New to CICU

Pediatric Critical Care Columnist · Apr 12, 2008

I've been working in a unit very similar to yours for almost 6 years. (We aren't a dedicated CICU right now, so we get traumas and all sorts of other peds critical patients.) There are lots of little things that I've learned over the years...

Never turn your back on a peds CV patient... they can dump their pressures in the time it takes you to turn around and they'll be in real trouble. Get comfortable with having a fluid bolus ready to go even if everything looks fine. When they first come back from the OR they often aren't adequately sedated and will have great BP. That honeymoon lasts a couple of hours. The post-pump slump often hits around the time the surgeon is going to bed for the night so be vigilant!

Don't neglect your chest tubes. Especially if they're sump tubes. Flush those suckers every 15 minutes for at least the first 8 hours or they'll clot off and the surgeon will hate you for disrupting his nap to come and Fogarty it out.

Always wear gloves when you handle pacing wires.

Expect your foley to obstruct about 16 to 24 hours after admission. For the first while you can milk the Y connector just above the tubing and get things flowing again, but that won't last forever. Eventually you'll need to put in a new one. The end will be crusted with crystalline gunk and there may be a tiny bit of blood in the urine in that first hour with the new foley. (Our OR is notorious for putting 6Fr foleys into 10 year olds!)

Know your blood product handling stuff inside and out. Filter or no filter, how fast it can be given, how long it can hang, what products are used for which purpose... and when you start nursing those ECMO patients, figure out what order you'll give them in, because when they've got DIC, you'll be giving lots and lots and lots, all at the same time.

Label all your infusion lines clearly at both ends. That way you can avoid pushing something into the same lumen where you've got your levo going! Make sure your art line is well identified so that you don't accidentally infuse meds into it.

Always double-pump your pressors. Learn how to do it and do it. It's almost impossible to change a syringe when the med is going at much more than 0.5 mL and hour without causing serious hypotension... and creating a LOT of extra work for yourself.

Remember that chloral hydrate, the PICU nurse's best friend, isn't as benign as some would suggest. First of all, it has NO analgesic properties, so if the kid is in pain, it isn't going to work. It's very corrosive in its natural state and should always be diluted BEFORE you give it. (Works faster that way too!) It's metabolized into alcohol so it's a good idea to give Tylenol with ever second dose to minimize the headache. And it causes a transient dip in BP 20 to 30 minutes after you give it, especially if they're also on diuretics. So decide what your panic threshold is for BP before you give it and how comfortable you'd be "riding it out". Oh, and before I forget, it really only puts the kid to sleep, it doesn't keep them asleep, so try not to bug them until just before you can give another dose!!

There are some things for starters. I'm always around for Q&A, so don't hesitate!

PEDSVA · Apr 13, 2008

Thanks Janfrn, I am going to copy those tips down. Changing the pressors out is a huge source of stress for me and the dbl pump idea is a great one, surprisingly I haven't seen anyone do it that way yet. I am still on nights and most of the time the drips are changed during the day. Thanks again, there will more ques. later

Pediatric Critical Care Columnist · Apr 13, 2008

Don't let 'em call you a nervous Nellie! I have 11 years of ICu experience and I know when I need to double pump and when I can get away without it.

In order to double pump your pressors, you need to make sure you have a free stopcock on the lumen you're using for pressors available, since you'll need to attach the tubing from the second pump. If you're running several, it's a good idea to stagger the times when you'll be changing them out so that you'll always have that free stopcock, and that there won't be any big dips in pressure. And don't plan it for a time when you'll be rushed or trying to do several other things at once. I usually start the second pump at half the rate the infusion is going at and watch the BP closely. When I see a slight rise I cut the first pump back by half. Then over the next few minutes I increase the rate on the second pump about every 30 seconds, decreasing the first pump by the same increment at the same time. You MUST watch the BP closely the whole time and adjust the speed with which you make your adjustments according to the patient's response. A BP that is too high is just as bad as one that's too low in the post op CV patient. It might take three or four minutes to get the first pump to off... but you should be able to make the change without any catastrophes if you pay attention to the patient's response. When that's done, I disconnect the first set-up and cap the end so that the tubing can be reused until it expires. If you choose to flush out the stopcock, you'll have to flush it onto a 2x2 or something so that the drug in the dead space isn't bolused into the patient. If you aren't comfortable with doing the double-pump thing on your own, find someone who hasn't eaten you for breakfast and have them watch you.