My name is Patrik Hutzel from Intensivecarehotline.com and welcome back to another quick tip for families in intensive care. Here at intensivearehotline.com, 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 making sure your loved one always gets best care and treatment, even if you’re not a doctor or a nurse in intensive care.

So, today I’m answering a question from Vimie who wrote to me with this heartfelt email.

Hi Patrik,

I just wanted some advice please. My brother is in intensive care due to chronic liver damage. He has been there for 2 weeks. He has jaundice and chest infection also high level of ammonia. He is on an airtight mask for oxygen aid. His kidneys are now also very bad, and they have given him dialysis to support and clear fluids. I am really scared now as all this looks really bad and they might now put him in an induced coma.

Would this be the right choice for him? Please, if you can advise.

– Vimie

And before I go into Vimie’s message, what makes me qualified to answer questions like this?

I’ve worked in critical care nursing for over 25 years in three different countries where I worked as a nurse manager in intensive care for over 5 years. 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 for our clients in intensive care with our consulting and advocacy. And you can verify that in our testimonial section at intensivecarehotline.com as well as on our podcast section at intensivecarehotline.com.

And Vimie, first of all, thank you for reaching out and trusting me with my advice. And you’re absolutely right to be asking these questions. Your instinct to question and advocate for your brother is one of the most important things you can do for him right now given how vulnerable he is.

And let me walk you through what is happening, what it means, and what your options are. Your brother has what clinicians call multiorgan dysfunction syndrome, also known as MODS, where more than one organ system is failing at the same time. This sounds terrifying and it is serious but is also something ICU teams treat every single day. Let me break it down for you.

Let’s start with Number 1. Chronic liver damage and acute-on-chronic liver failure (ACLF). Chronic liver damage means his liver has been struggling for some time. When the liver is then hit by an additional trigger such as an infection, a bleed or another stressor, it can easily decompensate rapidly. This is called acute-on-chronic liver failure. The liver stops being able to do its jobs, which include filtering toxins from the blood, producing clotting factors and regulating fluid balance throughout the body.

Number 2, jaundice. Jaundice, the yellowing of the skin and eyes, is a sign that the liver is failing to process bilirubin, a waste product from red blood cells. It confirms that his liver is under severe stress and is not functioning as it should.

Number 3, high ammonium levels, hepatic encephalopathy. This is one of the most critical pieces of Vimie’s message. The liver normally converts ammonia, a toxic byproduct of protein metabolism, into Urea, which the kidneys then excrete. When the liver fails, ammonia builds up in the blood and crosses into the brain, causing a condition called hepatic encephalopathy. Hepatic encephalopathy causes confusion, altered consciousness, agitation and in severe cases coma. It is important to understand that this confusion and altered conscious state may not be permanent. It is often hepatic encephalopathy causes confusion, altered consciousness, agitation and in severe cases coma. It is critically important to understand that this is very often reversible if the ammonia levels can be brought down with treatment. This is a game changing distinction for your brother’s situation. And the way to get down ammonium levels is simply with lactulose to keep opening bowels regularly.

Number 4, chest infection. A chest infection in someone with a failing liver and kidney is extremely dangerous because the immune system is compromised and the body is already under enormous strain. It will need aggressive antibiotic treatment and maybe putting additional pressure on his breathing which is why he’s on the tight-fitting mask which is also known as BiPAP/CPAP or non-invasive ventilation.

Number 5, kidney failure and dialysis. When the liver fails, it can directly impair kidney function through a condition called hepatorenal syndrome. The kidneys stop filtering waste products and maintaining fluid balance. Dialysis takes over the job mechanically. It filters the blood just as the kidneys would, helping clear toxins, including excess ammonia and fluids that are accumulating in his body.

Key takeaway:

Vimie’s brother has multiple failing organ systems, but several of the drivers: high ammonia, infection, fluid overload, can potentially be treated and reversed. The critical question is whether the ICU team are maximizing those treatment options before reaching for sedation, opiates, and intubation.

So, what is an induced coma, and would it be the right choice?

An induced coma or medically induced sedation with intubation means your brother would be put to sleep with powerful sedatives, anesthetic and opiate medications, have a breathing tube placed into his windpipe and throat, and be connected to a mechanical ventilator to breathe for him. This is sometimes necessary in ICU, but it comes with significant consequences for someone with liver failure.

Let’s now look at the risk of an induced coma in liver failure.

Sedatives, opiate, and anesthetic medications are processed by the liver. In a failing liver, these drugs accumulate and take far longer to wear off. Your brother may be very difficult to wake up. Intubation dramatically increases the risk of ventilator associated pneumonia (VAP). A serious and potentially life-threatening hospital acquired infection. Once intubated and sedated, weaning him off the ventilator becomes much harder and prolonged ventilation can lead to muscle wasting, delirium and ICU acquired weakness. Sedation can worsen hepatic encephalopathy because it masks the very symptoms the team need to monitor and may contribute to further deterioration in consciousness. Intubation commits your brother to an invasive path that is much harder to reverse than the non-invasive path he is on now.

