My name is Patrik Hutzel from intensivecarehotline.com, where we instantly improve the lives for families of critically ill patients in intensive care, so that you can make informed decisions, have peace of mind, control, power, and influence — even if you are not a doctor or a nurse in intensive care — making sure your loved one always gets the best care and treatment.

This is another quick tip for families in intensive care. Today I have an email from Gail, who asks:

“Hi Patrik.

My brother is 44 years of age and was admitted hypoxic and with acute liver failure. He has been in ICU for almost 5 weeks. As of today, he is getting 90% of oxygen or more with a tracheostomy ventilation. His kidneys have failed, and he is getting Continuous Renal Replacement Therapy (CRRT) dialysis, started today. His temperature has been as high as 38.5 degrees Celsius. His blood pressure is too low, and he is on medications for that. He has been unresponsive for 4 days, and they want to give him paralyzing medications to help with ventilation. What are his odds of surviving? Any hope?

From,

Gail

 

Gail, thank you so much for writing in, and I am very sorry for what you and your family are going through with your 44-year-old brother. I have worked in critical care nursing for over 25 years in 3 different countries, where I worked as a nurse manager in intensive care for over 5 years. I also run a service-intensive care at home.com, but let’s go to your questions.

I can hear the fear and love in your question. I want to give you a real and thorough answer, because your brother and your family deserve that.

How Serious Is This?

I am going to be very straight with you, Gail, because I believe families deserve the truth. Your brother is critically unwell. When we look at everything you have described:

• Acute liver failure (ALF) and multi-organ failure
• Kidney failure requiring Continuous Renal Replacement Therapy (CRRT) dialysis
• Tracheostomy ventilation on 90% oxygen or more
• High fevers up to 38.5 degrees Celsius
• Low blood pressure on vasopressors and inotropes
• 4 days of unresponsiveness
• ICU team wanting to use neuromuscular blocking agents (NMBAs) — also known as paralyzing medications

To manage his ventilation, this is one of the most severe clinical pictures you can have in the ICU. Hands down.

But I also want to tell you that serious does not automatically mean hopeless. People have survived situations like this. It requires the right treatment, the right team, close monitoring, and a family and an intensive care team that does not give up.

What Does Each Condition Mean?

1. Acute Liver Failure (ALF)

Acute liver failure (ALF) is defined as rapid-onset liver dysfunction in someone without prior liver disease. The liver performs hundreds of critical functions: detoxifying the blood, producing clotting factors, and regulating metabolism. When it fails acutely, it triggers a cascade that can affect the brain, the kidneys, the blood pressure, and the immune system all at once.

2. Hypoxia and Tracheostomy Ventilation on 90% Oxygen

Hypoxia and needing 90% oxygen tells us your brother’s lungs are struggling significantly. Needing that much supplemental oxygen means his lungs are not efficiently transferring oxygen into the bloodstream.

The tracheostomy — the breathing tube that goes directly into the windpipe through the neck — gives the ICU team better control of the airway and makes long-term ventilation more manageable. That is actually a step in the right direction compared to an oral breathing tube.

I am also surprised that they were able to do a tracheostomy, because many patients with liver failure have clotting issues — meaning their coagulation parameters such as activated partial thromboplastin time (APTT), International Normalized Ratio (INR), and platelets, are off, and patients are at very high risk of bleeding. Which means doing a tracheostomy is a super high risk for bleeding — but obviously, his clotting must be okay, otherwise they would not have done a tracheostomy. That is actually, I believe, a good sign.

3. Kidney Failure with Continuous Renal Replacement Therapy (CRRT) Dialysis

Continuous Renal Replacement Therapy (CRRT) — the kidneys have stopped doing their job of filtering waste and fluids from the blood. CRRT is a gentler, continuous form of dialysis used in ICU patients who are too unstable for standard dialysis, especially when they are on vasopressors and inotropes for low blood pressure. It is being used to keep the blood clean while everything else is being treated.

The kidneys have a reasonable chance of recovering if the underlying cause is treated — but there is no guarantee.

4. Fever of 38.5 Degrees Celsius is a serious concern.

High fevers in this context could indicate infection or sepsis, which is the immune system’s response to infection, causing widespread inflammation and organ damage. Sepsis on top of liver failure is particularly dangerous. The ICU team will be looking for the source of infection and treating aggressively with antibiotics.

