What kind of kids do you see in your PICU?

[sergel02]

Another pediatric question I was thinking about. I know every PICU is different and at a different level, but I was wondering what kind of kids you see in your unit. All I know is most PICU's have vented patients and open heart post-ops. I know at the 3 PICU's in my area, once a kid doesn't need the vent, they tend to get taken down to med surg.

Also, something I've been really curious about, is the age range you see. Mostly toddlers, under 8, adolescents, etc.? I have a friend precepting in a PICU and they get a lot of heart kids since there is a CVICU for peds, but since the hospital is also a major trauma center they get a lot of teens doing things they probably shouldn't have.

Thanks for any help :)

[sergel02, BSN]

There were so many terms I had to look up lol. I learned a lot from just that. I think that's something interesting about PICU and nursing in general, always something new to learn, which is great for me since I like that.

I knew there were like a 101 ways a kid could be born with a messed up heart, but the same seems true for getting issues with their renal system. Sad, but someone has to take care of them.

The age range is interesting. A lot of them do seem younger, and I don't know if it's a PICU thing vs. floor or all peds is like that. Something I wondered is how is treating say a 4 year old different from a 14, outside of dosages, and communication/psycho-social support?

Slight aside, but the friend I mentioned in the OP had her last day the other week in her preceptorship. It was also the first time she coded a patient, and the first time a patient died. It hit her hard, but she seems thankful it happened on the last day vs. the first.

[NotReady4PrimeTime, RN]

Besides the obvious, (size, cognitive and developmental stages) older children are more likely to injure you in some way. As you've said, a lot of PICU patients are 5 years old or younger, so the assumption is that moving them around (repositioning, diapering, boosting them in bed, keeping them ON the bed, transferring from bed to chair or stretcher) shouldn't require much in the way of help. So staffing is usually reflective of the single-person-can-do-it theory... and can lead to serious musculoskeletal injuries. A sedated and muscle-relaxed toddler who is vomiting is quite different from a sedated, muscle-relaxed teenager in halo traction who is vomiting and needs to be turned NOW. Then there's a huge difference between a combative preschooler and a combative adolescent. When the big kids take a swing at you, it's for effect, not a gesture. I've been punched, swatted, pinched, head-butted, choked and kneed in the head by older kids.

Doing CRRT on a toddler might mean 2 effluent bag changes and only single dialysate and replacement bag changes in a day, where CRRT on an older kid means changing one or another of the bags almost hourly. 5 litre bags of fluid weigh 5 kg. Raising them above one's waist to drain them or to suspend them from the priming hook in close quarters is a recipe for injury. Peritoneal dialysis when done manually is another area where repetitive strain injury is almost guaranteed. Those bags hold 3 litres and have to be suspended high above the bed. Bigger kids mean bigger fill volumes mean more frequent bag changes.

Sometimes drug dosages for older kids, when calculated by weight, are higher than adult doses and have to be adjusted accordingly. An anecdote that often comes to mind when talking about this refers to a teenager who arrested on the ward. The peds resident running the code was going by the PALS algorithm, epinephrine 0.1 mg/kg or 0.1 mL of 1:1000 per dose. The kid weighed 110 kg and the resident kept asking for 11 mL of epi. The adult dose is, of course, 10 mL. My friend who was the code nurse kept telling him he could only have 10 mL and he'd argue with her. It was a bit of a gong show.

That first code is always traumatic, whether the patient survives or not. So is the fifth. And the twelfth. And the twentieth. The main difference is in how long the feelings last afterward. One big difference between a code on an elderly adult and one on a child is that the peds code will last a LOT longer. 45 minutes isn't uncommon. And with ECPR (rapid deployment of ECLS following cardiac arrest) death may not come until days (or weeks) later. For some nurses, this is more traumatic than the arrest that leads directly to death. I never promise that working in PICU will be easy, only that it will be worth it.

[vampiregirl, BSN, RN]

1 cardiomyopathy on VAD (3 years)

I didn't realize that VAD are being used w/ pediatrics. Learned something new today!

Just curious - do these patients get released to home or stay hospitalized as long as they have the VAD?

Now returning to your regularly scheduled thread!

