Peds CVICU vs NICU

walkingthecow · Jan 7, 2015

I work in a CVICU in a children's hospital. Yes, most of our patients are babies, but we follow our patients for life--I often have toddler, teenaged, or adult pts. Then again we are a major transplant center, all CVICUs aren't necessarily.

CV is VERY specialized, and I often don't realize that until I'm floated. We don't have the fast paced traumas and revolving door of PICU, but on average I would say our patients are sicker. CV kids ride a very very fine line between compensating and not compensating.

I have not not floated to NICU yet so I can't speak to that, but keep in mind a lot of NICU is feeding, growing, and crying--even a level IV. Also keep in mind that CV is very intense. Your assessment skills have to be top notch, and you have to be able to make sense of complicated pathophys and what that means for your patient. It is also a very humbling experience--it takes a long time to really know your stuff and feel confident. It is a place with a lot of good outcomes and a lot of hope, but there are also chronic patients who will not survive to discharge.

babyNP., APRN · Jan 7, 2015

NICU kids can be just as sick as cardiac babies (especially in a Level IV), but as walkingthecow said, there usually is a sizeable population of feeder/growers.

I guess my thoughts are what do you want to do in the future? Do you want to be a PNP or NNP? Transport RN? Bedside RN for the duration? Don't know? (that's fine!)

If you tend to lean towards pediatrics (whether later transferring to PICU or becoming a PNP), CVICU would be a better choice as you would usually get older kids and get some good skills that would transfer more easily. But if you love babies, NICU is the way to go.

Either choice will provide excellent experience for either of the units if you transfer later in life. We've had nurses transfer from our Level IV NICU to the CVICU and did well and I can't imagine that it would be extraordinarily difficult going from CVICU to NICU.

I would also keep in mind if either of institutions is a "teaching" hospital; you'll probably have more opportunity for learning there as there is usually a good amount of money put into conferences, simulation labs, certification programs, etc. Of course any hospital can have any of these (and do it just as well), but teaching hospitals tend to have it built in better.

good luck! let us know how things go!

MGMR · Jan 8, 2015

Thank you both! Really great to have information from people with experience in these unique specialties.

I guess my thoughts are what do you want to do in the future? Do you want to be a PNP or NNP? Transport RN? Bedside RN for the duration? Don't know? (that's fine!)

I am interested in possibly pursing transport nursing, but at the moment, my focus is at the bedside for the next couple of years. Especially as a new grad in these specialties, I have years before I feel like I will be comfortable at all.

Another concern is that I've never been specifically drawn to cardiac as a system more than others, although I do understand it more thoroughly than others. But the congenital heart defects and vast number of them is pretty interesting to say the least.

It's just hard as I always saw myself in the NICU now being presented with this other somewhat similar but different opportunity. It IS important to me to have the majority of my patients be infants/neonates, but aside from that, I'm interested in everything there is to learn from both specialties.

Any other information/advice is greatly appreciated!

umcRN, BSN, RN · Jan 17, 2015

I have done both and prefer CICU which is where I work now. While there is a MAJOR focus on the heart you also have to remember that the heart effects every organ system, and many kids with congenital heart defects may have a syndrome of defects which affects multiple organ systems. We have kids with kidney, respiratory, liver, bowel, neuro, endocrine, oncology issues and hosts of others. Just an example I had two patients today, one is a premature neonate with a prenatally diagnosed congenital heart disease, now that the baby is out we actually don't think there is a heart defect at all but a brain MRI showed severe abnormalities. The parents are now facing decisions related to quality of life and palliative care - completely unrelated to a heart issue. The other kiddo is a few months old with a corrected complex heart defect, unfortunately this patient has a host of complications and a syndrome. Active issues aren't even related to the heart but to inability to wean from the vent (trach dependent), inability to advance feeds, dialysis dependence and new seizures - none of those things are cardiac but are all issues she has and that we deal with in the cardiac ICU.