So why would the ICU team be considering it?

There are genuine clinical reasons the team may be considering intubation for. If your brother’s breathing is deteriorating on the tight-fitting mask such as BiPAP (bilevel positive airway pressure) or CPAP (continuous positive airway pressure) and he cannot maintain his oxygen levels or carbon dioxide levels, the alternative to intubation may be respiratory arrest. The team will be watching his breathing closely, how hard he is working, his respiratory rate, his oxygen saturations, his carbon dioxide levels, his chest X-rays and as part of that they would be doing arterial blood gases.

However, and this is crucial, the question you need to ask is, have we exhausted all non-invasive ventilation options to keep my brother awake and off the ventilator with a breathing tube? What specific clinical thresholds or findings are driving the decision to intubate now rather than continuing the BiPAP or CPAP mask.

So, let’s now look at how to keep your brother awake, alternatives to an induced coma. There is a well-established principle in modern critical care called minimizing sedation and keeping patients awake wherever possible.

Here are the key treatment strategies the ICU team should be optimizing before considering intubation.

Number 1, aggressively lowering ammonium levels.

• Lactulose, a laxative given orally or via nasogastric tube or PEG tube that traps ammonia in the gut and clears it from the body. The dose should be titrated to produce three to four loose bowel motions per day.
• Rifaximin, an antibiotic that reduces the ammonia producing bacteria in the gut used alongside lactulose for hepatic encephalopathy.
• Dietary protein modification. Controlling protein intake to reduce ammonia production while maintaining nutrition.
• Zinc supplementation. Zinc deficiency is common in liver disease and worsens ammonia metabolism.
• Continuous renal replacement therapy/CRRT, or dialysis. His dialysis can help also clear ammonia from the bloodstream. So, dose and duration matter enormously.

Number 2, optimize his mask ventilation: non-invasive ventilation – the tight-fitting mask Vimie mentions is likely non-invasive ventilation or NIV either BIPAP or CPAP. This delivers pressured air and oxygen to support his breathing without a breathing tube. Crucially, the settings on non-invasive ventilation can be optimized. Higher pressure support, better positioning, frequent reassessment to maximize its effectiveness and delay or avoid intubation.

High flow nasal oxygen is another option that delivers warm humidified high concentration oxygen at high flow rates through nasal prongs. It is more comfortable than a tight-fitting mask and may be tried as a step up or step down.

Positioning. Keeping him sitting up at 45° or more, not lying flat, dramatically reducing the work of breathing and the risk of aspiration.

Number 3, treating the chest infection aggressively. Appropriate broad-spectrum antibiotics reviewed and narrowed once cultures results return. Regular chest physiotherapy to clear secretions. Bronchodilators if there is any wheeze or bronchospasm.

Number 4, optimize dialysis for fluid and toxin clearance. The dialysis he’s receiving should be reviewed for adequacy. Is the dose sufficient to clear enough ammonia, Urea, and excess fluid? Continuous renal replacement therapy/CRRT, run 24 hours a day, is often gentler and more effective in critically ill patients than intermittent hemodialysis.

Number 5, avoid sedating medications wherever possible. Benzodiazepines like midazolam or diazepam, opiates such as morphine or fentanyl, and any other sedatives that are metabolized by the liver should be avoided or minimized to the greatest extent possible. If he’s agitated or confused by hepatic encephalopathy, the answer is to treat the encephalopathy, not to sedate him on top of it.

Here’s an important note for you, Vimie. Keeping your brother awake is not about being cruel or forcing him to suffer. It is about protecting his liver, protecting his brain, and giving his body the best possible chance for recovery. Every hour he avoids intubation is an hour his body has to respond to treatment.

Next, you need access to all medical records immediately. One of the most important things I tell every family I work with is this. Access to medical records is non-negotiable. You and your family have the right to access all of your brother’s medical records, including nursing notes, medical progress notes, investigation results, imaging reports, and the treatment plan. Do not wait to be offered this information. Ask for it directly and insist on it.

And here’s why this matters so much. Medical records tell you exactly what the team’s currently thinking and how serious they believe the situation to be. Records allow you to track whether ammonium levels are going up or down in response to treatment, a critical indicator of whether the current management is working.

Understanding the trend. Are his kidney function markers such as creatinine, Urea, BUN levels improving or worsening? Are his liver functions – bilirubin, INR, albumin stabilizing? It gives you the power to ask the right questions. It’s also important that you watch for the coagulation markers for your brothers such as APTT and INR because many patients with liver failure have issues with blood clotting.

Medical records form the foundation of any second opinion or expert review. Without them, you are basically flying blind. If there is a conflict between what the team is telling you verbally and what is documented, the records will reveal it. Ask to speak with the ICU consultant, attending physician, and request a formal family meeting. Ask the team to walk you through the current treatment plan, the specific targets they are aiming for, and what criteria would lead them to change the plan. You deserve clear, honest answers.

