Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for Families of critically ill Loved ones in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a doctor or a nurse in Intensive Care!
This is another episode of “YOUR QUESTIONS ANSWERED“ and in last week’s episode I answered another question from our readers and the question was
You can check out last week’s question by clicking on the link here.
What Questions Should You Be Asking If You Have a Loved One in Intensive Care?
Even if I sound like a broken record, the biggest challenge for families in intensive care is that you simply don’t know what you don’t know.
In this article however I’m going to give you the most condensed form of everything you need to understand when you have a loved one critically ill in intensive care and what questions you need to ask.
Intensive care is such a highly specialized area and it takes many years of training either as a doctor or as a nurse to understand and master intensive care.
You will see that asking the right questions in intensive care is like going down a rabbit hole. One question leads to the next. It’s like a jigsaw puzzle. Miss one piece and the picture is incomplete.
When families come to us here at the intensive care hotline they are feeling lost, they are feeling challenged, outside of their comfort zone, they’re feeling vulnerable and they simply don’t know what to do.
Families in intensive care often come to us and ask what questions they need to ask when their loved one is critically ill in intensive care.
If it was only as simple as.
Yes you do need to know what the right questions are when your loved one is critically ill in intensive care and is fighting for life. As a matter of fact it’s absolutely critical to know the right questions to ask and connect the right dots.
Not knowing the right questions to ask could be the difference between life or death and it’s most certainly also the difference between you and your family being able to make informed decisions, get peace of mind, control, power, and influence.
Knowing the right questions to ask, knowing what to look for, and knowing how to manage doctors and nurses in intensive care- instead of the doctors and nurses managing you- will make all the difference when you have a loved one in intensive care.
The minute you start asking the right questions, you will get to the right answers and the dynamics will change in your favor.
- 7 QUESTIONS YOU NEED TO ASK THE MOST SENIOR DOCTOR/ PHYSICIAN/ CONSULTANT IN INTENSIVE CARE IF YOUR LOVED ONE IS CRITICALLY ILL IN INTENSIVE CARE
- “FOLLOW THIS ULTIMATE 6 STEP GUIDE FOR FAMILY MEETINGS WITH THE INTENSIVE CARE TEAM, THAT GETS YOU TO HAVE PEACE OF MIND, CONTROL, POWER AND INFLUENCE FAST, IF YOUR LOVED ONE IS CRITICALLY ILL IN INTENSIVE CARE!”
This is critical because you and your family are in a very challenging and “once in a lifetime” situation that you can’t afford to get wrong.
Having said that when families of critically ill patients in intensive care come to us they do ask what questions do they need to ask. They’re looking for the magic bullet and for all the right answers. And so they should.
You will see that as we go along in this blog post that there are dozens of very important and high stakes things happening simultaneously at the bedside of your critically ill loved one and each of those pieces fits in like a piece in a jigsaw puzzle.
If you’re missing one piece, the picture is either incomplete or the whole picture is falling apart.
When someone is critically ill in intensive care, especially when ventilated and on other mechanisms of life support, there are dozens of very big and little important things happening simultaneously.
All of those dozens of little and big things happening simultaneously are important and if you don’t understand those things happening simultaneously you will have a very difficult time understanding what is happening.
This is why intensive care is such a highly specialized area that takes years of training and years of practice to master and understand.
In this article I will help you understand so that you can learn and start speaking this “secret” intensive care language.
- WHY YOUR BODY LANGUAGE MAY BE YOUR BIGGEST OBSTACLE TO PEACE OF MIND, CONTROL, POWER AND INFLUENCE WHILST YOUR LOVED ONE IS CRITICALLY ILL IN INTENSIVE CARE
- WHAT YOUR BODY LANGUAGE AND YOUR TONE OF VOICE COMMUNICATES TO THE INTENSIVE CARE TEAM AND WHY YOU NEED TO CHANGE IT URGENTLY SO YOU CAN HAVE PEACE OF MIND, CONTROL, POWER AND INFLUENCE!
Especially during times when you might be locked out of ICU because of pandemic situations (I.e. COVID-19) you need to be in a position to get to crucial and more or less life or death information very quickly.
After having worked in intensive care for 20 years where I looked after thousands of critically ill patients and their families and where I also worked for over 5 years as a nurse unit manager in intensive care, I know how intensive care units operate.
I also know how you as a family feel when disaster strikes and you have a loved one in intensive care.
