Peds CVICU vs PICU

Double-Helix, BSN, RN · Jul 2, 2012

My PICU has a combination of both, so I have some experience with both areas.

I wouldn't stick with the assumption that all patients in the CVICU are babies or little kids. It might seem like most of your patients are young, because many congenital heart defects are diagnosed and corrected in infancy. However, (if your unit does open heart surgeries) you'll be taking care of patients of all ages as well. Some congenital defects aren't repaired until late childhood, and other defects require multi-stage surgeries. The later surgeries might be done as teenagers or young adults. Likewise, complications (such as a non-functioning replacement valve) might require these patients to have additional surgeries later in life. Since management of a patient post-op for a congenital defect is different than management of, say, a CABG, our unit also takes care of adults who are status post these surgeries. It's not uncommon for a 40+ year old to come to our unit post-op.

You'll also see patients with arrhythmias, syncope, s/p cardiac catheterizations, surgical complications like infection and chylothorax, possibly patients awaiting transplant, having symptoms of rejection, or multiple other issues. I don't think it will pigeon hole you at all. Cardiac problems in children is one of the most diverse fields there is. You'll have lots of other options- PICU, general peds, peds cardiac floors, adult cardiac ICU, telemetry, etc.

Like any peds field, there is no answer to the question "What's a typical day like?" You can be caring for one or more of kids that I described above. Some might be immediately post-op, intubated, with chest tubes, on pressers, very, very sick. Another day you might have a much more stable patient ready for transfer to a lower level of care. Absolutely no way to tell. But you can bet you'll be doing a lot of monitoring of vital signs, heart/lung sounds, EKGs, fluid balance, assisting with procedures such as chest tube and pacing wire removal, echocardiograms, abulating patients, teaching, communicating with cardiologists and much, much more.

There's also really no answer to which patients are more critical. It just depends. General PICU patients have a huge variety of illnesses: from trauma, to neuro, respiratory, GI, kidney, sepsis, poisoning, cancer and blood disorders, ex-preemies with chronic medical issues, status post operation, and genetic diseases. Depending on the acuity of the PICU and what children happen to be on unit at the time, PICU patients can be more critical than those in the CVICU. Acuity of patients seems to cycle. We'll have a few weeks where the kids are really sick, and then a few weeks when they are less critical. If your CVICU is doing a lot of surgeries, then the kids in CVICU will probably be more critical, in general, then the PICU, but fortunately they recover pretty quickly.

Where are the codes happening? Hopefully no where. I'm hoping that you're not going to choose your placement based on where more children are dying. Codes happen in both units- but fortunately not routinely. As PICU nurses, we pride ourselves on being able to recognize decompensation in our patients and intervene before it becomes a code situation. In the year that I've worked at my current PICU, we've have far more general PICU patients code then those with cardiac issues. But if you're asking which patients are going to experience more arrhythmias and require PALS protocol, then those are probably the CVICU kids.

Personally, I prefer general PICU kids. I like the variety of all the different diagnoses. I also have a passion for peds oncology and hospice. I don't have a ton of experience with the cardiac kids- especially those in the immediate post-op period, so I'm still a little nervous taking care the cardiac patients. It really just depends on your interests and your preference. Maybe you could ask to shadow in both units to get a better feel for the positions. I've learned that people often have a lot of pre-conceived ideas about pediatric units that turn out not to be true in the real world. I certainly wouldn't make your decision based on the ages of the patients you want to care for. Instead, try to find the area that you think your experience and interests would be the most useful.

Myprettykitty · Jul 2, 2012

Ashley,

Thank you so much for the information and your viewpoint. I really appreciate it. And no I don't want the codes or any children to die- that was just a quick question to gage how critical the unit is but I can see that it isn't a good gage at all. I agree that the variety of PICU is what makes me lean towards wanting to work there. So I think I am leaning that way overall. Thank you!

umcRN, BSN, RN · Jul 3, 2012

I worked NICU and now work Peds CICU (and days like today, I float to PICU).

I'll admit I chose CICU over PICU because of the younger population (and my comfort was NICU) but like Ashley said there are adults on the unit, I've had a 51 year old with a pulm hemorrhage. I also chose it though because I am interested in the heart and think congenital heart defects are fascinating. I'd had some experience with these defects in the NICU and wanted to experience more.

There are a variety of patients, but they are a variety of heart patients, but remember the heart effects everything, we get renal failure, liver failure, brain injuries, even certain cancers are caused by transplant meds so we get them too, but yes the focus is cardiac based. As someone who came from the NICU where we focused on all the systems I initially had a hard time adjusting, I find now though that this makes me more well rounded because I can think outside the "cardiac box" at times.

One thing I have learned in CI though is to never, ever trust a sick heart. Kids can and do compensate so long. My first full out, chest cracking, rapid deploy to ecmo was a three year old who an hour before had been sitting up in bed talking about mickey mouse while I got ready to transfer him to the floor. We debriefed on him quite a bit and while there were a few subtle signs (vomiting though he had a hx of severe reflux and his parents weren't concerned by his vomiting) of low cardiac output the doctors admitted that they had not responded to him appropriately prior to the event. I still haven't gotten over it and run it through my head at times.

