My name is Patrik Hutzel from intensivecarehotline.com and this is another quick tip for families in intensive care.  Here at intensivecarehotline.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 the best care and treatment in intensive care.

Every week, almost every day, I receive questions from desperate families all over the world who are sitting in waiting rooms in ICU or at home in the middle of the night, not knowing what’s happening to the person they love.  Georgia’s question today is one of those moments, and I want to answer it as thoroughly and as precisely as I can.

Here is what Georgia says:

“Hi Patrik, 

I hope that you will answer my question as my family and I are desperate. Our dad, almost 75, went into cardiac arrest 11 days ago. He was sedated and placed on a ventilator. The drug used for sedation was midazolam. He has stage 4 kidney disease, atrial fibrillation, and bradycardia, and last year in August had a pacemaker fitted. He had a bladder infection that we thought was gone. We saw him two days ago. He had his eyes open, not responsive. He was just staring. We need real insights. Thank you so much.” — Georgia

Georgia, first of all, I am so sorry your family is going through this. I want you to know your question is incredibly important, and I am going to do my best to give you real clinical insights so you can understand what may be happening and what you can do about it.

1.  What Happened? Cardiac Arrest, Sedation, and the Ventilator

When a person suffers a cardiac arrest, the heart stops pumping blood to the brain and vital organs. Every minute, every second without blood flow causes damage, particularly to the brain, which is extremely sensitive to oxygen deprivation.  When the ICU team resuscitated your dad and placed him on a ventilator, they were doing everything they could to support his body while his organs tried to recover.

Midazolam is a benzodiazepine sedative, also known as Versed in the United States and Canada. It is commonly used in ICUs to keep patients calm and comfortable while they are on a ventilator, because being mechanically ventilated is distressing for most people.  The problem with Midazolam, and this is very important in your dad’s case, it is being processed by the kidneys.  The Critical Point: Stage 4 kidney disease and Midazolam.  Your dad has stage 4 chronic kidney disease. This means his kidneys are significantly impaired. They are not filtering and clearing drugs the way a healthy person’s kidneys would. Midazolam, or Versed, and its active metabolites can accumulate in the body when kidney function is poor, leading to prolonged sedation that can last days or even weeks after the drug is stopped.  This accumulation effect is a recognized medical phenomenon. It is not necessarily a sign that your dad has suffered irreversible brain damage. It is a drug-related complication that the ICU team must account for.

2.  Eyes Open but Not Responding — What Does It Actually Mean?

This is one of the most frightening things a family can witness. Your dad has his eyes open but is unresponsive and just staring. This presentation can mean several different things, and it is essential that you understand the range of possibilities before drawing any conclusions.

Possible Explanation A: Prolonged Sedation — Drug Accumulation

Because of his stage 4 kidney disease, midazolam, or Versed, and its metabolites may still be circulating in his bloodstream even if the drug has been stopped or reduced. The eyes can open, especially during certain sleep cycles or as minimal awareness starts to return, while the person is still pharmacologically sedated. This is not a vegetative state. It is drug-related unresponsiveness.

Possible Explanation B: Anoxic or Hypoxic Brain Injury

If there was a significant period without blood flow to the brain during the cardiac arrest, your dad may have sustained an anoxic brain injury. The eyes open but not responding presentation can be consistent with hypoxic ischemic encephalopathy, which is brain injury caused by oxygen deprivation. The severity of this depends on how long his brain was without oxygen.

Importantly, the picture is rarely black and white at 11 days. Brain recovery after cardiac arrest can continue for weeks. It is far too early to make a definitive prognosis in many cases, and the ICU team should not be pushing you towards end-of-life decisions without giving his brain adequate time to declare itself.

Possible Explanation C: Post Cardiac Arrest Syndrome

This is a recognized syndrome that follows successful resuscitation from cardiac arrest. It includes a combination of brain injury, impaired heart function, systemic inflammation, and ischemia-reperfusion injury. The brain component often includes an altered level of consciousness that can look exactly as you are describing — eyes open, staring, not responding.

Possible Explanation D: Sepsis-Related Encephalopathy

Your dad had a bladder infection that you thought was gone. Sepsis, a life-threatening response to infection, is one of the most common triggers for cardiac arrest in older patients with complex medical histories. Even after the infection appears treated, sepsis-related encephalopathy can persist, causing altered consciousness, confusion, and unresponsiveness.