Intensive care teams are often vague in what they share with you and how transparent they are, because the stakes are often too high for them, just as much as the stakes are very high for you.
Intensive care teams have their own agenda, they manage beds, staff, equipment, financial budgets, clinical research projects and each piece of the puzzle makes its way in how they’re dealing with families in intensive care.
Unless you know what you don’t know unless you know what to exactly look for and unless you know how to manage doctors and nurses you’ll be standing no chance to make informed decisions, get peace of mind, control, power and influence when your loved one is in intensive care.
- THE 7 THINGS FAMILIES DO WHO MAKE INFORMED DECISIONS HAVE PEACE OF MIND, ARE IN CONTROL, HAVE POWER AND HAVE INFLUENCE, WHILST THEIR LOVED ONE IS CRITICALLY ILL IN INTENSIVE CARE (PART 1)
- THE 7 THINGS FAMILIES DO WHO MAKE INFORMED DECISIONS HAVE PEACE OF MIND, ARE IN CONTROL, HAVE POWER AND HAVE INFLUENCE, WHILST THEIR LOVED ONE IS CRITICALLY ILL IN INTENSIVE CARE (PART 2)
Once you know the exact clinical questions to ask, the intensive care team will know in a heartbeat that you are doing your research and that you are having resources available to you that help you understand intensive care and critical care.
The dynamics will then shift in your favor and you will have more leverage when dealing with and negotiating with the intensive care team.
But keep in mind, this is just the start, in order to really understand treatment options, prognosis and diagnosis more research and more in-depth conversations are needed.
Without further talk, let’s look at the things you need to ask when you have a loved one in intensive care. The questions I’ll be sharing with you are structured from head to toe just like medical and nursing assessments as well as handovers are done on critically ill patients.
Please note that whilst we look at the questions from head to toe, many of the questions can’t be looked at in isolation and span across more than one section.
- Neurological Condition
How awake is your critically ill loved one?
Are they in a natural or induced coma?
Are they conscious?
What is their Glasgow coma scale or GCS? The Glasgow coma scale is a commonly used neurological assessment tool to assess a patient’s neurological condition.
Is your critically ill loved one in pain?
If so, how is pain being managed?
Also, RASS score if you want to dig even deeper, especially when your loved one is in an induced coma.
Furthermore, you want to 100% find out what pain medication your loved one is on. There can be a big difference in how pain is being managed and also how this impacts on your critically ill loved one’s condition.
- The 5 Mistakes you are unconsciously making if your critically ill loved one is in an induced coma and is not “waking up”!
If they are on light pain killers such as Panadol or anti-inflammatory pain medications your loved one is most likely more awake but those pain killers have other side effects.
Overall the devil is in the detail in intensive care and you can see that as we go along in the questions you need to ask in order to make informed decisions, get peace of mind, control, power, and influence.
Also if your loved one is in intensive care with the following neurological conditions such as TBI or traumatic brain injury, subarachnoid hemorrhage, subdural hemorrhage, brain aneurysm, aneurysm coiling, stroke, seizures, hypoxic or anoxic brain injury, etc… your questions should focus on the following areas.
- A. For any of the conditions above you should be focusing on if a CT scan or an MRI scan of the brain has been done to get more information about the condition of the brain
- B. If your critically ill loved one is diagnosed with a TBI (traumatic brain injury) or with subarachnoid hemorrhage or subdural hemorrhage they may have an intracranial pressure monitor in their brain. This is also known as an ICP which is often attached to an EVD or external ventricular drain. ICP’s or intracranial pressures should be 5 to 15 mm Hg (7.5–20 cm H2O). Any measurements outside of those parameters can cause irreversible brain damage.
- C. If your loved one has been admitted with a stroke, again ask if a CT or MRI scan of the brain has been done for diagnostics and prognosis. You also want to find out if your loved one has had an ischemic or hemorrhagic stroke. Big difference there, mainly because of the cause but also in ongoing treatment.
- What happens if my critically ill loved one had a period where they had insufficient oxygen supply to the brain? What is the prognosis after the brain has not had sufficient oxygen supply (hypoxic brain injury)
- THE 10 THINGS YOU DIDN’T KNOW ABOUT SEVERE HEAD OR BRAIN INJURIES (INCLUDING TRAUMATIC BRAIN INJURY AND STROKE) IN INTENSIVE CARE THAT YOU MUST KNOW, ESPECIALLY IF YOUR CRITICALLY ILL LOVED ONE ISN’T WAKING UP OR IF THE INTENSIVE CARE TEAM IS SUGGESTING A POOR PROGNOSIS OR EVEN WORSE, IF THE INTENSIVE CARE TEAM SUGGESTS A “WITHDRAWAL OF TREATMENT” OR A “LIMITATION OF TREATMENT!