5. Low Blood Pressure on Vasopressors and Inotropes

Low blood pressure on vasopressors and inotropes means your brother’s heart and blood vessels are not maintaining adequate pressure on their own — pressure that is compatible with life and organ perfusion.

Vasopressor and inotropic medications such as norepinephrine, epinephrine, vasopressin, dopamine, dobutamine, midodrine, and milrinone are used to squeeze the blood vessels and keep blood pressure at a safe level. Being on these medications is serious, but it is a standard part of managing ICU patients with multi-organ failure. Without a blood pressure that is compatible with life — and therefore producing enough pressure to perfuse organs — your brother is at high risk of dying.

6. Unresponsiveness for 4 Days

Unresponsiveness for 4 days is likely related to hepatic encephalopathy (HE) — a condition where the failing liver cannot clear ammonia and other toxins from the blood, causing them to accumulate in the brain and reduce consciousness. This can range from confusion to deep coma.

While deeply worrying, hepatic encephalopathy (HE) can improve if liver function improves or if a liver transplant is performed. In the meantime, he might need lactulose, because lactulose helps to open your brother’s bowels and that also can get rid of ammonia.

7. Neuromuscular Blocking Agents (NMBAs) — Paralyzing Medications

Neuromuscular blocking agents (NMBAs) are used when a patient is “fighting the ventilator — meaning their own breathing efforts are out of sync with the breathing machine, causing damage to the lungs. Paralyzing the patient temporarily stops this from happening. It is a significant step and tells us the ICU team is very concerned about his oxygenation. It is not something they do lightly.

However, I do need to question this: if he has been completely unresponsive for 4 days, is he actually fighting the ventilator? Please check on that whether he is completely unresponsive, if he is fighting the ventilator.

Also, if he does need paralyzing medications, what goes hand-in-hand with neuromuscular blocking agents (NMBAs) is placing your brother in an induced coma with sedatives such as propofol, midazolam, versed, (Precedex), dexmedetomidine , and often high doses of morphine and fentanyl — which will further delay him waking up as he gets better. Just to keep that in mind.

But if he is fighting the ventilator and is not ready for extubation, then unfortunately, it is almost an inevitable step to use paralyzing agents or neuromuscular blocking agents (NMBAs).

What Are His Treatment Options?

The most important thing right now, Gail, is understanding what the ICU team is doing, what the plan is, and what options exist. Here is what I would be asking about and watching for:

1. What Is Causing the Acute Liver Failure (ALF)?

This is a critical question, Gail. If it is caused by a drug, toxin, viral hepatitis, or an autoimmune process, then there may be specific treatments available. If the cause can be reversed, the liver may recover. The ICU team needs to identify this urgently if they have not already.

2. Has Liver Transplantation Been Considered?

Liver transplant remains the most definitive treatment for patients who do not recover spontaneously. Your brother’s team should be consulting with — or should have already consulted — a liver transplant specialist. Even with kidney failure and ventilation, transplant can be considered if other factors are in his favor. You need to know whether this is on the table.

3. Infection Control and Antibiotics

Given the fever and his compromised immune system, identifying and aggressively treating any source of infection is essential. This may include bacterial infections, fungal infections, and viral causes of liver failure.

4. Continuous Renal Replacement Therapy (CRRT) Dialysis

This is the right move and should continue to support kidney function while the team focuses on the underlying cause.

5. Vasopressor and Inotropic Support

Stabilizing blood pressure and heart rate is vital to protect other organs. The team will be trying to wean vasopressors and inotropes as the situation improves.

Your brother might also have low hemoglobin and a low platelet count, and he might need blood transfusions. If he can recover good hemoglobin, platelets, and other blood products, his vasopressor and inotrope requirements will go down as well — so please check on that as well.

6. Nutrition

Even in a paralyzed, sedated patient, the ICU should be providing enteral tube feeding via a nasogastric (NG) tube if possible. Nutritional support is essential for healing. Enough studies have been done in the ICU showing that early and continuous feeding helps with recovery from critical illness.

7. Brain Protection

Managing ammonia levels, controlling intracranial pressure (ICP) if needed, and monitoring closely for signs of cerebral edema are all critical steps in a patient with hepatic encephalopathy (HE). Like I said especially with high ammonia levels, regular lactulose may help keep bowels opening frequently so that ammonia levels can be eliminated through the bowels.

Why You Need Access to All Medical Records

I cannot stress this enough, Gail. You and your family need access to all of your brother’s medical records— hands down.

