Peds CVICU

Pediatric Critical Care Columnist · Sep 2, 2009

Oh where to start! Most of our CVICU-type patients (our unit is a mixed one, but primarily CV) are neonates or infants, since most congenital defects are repaired very early in life. Then we have a subset of 3-5 year olds who come in for their third stage single ventricle palliation or for ASD/VSD closure. Once in a while we'll get an older kid with a suddenly-symptomatic PFO that needs dealing with or for a valve replacement. And of course cardiomyopathy doesn't care how old one is.

What do I like? Seeing the dramatic improvement in kids once their hearts work properly. Helping the families understand the surgical repair, the immediate aftermath and the long-term implications.

What do I love? The intellectual challenge of caring for these kids. The busy-ness of titrating multiple drips, giving fluid boluses, analyzing labs to see if we could do something better. When they come back for a visit two years later and you only know who they are because you recognize their mom... they look so healthy and normal.

What is challenging? Imagine a child who weighs 2.5 kg and is 18 inches long. Imagine a median sternotomy that is half the length of the child's chest that terminates with a mediastinal chest tube. The sternum is open and the skin sutured. There are also two pleural chest tubes, AV pacing wires and attached cables, a left atrial line and a right internal jugular triple lumen central line all occupying the same real estate. Now we'll add a Tenckhoff catheter. There are also a Foley and a rectal temperature probe in situ. Said child must be nursed with the backrest elevated to a minimum 30 degrees for VAP prevention so is supported by numerous rolled receiving blankets. Now tell me how you would change their diaper.

What do I hate? The attitude of the surgeon that as long as the heart is good they've done a good job... never mind that the kid has bled into his head, his kidneys are shot and his lungs are so bad that he's trached and ventilated months later. The attitude of the surgeon over lack of beds for the patients he has waiting in the wings... look around you, joker! Six of our beds are occupied by your successes that have been here for months and are going to need to be here for more months before they die anyway. Maybe if you wouldn't have done those nine surgeries on Johnny and admitted that he wasn't going to get better, you'd have a bed today. We had one kid who started out as a hypoplast who was with us for 15 months before he died. It was horrible. Another was a kid lost to followup who has now been in hospital 17 months, lost both legs and will need dialysis for life - but his heart works. Another victory, right?

I tend to get a little annoyed at the mother who sits at the bedside of her spoiled 5 year old who has just had a simple stitch ASD closure and came to the unit extubated and awake, crying her eyes out because he wants water and I won't give it to him. Look around you lady. The baby in the next bed has been here for a week, he still has his chest open, he's on huge doses of inotropes to keep the blood getting to his brain, he's on PD and insulin because his cardiac output isn't good enough to perfuse his kidneys and pancreas, he's still on ECMO alert and his parents are thrilled when he opens his eyes.

So that's my world in a nutshell. Those 50 year olds? They could take lessons from my toddlers who never complain about anything... except having tape removed!

sicushells, RN · Sep 2, 2009

lol, I try to empathetic to the 50 years old with a carepath CABG, but I often have some comment like, "Every day is a blessing, isn't it?" slip out of my mouth.

I'm going to apply for the CVICU that I've been looking at. Thank you for giving me some more information.

Pediatric Critical Care Columnist · Sep 3, 2009

We'll have to compare notes once you've been there for awhile.

sicushells, RN · Sep 3, 2009

:) I love your confidence in me. I still have to apply and get a job offer. I'll post with an update though.

Pediatric Critical Care Columnist · Sep 3, 2009

Of COURSE they'll hire you. They'll be able to orient you in no time flat and they'll have a good CV nurse with little or no effort on their part.

sicushells, RN · Sep 4, 2009

Do you have any suggestions for how I might reaquaint myself with the peds world? I would defiantely like to brush up before any interviews, and I really don't remember that much from my peds rotation in nursing school.

Pediatric Critical Care Columnist · Sep 5, 2009

The best place to start would be to review vital signs, weight and height norms for children of each age group. Do some peds drug calculations to refamiliarize yourself with how the dosages are determined. Most of our drugs are weight-based doses, so invent a few pretend patients and calculate meds for them. The most commonly used drugs in a peds CVICU would be things like infusions of epinephrine, norepinephrine, milrinone, heparin, amiodarone, morphine, midazolam, fentanyl, propofol, prostaglandin, furosemide and nitroprusside. Intermittent meds are usually things like morphine, lorazepam, chloral hydrate, cefazolin, piperacillin-tazobactam, magnesum sulfate, furosemide, Aldactazide, calcium chloride, acetaminophen, ibuprofen, captopril, sildenafil and so on. You can look at just about any drug resource and find peds doses listed. Have a look at http://www.cincinnatichildrens.org at their interactive cardiac section and check out the major cardiac lesions. And maybe take a look at the PALS algorithms, although I don't think you'd need to memorize them until such time as you're actually taking PALS. And if the opportunity presents itself in the interview to throw out something about asking the parents how the child usually behaves, reacts, responds to meds etc, GRAB IT!!

Good luck!

sicushells, RN · Oct 15, 2009

I have an interview in November! I've started to look at some of the peds info at Cincy's website, but now the the interview's closer I'll start to buckle down. Thanks for the help!

sicushells, RN · Dec 10, 2009

I just wanted to let you know that I got the job! I'll be starting in a few weeks.

rnguy25 · Dec 11, 2009

Congratulations sicushells!!! Kick butt!!!

janfrn, I know this is off topic, but I have to say that I admire what you write and what you do for this forum in many ways. You give hope, inspiration, knowledge, comfort, confidence, support, and much much more. I've been a PICU nurse for 6 years, haven't been a member of allnurses that long, nor do I post much, but being a lurker of these forums, I notice what you provide for this community and nurses all around. You rock!

sicushells, RN · Dec 11, 2009

Ditto!