? Just curious.

Thanks for the insight, we're still learning with these kids but so far our success rate has been good.

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    We send our Berlins (all of our VADs actually - Berlins, Heartmates, Heartwares) to the cardiology ward as soon as they no longer need ICU-level care and have been doing so since 2005. To be quite honest, these kids actually get better care from the ward nurses because they have care of them for so much more time than we do in the PCICU. The parents are trained to manage the IKUS and to do dressing changes as soon as is practicable. Once the parents have been trained, they're free to take their child off the unit independently. Toddlers soon learn just how much rope they have and tend not to over-reach. Two of our teenagers went home with their Berlins and went back to school. At least two of our Heartwares went home too. As for dressing changes, we use ketamine or fentanyl in the early days when the exit sites are still very sore, but eventually they need/get nothing.

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    Well our hospital will definitely not be sending them to the floor anytime soon...years maybe, our "stepdown" is a bit of a joke. (" oh we have to wean your milrinone by 0.2? Back to icu for you, home bipap at night? Nope sorry icu for you too). And parents are definitely not doing dressing changes. I think people are a little scarred because our very first Berlin had a massive wound that never fully healed until after transplant so dressing changes are a huge to do niow. At least this kid has no breakdown or wound issues anymore but she freaks out so Much that we give her a little versed which helps a lot...we tried with out and it was a disaster so our vad coordinator nixed that. We also require two vad nurses just to walk around the unit. Parents are not taught anything abourt the machine except what to do if its alarming because the cannula is kinked (all the freakin time w this kid who somehow ended up with two different catheter sizes and lengths, the aortic one kinks all the time if she is sitting and leans forward too much).

    Interesting to learn what I hope our future can be like. For now though we are stuck with them (and our states tax payers are left footing the multi billion dollar bill for the extended icu stay in the patients who lack insurance). We do have our first heart ware right now whose getting ready to go home (didn't go to the step down either) but still required two vad RNs for all travel, hall walks etc. Total overkill especially if you're walking around IN the unit...one would hope that if the kid went down for so!e reason SOMEONE in our 26 bed unit would come help

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    We definitely try to get our VAD kiddos to our step-down unit ASAP. We have VAD engineers who manage the pump and are responsible for checking it and our step-down unit as pretty awesome nurse patient ratios. Whenever possible VADs are in a 2:1 assignment or 3:1 at the most. It tends to get a little tricky when there are multiple VADs though. Kids really do much better in the step-down unit once they're allowed to be kids again.. They're allowed to go to playrooms, walk outside, etc. As far as dressing changes go, they get sedation in the beginning while their sites are healing, but eventually they don't seem to need anything. Childlife is really good at providing distraction tools or getting music therapy involved.

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    Our VAD kids stay with us in the CICU, we won't send them to the stepdown so they are at most a 2:1 assignment. As far as dressing changes our current kids don't require sedation although if the risk is there that the child will infect the insertion sites that would have to be taken into consideration. Our policy is to do any VAD, central, or art dressing with 2 RNs so one does the dressing change while the other assists keeping the child calm or holding them still.

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    Our VAD kids stay with us in the CICU, we won't send them to the stepdown so they are at most a 2:1 assignment. As far as dressing changes our current kids don't require sedation although if the risk is there that the child will infect the insertion sites that would have to be taken into consideration. Our policy is to do any VAD, central, or art dressing with 2 RNs so one does the dressing change while the other assists keeping the child calm or holding them still.

    It takes us FOUR people to hold this two year old down and sans sedation she screams bloody murder and shoots her heart rate up to 230+, even though her sites are completely healed. Our child life and music therapy are terrible and are no help to us for not just dressing changes but life in the cicu in general.

    Sigh. :banghead:

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    I remember a 3 year old who was like that. Not just with dressing changes but with ANYTHING. And the parents just sat and watched.

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    our "stepdown" is a bit of a joke. (" oh we have to wean your milrinone by 0.2? Back to icu for you, home bipap at night? Nope sorry icu for you too).

    Some of that could be due to hospital policy as well. Our stepdown is allowed to have a couple of straight rate pressors, but nothing titratable. No titrating home milrinone because you need to verify adequate contactity with SWAN numbers. No weaning long term vents. Pts must either be 24/7 vented or vented only at night. Some of the nurses who have been there a long time have some excellent critical thinking and assessment skills, more than me for sure, but hospital policy is hospital policy.

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    I was accepted an offer at a large teaching hospital in the PICU and I'm waiting for my copy of Hazinski's text to be delivered...meanwhile I'm learning tons of stuff trolling this board, lol (admittedly though most of it is coming from google searches of things like "Berlin" and "VAD"). So humbled to be joining such a rewarding specialty.

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    Welcome, welcome, welcome! I hope you love peds critical care as much as we do!

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    We're going on four months...O negative...:banghead:

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    If only the amount of frustration caused to nurse got her higher on the transplant list...

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