Vimie, I know how overwhelming this feels, but here is how a consulting call with myself at intensivecarehotline.com will help you right now because you are being given information in pieces and you are being asked to agree to decisions that you do not fully understand or feel comfortable with.

This is exactly the situation intensivecareholtine.com was created for. When you work with me and my team, here is what we do for you. We review medical records for you and with you. Explain exactly what every result, every medication and every intervention means in plain English. We identify whether the ICU team is following best practice and best evidence case-based guidelines for acute on chronic liver failure, hepatic encephalopathy and multi-organ support. We help you formulate the right questions to ask the medical team and coach you on how to ask them, so you get real answers.

We can join a phone or video call with the ICU team alongside you and your family, advocating on your brother’s behalf, questioning decisions and ensuring nothing is overlooked. We help you understand whether the decision to induce a coma is premature, appropriate, or whether non-invasive alternatives have been fully exhausted. We help you navigate goals of care conversations. What does your brother want? What are his wishes? This matters enormously.

Let’s now also look what if your if your brother cannot be weaned off the ventilator.

Vimie, I think you deserve the full picture. In some cases of severe liver failure, especially if there is irreversible liver damage or reversing liver damage might take longer than expected. A patient might need to be intubated and then find it very difficult to be successfully weaned off the ventilator. They then may also require long-term tracheotomy care, ongoing ventilation support or potentially palliative care at a level of complexity that is difficult to manage at home without specialist nursing, assuming you don’t want your brother in ICU long term or he might need long-term non-invasive ventilation such as BiPAP or CPAP.

In any case, if your brother reaches that stage, I want you to know that there’s an option beyond the hospital and there’s an option beyond ICU. And that’s where Intensive Care at Home comes in, a long-term alternative to ICU. If you look at www.intensivecareathome.com, you will find more information about how we look after ventilated adults and children at home with and without a tracheostomy. So that means we care for patients who need long-term ICU and therefore need long-term invasive ventilation with a tracheostomy, non-invasive ventilation BiPAP or CPAP, or tracheotomy care without ventilation or otherwise complex palliative care in their own home surrounded by their family with 24/7 dedicated critical care registered nurses.

We are third party accredited for intensive care at home nursing. We’re currently operating all around Australia in all states and territories, but we’re also helping families in the USA, in the UK, in Canada. Please reach out to us. If you need help, we can help you in those countries as well.

Keeping a patient at home with specialist home nursing costs approximately 50% of an ongoing ICU admission and the quality-of-life difference is immeasurable. And we also help hospitals and ICU free up ICU beds.

Let’s look at the summary. What Vimie should do right now. Let me summarize the key steps for Vimie and her family.

Request a formal family meeting with the ICU consultant today. Do not wait for the team to come to you. Ask specifically what non-invasive ventilation options are still available before we consider intubation. Have lactulose, rifaximin, and optimized dialysis all been maximized? Have medications such as Parallax be considered?

Request access to all medical records, nursing notes, doctor’s notes, specialist notes, blood results, imaging, medication notes, ventilation charts, ventilation parameters, vital sign charts, treatment plans. Leave no stone unturned. You are entitled to medical records.

Track the trends in ammonium levels, kidney markers, especially creatinine and liver markers such as bilirubin, INR, and albumin. Ask for these numbers daily.

Ask about your brother’s goals of care and his previously expressed wishes. if he has an advanced care directive or has ever spoken about what he would want in this situation. Make sure the team knows and contact us at intensivecarehotline.com today to have an expert review of the situation with you, help you interpret the records and advocate directly with the ICU team.

Remember Vimie, you are not a bystander in your brother’s care. You are an essential part of his care team. Asking questions, requesting medical records, and seeking expert support are not signs of distrust. They are a sign of love and advocacy. They can make the difference between life and death.

If your loved one is in ICU and you need expert guidance, independent reviews of their medical records, or direct advocacy with the ICU team, call us today at www.intensivecarehotline.com. intensive care.com. And if your brother or anyone watching these needs long-term ventilation and home care for ICU patients long-term go and check out www.intensivecareathome.com. If today’s videos have helped you, please share them with other families who are going through the same experience and subscribe to my YouTube channel. Click the like button, click the notification bell, and comment on what you want to see next.

I have worked in critical care nursing for 25 years in three different countries where I worked as a nurse manager for over 5 years in intensive care. I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. I can very confidently say that we have saved many lives with our consulting and advocacy because of our insights. You can verify that on our testimonial section at intensivecarehotline.com. You can verify it on our intensivecarehotline.com podcast section where we have done client interviews because our advice is absolutely life changing.

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.

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 best care and treatment always. 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.

That’s why I do one on one consulting and advocacy over the phone, Zoom, WhatsApp, whichever medium works best for you. 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. 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 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 eBooks and 21 videos that I have personally written and recorded. 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 best care and treatment always.

All of that you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or simply send us an email to [email protected] with your questions.

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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.