Possible Explanation E: A Combination of All of the Above

In a 75-year-old man with stage 4 kidney disease, atrial fibrillation, bradycardia, a pacemaker, and a recent bladder infection, the most likely reality is that multiple factors are contributing simultaneously.

The ICU team needs to be working through each of these systematically, and you need to know which one they believe is most prominent and what they are doing about it.

3.  His Complex Medical Background — Why It Matters

Your dad’s pre-existing medical conditions are not background noise. They are central to understanding what is happening and what the treatment options are.

• Stage 4 Chronic Kidney Disease: Severely reduced kidney function changes how drugs are cleared, how fluids are managed, how the body responds to infection, and how organs recover after a major event like cardiac arrest.

• Atrial Fibrillation (AFib): An irregular heart rhythm that increases the risk of blood clots, stroke, and hemodynamic instability. The ICU team must manage anticoagulation carefully, such as heparin, warfarin, Clexane, aspirin, or even Plavix in certain cases.

• Bradycardia and Pacemaker: Bradycardia is an abnormal slow heart rate. The pacemaker was inserted to regulate this. Post cardiac arrest, pacemaker function and cardiac output must be closely monitored.

• Recent Bladder Infection: Even a resolved UTI (Urinary Tract Infection) in an elderly person with kidney disease can have ongoing inflammatory effects and may have been the precipitating trigger for the cardiac arrest itself.

4.  The Treatment Options — What Should Be Happening

Based on your description, Georgia, here is what I would expect a thorough ICU team to be considering and doing for your dad. 

A Proper Neurological Assessment

• CT (Computed Tomography) scan of the brain to look for stroke, bleeding, or structural injury
• EEG (electroencephalogram) to assess brain electrical activity — particularly important if there is any suspicion of subclinical seizures, which can look like staring unresponsiveness
• MRI (Magnetic Resonance Imaging) of the brain — often done several days after the arrest to give the clearest picture of ischemic injury
• Formal neurology review and regular GCS (Glasgow Coma Scale) assessments
• SSEPs (somatosensory evoked potentials) — a key prognostic test in anoxic brain injury
• Sedation Review and Washout. If midazolam is still being administered, it should be reviewed urgently, given his kidney disease
• A sedation hold or sedation vacation should be performed daily to assess his underlying level of consciousness without the drug on board
• Renal clearance of midazolam metabolites must be factored into the timeline — it may take many days for the drug to fully clear

Cardiac Management

• Echocardiogram to assess heart function post-arrest
• Pacemaker interrogation to confirm it is functioning correctly
• Cardiac output monitoring
• Careful management of atrial fibrillation in the context of post-cardiac arrest hemodynamics

Infection and Sepsis Management:

• Blood cultures, urine cultures, and inflammatory markers — CRP (C-reactive Protein), procalcitonin, white cell count
• Ensuring any residual infection, bladder or otherwise, is fully treated with appropriate antibiotics
• Sepsis screening protocols

Renal Support

• Assessment of whether acute or chronic kidney injury has occurred on top of his existing stage 4 chronic kidney disease
• Fluid management tailored to his renal function
• Consideration of renal replacement therapy, such as dialysis or hemofiltration, if kidney function has deteriorated further — this can also help clear drug metabolites faster

Ventilation Management and Weaning

• Daily spontaneous breathing trials once he is stable enough
• Assessment of his ability to protect his airway
• If he cannot be weaned from the ventilator, a tracheostomy should be discussed more on this a bit later.

5.  The Most Important Thing You Must Do Right Now: Get Access to All Medical Records

Georgia, medical records are non-negotiable. You and your family have the right to access your dad’s medical records. This is not optional — it is essential.  Without the medical records, you cannot fully understand what has happened, what the ICU team’s reasoning is, or whether the right decisions are being made.

The medical records will tell you:

• What drugs were given and at what doses
• What the results of all investigations are — blood tests, scans, cultures
• What the ICU team’s documented assessment and plan is
• What sedation levels have been used and for how long
• What his neurological assessments have shown
• What conversations have already taken place about prognosis and treatment direction

Request the records in writing. In most countries, you have a legal right to the medical records.

Do not be put off or told to wait. Get them now.

