Cardiac PICU

Okay, you know that we're not able to give medical advice here, and I don't get the sense that you are asking... more of a mom-space kind of query. As a PICU nurse yourself there will be a lot of this experience that will be very familiar. For the moment I'll pretend I don't know you're a PICU nurse and tell you the kinds of things I tell my patients' moms all the time.

AVSD isn't common, especially in children without chromosomal abnormalities or other congenital issues. My hospital does approximately 900 cardiac surgeries a year between our 3 surgeons, with an overall mortality rate of about 3%. Of those, perhaps two dozen are for AVSD and they often appear in clusters. Surgery usually occurs within the first 4 to 8 weeks of life for children with CHF, and between 3 months and a year for those with less-significant defects; depending on the size of the defect and its associated symptoms, the timing of surgery is predicated on the degree of congestive heart failure the baby is experiencing. The surgery typically takes about 4 hours if all goes according to plan. Add in pre-op prep time and you're looking at about 5 to 5 1/2 hours.

When the baby comes onto the unit post-op, there are a number of things that happen simultaneously. Monitoring is established, lines are sorted out, the chest tube(s) are assessed for bleeding and suction applied, labs and gases are drawn, the pacemaker is attached (whether or not it's ever needed we attach it for the first 24 hours), IV fluids are changed, fluid boluses are given as indicated, analgesic and sedative infusions are started, a chest x-ray, a 12-lead ECG and post-op orders are obtained. Most babies will be on an inodilator like milrinone to improve contractility, decrease systemic vascular resistance and minimize metabolic demand. It looks totally chaotic but really isn't. A good team can get all of this done in under 30 minutes. I try to have the parents brought to the bedside once the chest xray has been done.

Looking at the baby, you'll see the obvious: ETT, NG, central line (usually a right internal jugular but may be left IJ or femoral), arterial line (perferentially a right radial - my preference!), left atrial line (allows easy assessment of myocardial function - high LAP means poor LV function) sternotomy incision, mediastinal chest tube (ours are sumped so they can be flushed with sterile saline as often as q5 minutes if there is a lot of bleeding - prevents tamponade), temporary pacing wires, Foley catheter, temperature probe and oximetry. There are often at least a couple of peripheral IVs as well. The surgeon may have opted to leave the sternum open and only suture the skin closed, if there has been a lot of myocardial swelling. This is subsequently closed in a second procedure a few days later.

Children with surgical interventions in the area of the AV junction will usually have some conduction issues in the days following surgery. The most common of these is junctional ectopic tachycardia, a self-limiting state that responds to cooling, sedation/paralysis and overdrive pacing. Very infrequently they require an implanted pacemaker. Valves may need further adjustment or replacement in a small number of children, often as they approach adolescence.

The typical ICU stay for a partial AVSD repair can be as few as 2-4 days with a total hospital stay of about a week. More time is obviously required for children with complex lesions and post-op complications. The time to extubation is often related to the degree of pulmonary hypertension the baby has developed.

Cardiopulmonary bypass definitely has its risks, but in the OR setting with all the checks and balances in place and the intense monitoring the patient receives, it's by far less fraught with problems than bedside ECMO in the ICU. I know this is all very scary and overwhelming. But I also know that the odds of everything going absolutely perfectly are far higher than you think. Best of luck to you and your baby. Let us know how it all goes.

You're so welcome.

Older kids have told us that the most painful part of the surgical experience for them is the chest tube. The sternotomy isn't uncomfortable by itself... there isn't a whole lot of movement there. The chest tube on the other hand moves with deep breathing, coughing, laughing, repositioning and so on. Once that's gone so is the source of pain. We give our kids 1 mcg/kg of fentanyl before we pull them so they're pretty oblivious.

Caring for post-op cardiac patients is interesting but can become quite routine. I'm very glad that we also do a good amount of med-surg on our unit. Our acuity is quite high, no matter what we're doing. We do neuro, ENT, solid organ transplants (including heart, heart-lung, lung, liver, kidney and multivisceral), trauma, and the rest of the typical PICU kind of stuff. The reason we do so many cardiacs is because we serve half of Canada, from Lake Superior to the Pacific.

Your guy has an excellent outlook. Best wishes.

That's great news!! The star were all aligned for him that day, weren't they? We'll all hold good thoughts for August.