Some kids are born with their problems and others acquire them later in life, we'll get older kids who end up with post chemotherapy induced cardiomyopathy and other diagnosis that can turn up later. Yes most of the patients are babies but we get all ages, in one day you can be taking care of a two day old and a 56 year old (yes I had that day) at the same time.

Generally speaking I think the patients in the CICU are sicker but it's because they have such little reserve to begin with. I worked in the NICU (Level IV) for two years and I will tell anyone that the babies up there can be sick as snot, especially the term PPHN/CDH kids and the preemies who get NEC and spiral down fast however looking at the units as a whole the cardiac kids are much less trustworthy. My first cardiac code was a three year old who spent the morning bouncing on his bed watching mickey mouse and waiting for a bed on the floor to open up. One moment he was fine next we were coding him, cracking his chest and putting him on ecmo. Sadly he didn't survive. Their hearts are so tenuious, one point drop in a base deficit or a half point rise in a potassium level can completely knock them off the edge and into a deadly spiral. Many, MANY of the babies have their chests left open after surgery so consider that too, is that something you feel like you'll be able to handle? Literally watching your patients heart beating with the possibility of needing to use three fingers to do chest compressions on it?

I don't think you can say the units are similar at all personally. I think the transition was easy enough though there were a few things I struggled with initially but I think any ICU to ICU transition shouldn't be all that hard, so long as you know how to code a patient technically you should be safe in any of them but to say they are similar I don't think that's true.

MGMR · Jan 19, 2015

Thank you umcRN for the great info! I wasn't really saying the units are similar (especially as a new grad with no exposure to either specialty), just that the patient population seems to be the most similar between the NICU and Peds CICU than the NICU and any other unit. At least at the Peds CICU I'm looking at, as they explained they've made the unit strictly pediatrics and won't typically accept adults any longer. Also that almost all the patients are babies. Otherwise they seem extremely different, which is why I'm having such an issue.

If you don't mind, could you tell me why you made the switch from NICU to Peds CICU? Did you feel that you had quickly gotten comfortable in the NICU, even being a level IV? I have heard many times that the NICU can become routine with similar diagnoses after a while, but that a level IV can see more variety. The post-op cardiac patients in this level IV hospital however get sent to the PICU which is disappointing.

Also, do you think a new grad with about 12-14 weeks orientation is capable of succeeding in either of these units? The NICU hospital accepts new grads often on their unit, but the Peds CICU is new to training new grads on their unit even though they said I could extend the time if needed.

Thank you again for the time and input, it's greatly appreciated!

Pediatric Critical Care Columnist · Jan 20, 2015

I can explain why the cardiac surgery kiddos go from the OR to PCICU and not back to NICU. Although many CV surgery patients are neonates, probably 1/3 of them are not. Rather than divide the expertise between two units it's better to consolidate it on one unit that can manage all of the CV surgery patients. That's how our hospital works. All the kids come to PCICU immediately post-op. Once the neonates are stable, their pressor support minimal and their intracardiac lines out, they go back to NICU for the remainder of their ICU stay. Our NICU is a surgical unit; they don't have the prems and feeder-growers common to other NICUs, although they get their share of prems with surgical requirements. The system works fairly well, although we're always faced with capacity issues.

umcRN, BSN, RN · Feb 6, 2015

I made the switch from NICU to CICU for several reasons. One; my original "5 year plan" was (like many new grads) to get my two years experience and move on. I am not from the state where I work and I always wanted to travel then move home. NICU was not my first choice but it was my first and only offer and I wanted to work in a large children's hospital so i took it. I loved it but the long stretches of time not having a "sick" kid really dragged me down, there's only so many times I can encourage a pokey preemie to eat and the PPHN/CDH/ECMO and other more interesting surgical kids were just fewer and far between. I also had some personal issues with some of the docs (work related and mostly all boiling down to one patient whom the docs refused to listen to many nursing concerns, not just mine, until it was too late). I got ready to go traveling but figured while I was in such a great children's hospital I should get a little more experience and try another unit to make myself more marketable. PICU was out for me, I'm just not interested in it and the varying cardiac anatomy was always interesting to me, especially since every so often we would get a cardiac baby in the nicu and have to transfer it out once we figured it out.