6.  How a Consulting Call with the intensivecarehotline.com Team Can Help

Your family is in one of the most precarious, overwhelming situations a person can face, Georgia. You are trying to understand complex medical information, navigate an ICU environment where time with doctors is limited, and advocate for your dad — all while being terrified about his future.

This is exactly why I built intensivecarehotline.com.

When you book a consulting call with me or my team, here is what we do:

• We review the medical records with you so you understand what they mean
• We help you formulate the right questions to ask the ICU team — questions that doctors will take seriously
• We can join a call with the ICU team directly and advocate on your behalf, questioning decisions, asking for clarification, pushing for appropriate treatment
• We give you an independent clinical perspective so you are not only reliant on what the hospital chooses to share with you
• We help you understand what should be happening so you can identify if anything is being missed

You should not have to navigate this alone. Call us on one of the numbers at intensivecarehotline.com or send us an email to [email protected]. 

 7.   What If He Cannot Be Weaned Off the Ventilator Right Now? The Long-Term Care Option

I want to address something that many families are not told about, and it may become very relevant for your dad.

If your dad cannot be weaned off the ventilator — whether because of his brain injury, his underlying heart and kidney conditions, or his respiratory status — that does not automatically mean he has to stay in an ICU for the rest of his life.  Intensive Care at Home is a real long-term option.

My other company, Intensive Care at Home, provides tailor-made solutions for:

• Long-term ventilated adults and children with tracheostomies
• Home care for ventilation without tracheostomy, such as non-invasive ventilation including BiPAP or CPAP
• Tracheostomy without ventilation for adults and children
• ICU-level nursing care in the family’s home
• Ventilation weaning at home
• Cough management at home
• Home TPN (Total Parenteral Nutrition), home IV fluids, home IV antibiotic infusions, potassium, magnesium infusions
• Central line, PICC line, Hickman’s line, and port management at home
• IDC (indwelling urinary catheter), SPC (suprapubic catheter), nasogastric, Naso jejunostomy, PEG (percutaneous endoscopic gastrostomy), and PEJ (percutaneous endoscopic jejunostomy) tube management at home

The goal is to keep patients out of ICU predictably and permanently by bringing the clinical expertise of the ICU to them at home, where quality of life is incomparably better.

You can learn more about our Intensive Care at Home nursing service at Intensive Care at Home. We are the only third-party accredited nursing service in Australia for intensive care at home, and if you are watching this from the US, the UK, or Canada, please contact us as well — we can help you in those countries privately as well.

If your dad does end up needing a tracheostomy or long-term ventilation, please know that going home with the right support is a real and viable option. Families who choose this path consistently tell us it was the best decision they ever made.

So, now let’s look at Questions You Should Be Asking the ICU Team Right Now

1. What is the most likely cause of my dad’s current unresponsiveness — drug-related, brain injury, or both?
2. Has a sedation hold been performed, and what was his level of consciousness without sedation?
3. Has an opiate hold been performed, such as stopping morphine, fentanyl, or any other opiates?
4. Has he had an EEG? If not, why not?
5. Has he had an MRI brain?
6. Has he had a CT scan of the brain? If not, when will this be done?
7. What are his kidney function levels currently, and how is this affecting drug clearance?
8. What was the duration of cardiac arrest before ROSC (return of spontaneous circulation)?
9. What are the inflammatory markers showing? Has sepsis been fully excluded?
10. What is the plan for ventilation weaning, and what are the criteria you are using?
11. At what point will you consider a tracheostomy?
12. What is the prognosis, and what evidence are you basing this on?

Conclusion

Georgia, I want you to hold on to this. 11 days after cardiac arrest in a man with stage 4 kidney disease and midazolam sedation is not long enough to give up hope or accept a grim prognosis without a thorough clinical workup.

The eyes open but not responding presentation can have multiple explanations — drug accumulation being high on the list given his kidney disease.  Demand the full neurological workup. Demand a sedation hold with proper monitoring. Get all of the medical records — doctor’s notes, nursing notes, ventilation charts, neurological assessment charts, vital sign charts, lab results, medication charts, and fluid balance charts. Leave no stone unturned. Ask the hard questions.

And please get expert support, get advocacy, get consulting. You should not be trying to decode this alone.  If your loved one is in ICU after cardiac arrest, every day matters. Book a consulting call with me and my team at intensivecarehotline.com today. Go to intensivecarehotline.com, call us on one of the numbers at the top of our website, or simply send us 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.

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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.