- D. If your loved one has been admitted to intensive care with seizures, how are seizures being treated? What is their first line management? I.e. benzodiazepines such as Diazepam (Valium), midazolam (versed), or medications such as Keppra (Levetiracetam), Phenytoin (Dilantin), Vimpat (Lacosamide), Sodium Valproate, etc…
As you can already see, asking questions about your critically ill loved one’s condition in ICU is going down a rabbit hole.
I’ll talk more about induced coma under the respiratory or ventilation side of things. Technically, induced coma it’s a neurological issue, however, one of the main reasons for an induced coma is mechanical ventilation with a breathing tube or endotracheal tube, hence the reference to the respiratory system further down the line.
Questions to ask as part of the neurological assessment:
- Is your loved one awake and conscious?
- What is their Glasgow coma scale (GCS)?
- Do they have a head or brain injury?
- Do they have a stroke, seizures?
- Is pain an issue? If yes, is it controlled?
- If your loved one has a traumatic brain injury, a subarachnoid, or subdural hemorrhage, do they have an ICP monitor and/or EVD drainage?
- If yes to 6) are ICP’s under control?
- If yes, to 4), 6) has a CT brain or MRI brain been done? What are the results?
- If yes to 4) how is the stroke or seizures being managed? Is airway stable?
- Is your loved one on any sedation? If yes, what are those? How much they are giving? When was the last time it was given?
- 2. Cardiovascular System or Hemodynamic System
What is your loved one’s heart rate and their heart rhythm? A faster than normal heart rate might indicate pain, discomfort but could also be a sign of infection/sepsis.
If the heart rate is irregular such as AF or atrial fibrillation of it and how are they treating it?
Often when the irregular heart rhythm is present other complications might occur such as an unsustainable low blood pressure that needs to be supported with life-supporting drugs such as inotropes or Vasopressors.
If your loved one is on inotropes or Vasopressors they are also on life support, as inotropes and Vasopressors are considered life support. Common medications being used for inotropes and Vasopressors are epinephrine, norepinephrine (levophed), Noradrenaline, Dobutamine, Dopamine, Milrinone, Vasopressin to mention the most common inotropes/Vasopressors being used in intensive care.
On the other end of the spectrum, sometimes your loved one can be hypertensive as well, where systolic blood pressure can be >140 mmHg
If that is the case it often needs medical management with vasodilators, which are the opposite of Vasopressors and inotropes. Common vasodilators being used in ICU are GTN, SNP gave intravenously.
You therefore also need to ask what is your loved one’s blood pressure? Is it sustainable with life? If it’s not sustainable with life that’s when your loved one needs said inotropes and Vasopressors.
One of the main side effects of unsatisfactory or low blood pressure is kidney or renal failure. If the blood pressure is low for prolonged periods (systolic blood pressure <90 mmHg and mean arterial pressure <65 mmHg) the risk for kidney or renal failure is increased.
There are various ways in how the cardiovascular system is being assessed and continuously monitored in intensive care such as heart rate, blood pressure, temperature and you will need to find out those parameters.
The heart function is crucial as nothing happens without a well-oiled and well-functioning heart.
If there are any issues with the heart such as a heart attack, cardiac arrest, post open heart surgery, etc.… your critically ill loved one should have an ultrasound/echocardiogram of the heart or a TOE (transoesophageal echocardiogram) of the heart to determine cardiac/heart function and determine ejection fraction or EF (Normal: 55% to 70%), which indicates the contractility or pump function of the heart.
This is an important indicator of cardiac/heart function and also an indicator if life-sustaining measures such as inotropes or Vasopressors are required long term.
Long-term Inotropes or Vasopressors for a poor cardiac or hemodynamic function or because of severe sepsis are not an option and irreversible cardiac failure or respiratory failures such as ARDS or cystic fibrosis may warrant ECMO treatment.
We have numerous articles and case studies on our website about such issues and treatment options such as ECMO, cardiac failure, respiratory failure (ARDS), etc… just use our search bar and type in your search terms.