Shortly after starting in the CICU I got sick and was out of work for a few months. Once I went back it was really more of a necessity to stay in order to keep my great health insurance and benefits (luckily I did since I got sick again a year and a half later and doing that on travelers health insurance would have been hard). I'm now going on almost 4 years in the CICU (total of almost 6 at my hospital) and I am happy. I love the intensity of the CICU and am soon taking the class to sit on the ecmo pump side (take over the care of the pump not the patient), I am happy in my unit, I have great coworkers and the patients keep my on my toes. I have found love in this state (for now though I do hope it lasts) and while I never got around to travelling I am ok with it right now. In two weeks I will be going on a cardiac surgery mission trip and couldn't be more excited, I love these heart kids.

I'm sorry that was the really long winded answer to "why did you leave the nicu" but it's just sort of how my life happened.

Also as far as new grads in the ICU all of the ICUs at my hospital have new grad programs (I was one in the nicu) and I think with appropriate training, support, classes and flexibility with orientation length that new grads can do very well in any ICU setting. We have had new grads that didn't do well for whatever reason and in those instances (in both units I worked in) the educators worked hard to find them a more suitable unit within our hospital if possible.

Whichever unit you choose will give you a solid ground for icu experience and make the transition to pretty much any unit more feasible than having no icu experience at all. Let us know which you choose and good luck!

MGMR · Feb 10, 2015

Thank you all so much for the insight! I've decided after much much thought to go the PCICU route. A lot of factors such as income, commute, and quality of life went into the decision which ultimately made the PCICU the winning choice. I think NICU may still be an end goal for me personally (I couldn't stop smiling when touring their unit), but getting two or more years of experience in a PCICU will obviously only help me to be a better nurse with a broader scope of knowledge. I may end up never wanting to leave the PCICU as well! I'm so excited, these kids look so sick and I have a LOT to learn.

Does anyone have a good PCICU nursing book as a guide for me to begin looking over as I begin? There's a lot of good websites out there for congenital heart defects, but I personally prefer something like a textbook to learn this stuff.

Once again, thanks for all the insight and help :)

Pediatric Critical Care Columnist · Feb 10, 2015

AACN's Core Curriculum for Pediatric Critical Care Nurses has an extensive section on cardiovascular care. It's in my library. I also have The Perinatal Cardiology Handbook by Rima Bader, Lisa K Hornberger (I know her personally, but didn't meet her until after I bought this book) and James Huhta. While that one is more directed at diagnosis there's a lot of solid information about embryologic development, palliation, repair and long-term outcomes. Both books are available through Amazon.

umcRN, BSN, RN · Feb 11, 2015

We teach our new grads to not get too hung up on the cardiac defects during the first weeks of orientation. Better to get your "normal" cardiac anatomy down and focus on getting solid assessment, knowing the normal pediatric vitals and charting skills. So many kids may have the "same" defect but have very different hearts, with time the defects come to be easily remembered but there will always be a kid that comes along and trips up even the most experienced nurses (and doctors!).

prnmed · Mar 12, 2015

In my limited experience, CVICU's hold the sickest of the sick but to echo the sentiments above it is very specialized. Nearly all of the patients you encounter in the CVICU are going to be patients born with congenital heart defects. The road is long and the prognosis isn't always good. I am of the belief that if you can hang in there in a CVICU, you are likely able to do anything. Assessments are ongoing, they don't follow a Q4 cares schedule. Its not uncommon to have patients so ill that I literally follow a "no touch" policy as closely as possible.