Every blood test, every scan, every ICU progress note, every nursing note — not just the verbal updates at the bedside — the actual records. Why? Because the records tell you the full picture. They tell you what the ICU team is thinking, what the trajectory has been day by day, what decisions have been made and why, and — critically — what has been left undone or unconsidered. They also allow you to verify that what they are telling you actually matches the medical records and vice versa.

I have worked in critical care nursing for over 25 years in 3 different countries, including as a nurse manager in ICU for over 5 years, and I have been consulting and advocating for families in intensive care, here at intensivecarehotline.com since 2013. I can confidently say that we have saved many lives here in intensivehotline.com with our consulting and advocacy. I have seen families who accessed their loved one’s medical records uncover information that completely changed the direction of their care. We can help you with that because when we look at medical records, we see straight away what’s going on. We catch errors, we identify misdiagnoses, and we open conversations that would have never happened otherwise.

You have the right to request these medical records. In most jurisdictions around the world, the next of kin or legal representative can access medical records. Do not be put off or intimidated. This is your brother’s life, and you need to fight for it.

One of the most powerful things you can do right now is book a consulting call with me and my team at intensivecarehotline.com.  On that call, we go through your rights, we can review your brother’s medical records with you and explain exactly what they mean in plain language, we can set you up with the right questions to ask, or we can speak directly with the ICU team on your behalf — and with you on the phone — asking all the questions families do not know to ask. Because I ask all the questions you have not even considered asking, but which must be asked when you have a loved one critically ill in intensive care.

We question the treatment plan, challenge assumptions, and advocate for your brother’s best interest. We help you understand whether a liver transplant assessment is appropriate and whether it is being pursued. We make sure the goals of care are aligned with what your brother and your family want— not just what is convenient for the ICU and hospital system.

We have helped hundreds, if not thousands, of families in situations like yours.  Families who felt lost, scared, and completely shut out of the conversations and who, with our support, were able to become powerful advocates for their loved ones.

Go to Intensive care hotline.com right now, call me on one of the numbers on top of our website, or book a consulting call with me on the scheduled appointment button, or send me an email to [email protected], and let’s get to work for your brother.

Is There Hope?

So, Gail, you asked, is there hope?  Yes, Gail, there is hope — but I want to be clear with you about what hope looks like. Your brother is 44 years of age, which is very young in ICU terms, and age is a factor in his favor. Whether he survives, and to what degree, depends on several things: what is causing the liver failure, whether the liver can recover or a transplant can be offered, whether the infection can be controlled, and whether multi-organ support can bridge him through this critical phase.

Acute liver failure (ALF) with multi-organ failure carries a high mortality. I won’t hide that from you. But high mortality is not the same as no chance. People do survive this.

The ICU team has tools and treatments, and a family that fights for their loved one — that demands answers, accesses medical records, asks us, looks at medical records, and advocates at every step along the way — can genuinely change outcomes.  I want you to look at our testimonial section as well, and you will see that we have helped and saved many lives for our clients in ICU.  Because you can never give up, and also don’t wait, get informed, get those medical records, get on a call with me, to take the next steps.

Keep in mind that approximately 70–90% of ICU patients survive. That is the majority. The odds are in your brother’s favor. But I will also say that your brother is extremely critically unwell, and his chances of survival might actually be less than 70–90% given his acute, critical illness. But that should not stop you from giving up, not stop you from advocating, and it should not stop you from getting access to medical records..

What If He Cannot Be Weaned Off the Ventilator?

I also want to make sure you know about something that very few families — but more and more — are ever told about by the ICU team. If your brother survives this critical phase but cannot be weaned off the ventilator, if he still needs a tracheostomy and mechanical ventilation long-term, there is an option beyond indefinite ICU admission or institutionalized care. That option is Intensive Care at Home — and you can find more information at intensivecareathome.com.

Intensive Care at Home is Australia’s only third-party accredited specialist home nursing provider for ventilator-dependent adults and children.  We provide invasive home ventilation for patients on tracheostomy mechanical ventilation who are medically stable enough to leave the ICU but not yet ready to breathe independently.

We provide 24-hour nursing care for that, as well as for non-invasive home ventilation such as BiPAP (Bilevel Positive Airway Pressure) or CPAP (Continuous Positive Airway Pressure) for patients requiring ongoing breathing support via mask rather than tracheostomy.