A central line(CVC) is important to
- A. Give certain drugs such as inotropes or Vasopressors that couldn’t be given via a normal peripheral IV line. Other medications that can only be given via central line (CVC) are Total Parenteral Nutrition, Potassium, certain antibiotics, 25% dextrose and generally speaking drugs with a PH <4 or >9
- B. Measure CVP= central venous pressure. The CVP indicates the fluid or volume status of a critically ill patient. It indicates dehydration vs fluid overload. A normal CVP is 2-6 mmHg
- C. Give fluids rapidly in emergency or semi-emergency situations such as blood products or hydrocolloids
If a long term central line (CVC) is required a PICC (peripherally inserted central catheter) is preferred.
If certain clinical criteria are met, a swan ganz or PA catheter is indicated. With a swan ganz or PA-catheter more sophisticated clinical parameters can be obtained such as cardiac output, cardiac index, again to determine heart functionality such as contractility (pump function), fluid status, lung volume, vascular resistance.
Both, Swan ganz (PA) catheter and the central line also pose a high infection risk.
Other issues as part of the hemodynamic or cardiovascular system are daily and sometimes twice daily blood results.
Blood results you should be focusing on are
HB= Hemoglobin, also known as red blood cells
WCC= white cell count for signs of infection
CRP= inflammation or infection marker
If Potassium and Magnesium are out of balance this could cause irregular heart rhythms
Troponin for indication of a heart attack. Normal Troponin levels are 0-0.4 nanogram/ml
CK levels 22-198 U/liter
You can find more general information about blood and pathology results in intensive care here
Furthermore, if your critically ill loved one has ongoing bleeding or is anemic because of other medical conditions and hemoglobin is low, they might need a blood transfusion in the form of red blood cells.
Normally, the threshold for requiring a blood transfusion is at 6 g/liter or 7 g/liter (60 g/dl or 70 g/dl)
Especially in light of the fact that low hemoglobin can cause hypotension (low blood pressure) and therefore inotropes/Vasopressors use, one way to reduce inotropes or Vasopressors is to give blood products.
Other blood products that can be given are FFP’s (fresh frozen plasma), Platelets, or Albumin.
Also, part of the cardiovascular system is the administration of anticoagulants or “blood thinners”.
When being critically ill and immobile or at the very least being restricted with mobility, anticoagulants (“blood thinners”) need to be given to prevent deep vein thrombosis (DVT). If anticoagulation is contraindicated, at the very least ted stockings or calf compressors need to be worn to keep the blood circulating and again to prevent. DVT’s are also known as blood clots.
The risk of a DVT is real in ICU without anticoagulation, ted stocking, or calf compressors.
Commonly used anticoagulation drugs or “blood thinners” being used are Enoxaparin/Clexane, Fragmin, Heparin, Warfarin, Plavix/ clopidogrel.
Also, when we consult families in intensive care 1:1, we ask them to send us pictures of the bedside monitor so we can ascertain quickly their hemodynamic status.
Questions to ask as far as the cardiovascular system is concerned
- What are your loved one’s vital signs, I.e. heart rate, heart rhythm, blood pressure, oxygen saturation, temperature
- Is your loved one on inotropes, vasopressors or vasodilators(inotropes, Vasopressors or vasodilators are considered life support)
- What are the blood results as per the list above?
- Does your loved one have a central line (CVC)?
- Is your loved one receiving any blood products or blood transfusions?
- Is your loved one’s heart function a concern?
- If yes to question 6) has the heart been formally checked with an ultrasound or a TOE(transoesophageal echocardiogram)
- If yes to question 6) and 7) what is your loved one’s ejection fraction(EF)?
- If yes to question 6) do they have a swan ganz or PA catheter to measure cardiac output and cardiac index?
- Is your loved one on anticoagulation or blood-thinning medications? If no, are they wearing ted stockings or are they attached to calf compressors?
- Have sputum samples, urine samples, and/or blood samples been done to look for sources of infection?
3) Respiratory System
So we have moved from the head, to the heart and now we go the lungs as we work our way downwards.
Many patients when going into intensive care need the support of their respiratory system because of their inability to breathe.
The following is applicable when patients go into intensive care as far as their respiratory status is concerned.