[NotReady4PrimeTime, RN]

Our pediatric VAD program uses four different ventricular assist devices: Berlin heart, Pedivas (formerly Levitronix), Heartware and Heart Mate. We've had babies only a couple of weeks old on Berlins or Pedivas'. Pedivas is very costly and the rotaflow impeller needs to be replaced more often that our other devices so it's usually a temporary thing for kids who aren't able to get enough cardiac output from a Berlin initially. Our youngest Heartware patient was 6, a bridge to transplant. We've explanted 3 kids whose hearts recovered enough not to need support any more. One subsequently required a transplant but didn't need to go back on a VAD to get there. We've sent kids on Berlins and Heartwares home. I think we've only ever placed one Heart Mate though.

[meanmaryjean, DNP, RN]

To the OP: There are not 101 ways to be born with a jacked up heart- there are 1,000,001 ways- and I think I've seen them all.

Top Two:

3 atria/ 1 ventricle

Transposition/ dextrocardia/heterotaxy (that kid made the news!)

[meanmaryjean, DNP, RN]

We currently have:

13 yo heroin OD

3 RSV bronchiolitis/ 2 vented 1 on cuirass: all infants

2 acute renal failure / 1 on PD (age six)one on HD (age 14) :

unrepaired, unbalanced AV canal with downs/ vented 4 months

two teenage scoli repair (they typically spend the night of surgery only with us)

1 newborn HLHS post Norwood

acute CVA/ AMS Age 7

.....

[sergel02, BSN]

To the OP: There are not 101 ways to be born with a jacked up heart- there are 1,000,001 ways- and I think I've seen them all.

Top Two:

3 atria/ 1 ventricle

Transposition/ dextrocardia/heterotaxy (that kid made the news!)

That's kind of tragic and amazing simultaneously. One of the hard parts of seeing ICU patients in general for me is all the monitors, lines, tubes, and everything else. Sometimes it feels like you're caring machine. But it must be nice when you can slowly take the patients off those devices.

Thanks for the replies so far everyone!

There was something else i'm curious about, the psychosocial aspect. A peds nurse told me she felt like she was doing a lot more psycho-social care for the patients and teaching for the whole family compared to adult nursing, and she loves that! But she said she wasn't sure how different that aspect is for PICU nurses, since she's always done general peds floor.

In PICU, with so many patents under 5, vented, or sedated, how are you really able to address those needs in your kids, especially given how acute PICU patients are? Is it just something you're not able to deal with often in picu (as I type that out it sounds silly, of course you will be doing it some, but I have to ask).

[meanmaryjean, DNP, RN]

We do a lot of in-the-moment teaching. What does this new diagnosis mean TODAY? Why is that machine beeping and why doesn't the nurse run in here when it does? What can I do for my child- what can't I do? That sort of thing.

[NotReady4PrimeTime, RN]

As MMJ said, a lot of the psychosocial stuff is done on the fly. And often the same information has to be reframed and restated multiple times. With the kids, having a good "kid" vocabulary is important. You'll be telling the 4 year old, "Okay, you have a tube in your nose that's helping you breathe. That's why you can't talk. And it has to stay there for now. You have a tube in your (private parts - ask for terminology from family) that drains your pee away, so even though it feels like you have to pee, you're not going to wet your bed. And it has to stay there for now. You have some little tubes in your arm that let me give you medicines and take samples without having to poke you. And they have to stay in there for now. You had an operation to fix your (whatever) and that's why your (body part) hurts right now. I have some good medicine that will help you feel better." Things along that line. The older they are the more complex your descriptions can be. Most shifts I talk almost continuously to someone... patient, parent, orientee. But this is important: Make sure you know what you're talking about before you say something. I once heard a nurse who was not new on the unit describe CPP (cerebral perfusion pressure - the difference between the mean arterial blood pressure and intracranial pressure) as "central" perfusion pressure and didn't explain what s/he meant. And one of our educators (!!) taught a group of new grads that Cushing's Triad was HYPOtension, TACHYcardia and apnea, and argued with several very experienced nurses that his version was correct. So don't ever make things up just to have a response to a parent or patient question.

Another aspect to PICU's version of psych-soc care is that there will be a maelstrom of emotion swirling around the bed. Fear, guilt, distrust, shock, pain, grief and many others will manifest themselves at different times and in different ways. The best way to deal with the shoulda-coulda-wouldas is to tell the parent they did everything right and nothing they did or didn't do would have changed what happened. (Unless the kid is a non-accidental trauma, and then you'll be dealing with a whole lot of other stuff.)