We provide tracheostomy care at home without ventilation, full 24-hour intensive care nursing support for patients with a tracheostomy who cannot be decannulated — meaning the tracheostomy cannot be removed.

We also provide palliative care at home — compassionate, high-quality end-of-life care in the comfort and dignity of your own home, rather than in an ICU bed. We also provide Level 2 and Level 3 National Disability Insurance Scheme (NDIS) support coordination for eligible patients to fund and coordinate home-based intensive care.

We operate all around Australia in all major capital cities, as well as in all regional and remote areas. We also serve clients in the US and the UK. Please reach out to us. We have been doing this since 2012. If this is ever relevant to your brother, we are here for you.

Your Next Steps — Act Now, Do Not Wait

1. Request all medical records — every progress note, blood result, scan, and nursing note from day one in ICU.
2. Book a consulting call with me at intensivecarehotline.com — or call me on one of the numbers on the top of our website. I will speak with you directly and with the ICU team if you want me to.
3. Ask the ICU team directly: Has a liver transplant specialist been consulted? Is your brother on a transplant assessment pathway?
4. Ask about the source of infection: What are they treating, and is it responding to treatment?
5. Never give up. Families who are present, informed, and vocal genuinely make a difference to outcomes.

 

I know, Gail, this is one of the most terrifying things a family can go through. I have been in critical care nursing for over 25 years in 3 different countries, and I have seen families transform the care their loved ones received simply by showing up, asking questions, and refusing to be silent.

You have already taken the first step by reaching out. Now let us keep moving forward — together.

Go to intensivecarehotline.com and book your call now — or call me directly on one of the numbers on the top of our website — or send an email to [email protected].

I have worked in critical care nursing for 25 years in three different countries where I worked as a nurse manager for over five years in intensive care. And I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. And I can very confidently say that we have saved many lives with our consulting and advocacy, because of our insights, and you can verify that on our testimonial section  at intensivecarehotline.com and you can verify it on our intensivecarehotline.com  podcast section, where we have done client interviews.

And because our advice is absolutely life-changing, right? The biggest challenge for families in intensive care is simply that they don’t know what they don’t know. They don’t know what to look for, they don’t know what questions to ask, they don’t know their rights, and they don’t know how to manage doctors and nurses in intensive care. And that’s why we help you to improve your life instantly, making sure you make informed decisions, have peace of mind, control, power, and influence, making sure your loved one gets the best care and treatment always. And that’s why you can join a growing number of members and clients that we have helped over the years, saving their loved ones’ lives.

And that’s why I do one on one consulting and advocacy over the phone, Zoom, WhatsApp, whichever medium works best for you. And I talk to you and your families directly. I handhold you through this once-in-a-lifetime situation that you simply cannot afford to get wrong. And when I talk to families directly, I also talk to doctors and nurses directly, asking all the questions that you haven’t even considered asking but must be asked when you have a loved one critically ill in intensive care.  I also represent you in family meetings with intensive care teams.

We also do medical record reviews in real time so that you can get a second opinion in real time. We also do medical record reviews after intensive care, so, if, in case you have unanswered questions, if you need closure or if you are suspecting medical negligence.

We also have a membership for families of critically ill patients in intensive care, and you can become a member if you go to intensivecarehotline.com. If you click on the membership link or if you go to intensivecaresupport.org directly. In the membership, you have access to me and my team 24 hours a day in the membership area and via email, and we answer all questions intensive care-related. In the membership, you also have exclusive access to 21 e-books and 21 videos that I’ve personally written and recorded. And all of that will help you to improve your life instantly, make informed decisions, have peace of mind, control, power, and influence, making sure your loved one gets the best care and treatment always.

And all of that you get at intensivecarehotline.com. Call us on one of the numbers at the top of our website or simply send us an email to support at intensivecarehotline.com with your questions.

If you like my videos, subscribe to my YouTube channel for regular updates for families in intensive care. Click the like button, click the notification bell, share the video with your friends and families, and comment below what you want to see next, what questions and insights you have from this video.

I also do a weekly YouTube live

where I answer your questions live on a show and you will get notification from the YouTube Live if you are a subscriber to my YouTube channel or if you are a subscriber to my intensivecarehotline.com email newsletter at intensivecarehotline.com.

Thank you so much for watching.

This is Patrik Hutzel from intensivecarehotline.com, and I will talk to you in a few days.

 

Take care for now.