Like ashley said the ratio of codes per unit is probably roughly the same...and not really something to choose a unit by. (the reason they code will be different between the units and therefore how you respond will vary) This probably sounds terrible to some but I think for me the hardest part about PICU is that many of the patients were normal healthy kids before something happened that landed them in there, I just don't know how I could handle those deaths (while in the CI I am part of the bereavement team). In the CI (and nicu) most of the patients are sick from birth, and while sad, their families are usually more prepared for their lifetime of potential problems, deal with things easier and have an easier time accepting death as freedom from pain and suffering.

This probably didn't help you too much but just sharing my experience

Wolf at the Door, BSN · Jul 3, 2012

Thanks so much you all. I had the same question as the threads creator. Looking to here more. I kind of leaning towards pursuing CVICU.

Myprettykitty · Jul 3, 2012

Thank you umcRN! I loved hearing your perspective as well. It pushes me back towards wanting to work in the CVICU. I do love the wee babies. I was initially interested in NICU (All through nursing school and my 3 years thus far as a nurse until recently other interests started growing.) I would still perhaps choose NICU if the opportunity were there, but the market here is saturated with nurses who are never leaving their NICU jobs. It seems impossible to get in and in a way I think having experience works against me. So I guess I have decided I would be happy with any peds critical care. The PICU and CVICU interest me for slightly different reasons but in the end, I would be happy with either. The more I hear about and read about CVICU, the more I think I would love it there too. Thank you for all of your input.

Myprettykitty · Jul 3, 2012

And that is very helpful what you (umcRN) said about the bereavement process in PICU vs CVICU. I have been worried that I wouldn't emotionally be able to do my job and deal with death in the moment and in the aftermath of a loss. I want to be able to handle it and I figure that others do it and I am as strong as them and will learn to handle it too. At least enough to get my job done and do what needs to be done for the patient and families. I do appreciate the nuance you gave to the subtle difference in the two units. Something to think about.

umcRN, BSN, RN · Jul 3, 2012

Also know that most PICU's and CICU's have not separated yet it, is becoming a trend in pediatric hospitals for sure but many cardiac patients still go to PICU's so if you want a little of both and have a unit like that near you that would also be a good choice

OP i realize this is not your situation (it seems) but I just wanted to let others know that not all ICU's have separated out into the two yet so that in some areas people can pursue both.

You will learn to handle death in your own way. Some people embrace that part of the job (I do) and others want nothing to do with it, however even those that want nothing to do with it have coping strategies and are able to work through it. It's important to remember too, when it comes to caring for the dying child we must shift our focus to caring and being there for the parents almost more than for the child.

Double-Helix, BSN, RN · Jul 3, 2012

In regards to patient deaths in peds, I have to say that I find the sudden, tragic ones few and far between. Usually they are SIDS, accidental drowning, or anoxic brain death for various reasons. It's really quite rare that we see these kids, though. Much more frequently, our patients that pass away tend to be those with chronic conditions, cancer and blood disorders, and genetic diseases (like SMA). So like the cardiac kids, these families also have time to prepare for their child's death.

Pediatric Critical Care Columnist · Jul 3, 2012

The unit where I work has split... sort of. The split was poorly-planned and organized so it's not a real split in the sense of two completely separate units. We're separated by a hallway. The med-surg PICU was moved into a decommissioned former adult CVICU without any apparent recognition of the need for isolation for med-surg patients. There are only two isolation beds on that unit and 8 on the CV side. (They thought we could put two patients into each of those rooms but guess what? We can't.) So there are almost always med-surg patients in the CV-PICU's isolation rooms. Sometimes there are more med-surg kids on that side than there are on the med-surg side, and those kids are usually the sickest ones! The other thing that hasn't split is the staff. We never know what we're going to be doing until we get there.

We've been told that eventually the CV-PICU will move into the neighbouring heart institute. That move will create a lot of logistical problems. How will they decide which staff members will work on which unit? Will staff members have a choice in where they go? If they're arbitrarily assigned to the unit they wouldn't have chosen, will they then decide to quit? What kind of administrative burden will this move create? I prefer the med-surg aspect myself and have made this known to the powers that be. But I suspect that I'm on the list of people who will be expected to work on the CV-PICU. I'm going to have some decisions to make...

suzy192 · Jul 14, 2012

i work in a combines cardiac/picu unit and i must say that the cardiacs can be the most challenging of all the patients. They are the ones everyone gets most nervous about. Being quite specialised you have a whole range of things you have to monitor and think about that you wouldnt even think of in the general picu kids. CVICU will build up you skills amazingly, i say go for it.

Myprettykitty · Jul 14, 2012

Thanks for the input suzy192! I really appreciate it and I have told them to send me to the CVICU! Very excited.