[Tzs1981rn]

We have a dedicated peds cardiac ICU, so we don't get a lot of cardiac kids in our picu. We are a trauma center, and a freestanding children's hospital. We get traumas (car accidents, abuse), various causes of respiratory failure or distress (rsv, flu, etc), dka that have too low of a bicarb and too high of a blood glucose to go to step down, post op craniotimies, sepsis (meningococcal mephitis recently), stroke, ingestion, we do ecmo and crrt, end of life heme/onc kids that aren't dnr yet, sids, near drowns, and a whole host of rare disorders. We have ages newborn all the way up to 20. I'd say 75% of our kids are intubated and vented at any time.

[sergel02, BSN]

We have a dedicated peds cardiac ICU, so we don't get a lot of cardiac kids in our picu. We are a trauma center, and a freestanding children's hospital. We get traumas (car accidents, abuse), various causes of respiratory failure or distress (rsv, flu, etc), dka that have too low of a bicarb and too high of a blood glucose to go to step down, post op craniotimies, sepsis (meningococcal mephitis recently), stroke, ingestion, we do ecmo and crrt, end of life heme/onc kids that aren't dnr yet, sids, near drowns, and a whole host of rare disorders. We have ages newborn all the way up to 20. I'd say 75% of our kids are intubated and vented at any time.

My friend jokes that she loves 2 year olds, but she loves them a bit more when they're sedated.

I'll get to see how much I like critical care in Autumn, but hearing all these stories is fascinating.

Having an abuse case in PICU must be tough, given what they must have gone through to end up there.

A lot of students in other semesters wanted to do pediatrics like there was no tomorrow, but once they did they're rotations their minds changed. In peds the variance was hard for some. A kid who doesn't want their temp taken isn't going to have their temp taken. I imagine that's not nearly as constant of an issue in PICU, but you have other things taking your time.

Another colleage enjoyed her half day in PICU. Her patient was in coma for a few months, and just moving the patient was a big deal. She was telling me her patient was on a certain kind of vent she can't recall the name of, something that rushed air in so fast it's like the patient's body is vibrating.

[NotReady4PrimeTime, RN]

Having an abuse case in PICU must be tough, given what they must have gone through to end up there.

They're some of the hardest situations you'll ever have to deal with as a peds nurse. I remember covering a break for a coworker whose toddler patient had come in with severe head trauma and bilateral retinal hemorrhages. He had been left alone with Mom's boyfriend for a couple of hours while she was at work. My coworker left for her lunch just as our attending arrived to perform the first brain death criteria exam. The mom asked if she could be present. It broke my heart to watch her watch us confirm what we'd already surmised... her baby was brain dead. Another kiddo that stays with me is a little girl, our third non-accidental head trauma that month. All 9 month-old girls. All injured by the male parental figure. This one had red hair like her dad. She came up from the ER in extremis and required high frequency oscillatory ventilation. We worked on her for hours before her mother arrived. The woman took one look at her baby and nearly knocked the ventilator over when she went down. Then she flew at her husband, screaming at him, "What did you do to my baby, you b******?!!" The little girl died later that night, joining the other two little girls whose lives were also ended by someone who was supposed to love them. You don't get over things like that.

Another colleage enjoyed her half day in PICU. Her patient was in coma for a few months, and just moving the patient was a big deal. She was telling me her patient was on a certain kind of vent she can't recall the name of, something that rushed air in so fast it's like the patient's body is vibrating.

That ventilator is an oscillator and we call that vibration "wiggle". It works by blowing tiny breaths into the lungs at a very high frequency and then sucking them back out again at the same pace using a piston. It's similar to what happens when a dog pants. The settings used are Hertz (60 breaths or cycles per Hz), mean airway pressure and amplitude or strength of cycle. This splints the small alveoli open so that there is no interruption to gas exchange. In neonates, the Hz could be as high as 15 (900 'breaths' per minute). If HFOV doesn't improve oxygenation and CO2 clearance within a few days the only other strategy is ECMO. Which isn't available in most PICUs. Repositioning any ventilated patient can be tricky but those on the oscillator have a much larger, bulkier, heavier ventilator circuit pulling on the tapes holding their endotracheal tubes in place. And lung tissue can derecruit quickly if the bias flow of gas is disrupted. It's NEVER a one person job.

Look at how much you're learning!