Cardiac PICU

Pediatric Critical Care Columnist · Feb 12, 2011

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.

heartmom27 · Feb 13, 2011

Thank you! Thank you so much for taking the time to share all of that information. I have been fascinated with CHDs since my son was diagnosed. To be honest I really did not know much before now since we do not do cardiac in my unit.

From a mother's point of view the whole thing sounds terrible to see my baby have to go through this but from a weird nursing point of view it sounds like it would be a fun to take care of cardiac babies post-op in the PICU. We don't get a lot of really sick critical pts in my unit but when we do it is the assignment everyone wants.

I can't believe how many cardiac surgeries your hospital does in a year. From what I have learned the AV Canal does seem rare. I am so blessed we only live about 35 minutes from Johns Hopkins so that is where we are going. So far my son is 15 weeks old and the last echo he had showed the vsd closed and there was minimal leaking which told them that his pulmonary pressures were not high (fascinating!) So as of now he is not on any medications and they said we would probably get the surgery closer to when he turns one.

One thing that I have come across that I found interesting is the use of stem cells to make heart valves. I am amazed at what science can do today.

Thank you again for sharing all this knowledge. I love our doctors but it is the nurse who is really with the patient all the time. I am just praying everything goes smooth and they are able to keep his pain under control. Who knows I am loving learning about cardiac so much that I might consider going to a hospital that does cardiac. I will definitely let you know how it goes.

Pediatric Critical Care Columnist · Feb 13, 2011

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.

NeoPediRN · Feb 17, 2011

I just wanted to chime in. I was diagnosed at two years old with a transitional AV canal (ASD/VSD/PDA). I had immediate surgery, spent a month in the PICU (this was back in the 80s), and am now 26 years old and healthy. I've had a yearly EKG and echo my whole life, and a stress test starting this year, and have never had to go back to the OR. I have mild mitral and tricuspid regurg, and don't even need antibiotics before a dentist appointment anymore. My patch has held up really well, and so far there's no sign of a valve replacement in sight! The only thing I've battled is poor endurance. I could never keep up in gym class and exercise has always been a challenge for me (but I'm also lazy and don't like to exercise). Sending you good thoughts. The procedure has come far since I had it and I'll keep my fingers crossed for an easy and uneventful surgery for your son.

heartmom27 · Jun 20, 2011

I just wanted to update everyone. My son did have his open heart surgery to repair his AV Canal defect on May 2nd. He started actually losing weight. It took him 2.5 months to gain 3oz before surgery and in only 6 weeks he has gained two pounds.

He did amazing with the surgery. He only spent one night in the PICU and two nights on the floor. So a total stay of only 3 nights in the hospital. Amazing! His follow up two weeks after surgery showed moderate leaking of the mitral valve so we are now praying when we go back in August this will improve and he won't need another surgery. So the unexpected journey continues. Thank you to everyone for all the PICU RN to RN advice and support. Sometimes you just need to hear things from another nurse.

Pediatric Critical Care Columnist · Jun 20, 2011

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