A day in the life of… a Registered Nurse on a Cardiac Surgery Intensive Care Unit?
Well, every day is vastly different. For starters, I work on a unit that accepts patients of all ages – neonates to elderly. Please note that this is NOT common practice, but poses a very unique nursing experience. Okay, let’s talk Cardiac Surgery. Every patient I care for in CVSICU has had some type of cardiovascular surgery. Who would have thought? Some common surgeries you may have heard of are valve repairs, valve replacements, coronary artery bypass grafting, and aneurysm repairs. Some less common surgeries known to public but oh-so-familiar to a CVSICU nurse include myectomy, aortic root reconstruction, ventricular assist device implantation and explantation, total artificial heart implantation, heart and lung transplants, and a multitude of congenital heart defect repairs/reconstructions.
Believe it or not, while all of the surgeries I listed are incredibly different, the post-operative care for each is relatively similar. Of course, there are special considerations for each but I have a general mental checklist of to-do’s, complications to watch for, parameters and trends to report to the MD/PA/NP, etc. Some patients are “moderately stable”, meaning they require ICU care still, but they’re not on the verge of coding every 5 minutes. Then there are the patients who are unstable. These patients likely have many machines in their room and maybe even a code cart outside their room. Eek!
Let’s start with some of the basics! Nearly every patient in CVSICU will have an arterial line to constantly monitor their blood pressure and some sort of central line to administer medications through. Many patients need inotropic and vasopressor support with medications like epinephrine, norepinephrine, vasopressin, milrinone, and phenylephrine. Some patients may have a pulmonary artery catheter in their central line to monitor different pressures throughout the heart. Nurses are responsible for monitoring these pressures and titrating medications accordingly. This requires extensive education on hemodynamics prior to and throughout orientation to the unit. Some less exciting things you may see in the CVSICU include urinary catheters, JP drains, chest tubes, and lumbar drains. Nurses are also responsible for monitoring heart rhythm, reporting changes and managing temporary pacemaker settings. Temporary pacemakers can be via epicardial wires, venous wires or sometimes a permanent pacemaker is placed but not implanted until a later time. You will also find a ventilator in nearly every room in the CVSICU. Patients come to us straight from the operating room, meaning they are still sedated and intubated. Many patients are not stable enough to extubate the day of surgery. Some patients even come to us from the OR with their chest still open! These patients will return to the OR at a later date to finish the surgery. Crazy, right?
Some of the bigger machines you may see in a patients’ room include IABP (intra-aortic balloon pump), Impella, ECMO, and continuous renal replacement therapy (dialysis). Intra-aortic balloon pump assists the heart by inflating during diastole to increase coronary perfusion and deflate during systole to decrease afterload. We most often see IABP in the CVSICU for patients who are in cardiogenic shock, however, sometimes we see them for a post-CABG patient needing assistance with coronary perfusion. Extracorporeal membrane oxygenation (ECMO) is another common machine in the CVSICU, which is essentially a heart-lung bypass machine. It provides heart and lung support for patients who are unable to perfuse and oxygenate their own body. ECMO can be a really useful tool for many different types of patients since it assists with lung and/or heart support. Sometimes patients have a hard time coming off bypass in surgery, in which the surgeon decides to put them on ECMO and eventually “wean” off the life support. Other patients you may find on ECMO are those who are in ARDS or waiting for a heart or lung transplant. ECMO is a very specialized life support that is typically only supported on Cardiovascular ICUs.
Each day can be so different – long term patients, landing fresh post ops, moderately stable, unstable, transfer to PCU, road trips, etc. Some patients have “rapid recovery” status, where they only stay in the ICU one night and are stable enough to transfer to progressive care as soon as the morning after surgery. Other patients are on the unit for months. Some are even on the unit up to a year or more – often waiting at the top of the list for a heart/lung transplant. Overall, being a nurse on CVSICU is quite exciting. Between monitoring ECG, I&O, labs, titrating drips, adjusting pacemakers, doing site care, administering blood and following protocols… there is never a dull moment! Some days we get to help with intubation, extubation, bronchoscopies, bedside sternotomies, and run our own codes.
I certainly use my education to the fullest here in cardiac surgery and I am truly learning something new each day. I enjoy the amazing teamwork involved in caring for some of the sickest patients in the hospital. It takes a village – registered nurses, registered respiratory therapists, nurse practitioners, physician assistants, physicians, occupational therapy, physical therapy, chaplain services, etc. Much like any other intensive care unit, without the collaboration of these folks, the CVSICU wouldn’t work!
I could go on for days about what we do here on CVSICU so I want to know… What do YOU want to hear more about? What aspects of ICU nursing do you have questions about? More blog posts to come, thanks to you!!