Code Blue Peds Cardiac ICU vs PICU

[MGMR]

Hey all!

I was wondering if any of you experienced RN's could tell me some differences (if any) you found in technique, method, etc. in coding a cardiac kid vs a general PICU patient. Or any techniques/ unit preparations that you found helpful specifically in a cardiac unit.

In my unit, the only difference I have seen so far is that sometimes we prepare an "epi spritzer" for certain types of patients instead of giving a full code dose of epi. My understanding is that an epi spritzer helps to prevent the coronaries from being too constricted from a full code dose, impeding blood flow to the heart muscle. I could be wrong. I'm a new grad and have only witnessed about three code situations, so my knowledge is very limited.

Any and all feedback is appreciated, thanks!

[NotReady4PrimeTime, RN]

The "epi spritzer" is a common practice. 1 mL of 1:1000 epi in 9 mL NS, titrated to effect. It's usually effective in bradycardic arrests and severe hypotension heading toward arrest. We often will have one ready before we intubate a kiddo with dilated cardiomyopathy or some of the congenital defects, repaired or not, as well as when we do sternal closures on the unit or decannulate an ECMO patient. Our usual just-in-case code kit will also have 20 mL/kg of Plasmalyte, a code dose of calcium chloride and a code dose of epi ready to go. Our staff work both PICU and PCICU and there's not a huge difference in how we run codes for non-cardiac kids, other than the deployment of ECPR often being simpler in kids with previous sternotomies. Hope that helps.

[Julius Seizure]

The "epi spritzer" is a common practice. 1 mL of 1:1000 epi in 9 mL NS, titrated to effect.

I've only worked one hospital that used epi spritzers, but it wasn't necessarily 1ml epi in 9ml NS....it was 1 code dose of epi (weight based) in NS to make a total of 10ml.

So if your weight based code dose came out to a volume of 0.38ml, then you would mix with 9.62ml NS to = 10ml total. (Each ml theoretically having 1/10th of a code dose.)

Every other hospital that I've worked at has looked at me like I was making things up when I mentioned an epi spritzer :)

[Julius Seizure]

Oh, here is a difference - in my current hospital, at least, PICU is more likely to use calcium gluconate, while CVICU goes for calcium chloride first.

[MGMR]

That's interesting. In my unit (CVICU), I've never ever seen a morphine drip used actually. For sedation, we use Precedex for non-neonates and Fentanyl drips for neonates since precedex affects heart rate too much.

We also use calcium chloride for codes, but for replacements.. we strangely use calcium gluconate for neonates and calcium chloride for non-neonates. I asked around but no one knows why.

[NotReady4PrimeTime, RN]

Our unit is a combined PICU/PCICU; some of our practice is identical no matter which side of the hall we're on. Calcium chloride. Morphine and dexmedetomidine. Fentanyl for things like chest tube/pacing wire/intrathoracic line removal. Atropine, ketamine and rocuronium for RSI.

The epi spritzer recipe has been standardized along with all of our other drugs. When we first started using them, we did the code dose plus saline to make 10 mL but it's just easier to remember 1:10. We might give a weight-based spritz... 0.4 mL for a 4 kg patient.

[NotReady4PrimeTime, RN]

We also use calcium chloride for codes, but for replacements.. we strangely use calcium gluconate for neonates and calcium chloride for non-neonates. I asked around but no one knows why.

Calcium gluconate is more readily utilized by neonates with tetany or who are undergoing exchange transfusion but it may leach aluminum into the solution from the ampoule. It's not recommended for use in kids other than neonates. It's also not recommended for use in TPN because of the possibility of aluminum adsorption. There's also a difference in the primary cation measures - a threefold higher amount of Ca²+ gram-for-gram in calcium chloride, which should never be given IM. Calcium gluconate may in emergencies be administered via that route. Make sense?

[oopsididitagain]

I work in a PCICU and never heard of epi spritzers before. I guess it's a unit to unit difference. We do stock in our omnicell an epi drip in case of emergencies.

Oh also, cardiologists don't like NaHCO3. During codes with severe acidosis we do use it but in non codes we very rarely give bicarb. Fluid boluses are preferred. I believe NaHCO3 can lower intracellular pH. Bicarbonate therapy and intracellular acidosis. - PubMed - NCBI

We give Calcium chloride in codes and calcium gluc for regular replacements. I think it just depends on practice.