- Breathing spontaneously on room air or 21% oxygen
- Breathing spontaneously with oxygen support either via a nasal cannula or via an oxygen mask
- Breathing spontaneously with high flow nasal oxygen via nasal cannula
- Breathing with a ventilation mask either BIPAP or CPAP
- Breathing with a breathing tube/endotracheal tube attached to a ventilator. This mode of ventilation often goes hand in hand with sedation and an induced coma
- Breathing with a tracheostomy attached to a ventilator
- Breathing spontaneously with a tracheostomy with either humidified oxygen via tracheostomy shield or humidified air with tracheostomy shield
- Breathing via tracheostomy may also be a combination of being on and off the ventilator
Next, if your loved one is attached to a ventilator with a breathing tube/endotracheal tube or tracheostomy tube they will also need frequent suctioning to clear the airway because of their often limited ability to cough and clear secretions and airway.
The frequency as well as the amounts of secretions needing to be cleared is one of the indicators if a breathing tube/endotracheal can be removed or not. The same is applicable for the tracheostomy tube. The frequency as well as the amounts of secretions needing to be cleared is one of the indicators if a tracheostomy tube can be removed.
Next, if your critically ill loved one needs ventilation support in either of the forms I mentioned before, they will most likely need an arterial line.
An arterial line has the ability to check the effectiveness of ventilation/oxygen support by checking oxygen and carbon dioxide levels. An arterial blood gas can give many other blood results as well, but for the purpose of this section we just want to keep focusing on what up is important from a ventilation point of view.
Normal arterial blood gas levels are
pH: 7.35 – 7.45.
Partial pressure of oxygen (PaO2): 75 to 100 mmHg.
Partial pressure of carbon dioxide (PaCO2): 35 – 45 mmHg.
Bicarbonate (HCO3): 22 – 26 mEq/L.
Oxygen saturation (O2 Sat): 94 – 100%
Lactate 0.5-1 mol/litre
Irrespective of whether your critically loved one is breathing spontaneously or on a ventilator etc… the arterial blood gas results will give you a very good indication of how effective ventilation support is.
You should also be asking for ventilation modes when on the ventilator as it will indicate how far away from getting off the ventilator is.
There are several different ventilation modes when on a ventilator and once again, the devil is in the detail when it comes to ventilation forms and ventilation modes.
Also, if your loved one is in an induced coma and on sedation because of mechanical ventilation and the breathing tube/endotracheal tube, your critically ill loved one will be unconscious until they can either be extubated (=removal of the breathing tube/endotracheal tube) or until a tracheostomy can be performed.
The induced coma requires sedation and opiates. Commonly used sedatives in intensive care are Propofol (Diprivan) or Midazolam (Versed). Commonly used opiates or pain relief in an induced coma are Fentanyl or Morphine.
Another sedative combining pain relief and sedation is Dexmedetomidine or Precedex. Sometimes Clonidine (Catapres) is used for sedative and pain relief effects also.
Other issues that may come up whilst in an induced coma are issues that sometimes muscle relaxants or paralyzing agents are given because of ventilation issues or to enhance patient-ventilator synchrony, enhance gas exchange, and diminish the risk of barotrauma. They can also be employed to reduce muscle oxygen consumption, to prevent unwanted movements in patients with increased intracranial pressure, and to facilitate treatment of acute neurologic conditions.
If your critically ill loved one is in ICU with breathing problems they should have physiotherapy or physical therapy to improve their breathing. This is also commonly known as chest Physio.
Early mobilization does also help with respiratory or breathing issues, hence the sooner your loved one gets out of bed, the higher the chances their breathing and spontaneous breathing efforts will improve.
It’s also very important to have a basic understanding of ventilation modes in intensive care.
There are many ventilation forms in ICU that indicate varying degrees of controlled ventilation, spontaneous ventilation, or a combination of controlled and spontaneous ventilation. Those ventilation forms are important to ascertain how far away your critically ill loved one is from getting extubated or being weaned off the ventilator and the tracheostomy. When we consult families in intensive care 1:1 we often ask them to take a picture of the ventilator so we can ascertain quickly how far away their loved one is from being weaned off the ventilator.
Questions to ask about ventilation and the respiratory system
- Is your loved one breathing spontaneously or with a machine?
- Do they need oxygen?
- If breathing without a ventilator, is breathing adequate? Is your loved one at risk of needing a ventilator?
- What does the latest chest X-ray results? (Your loved one should have daily chest X-rays whilst being ventilated and in ICU)
- What are the latest arterial blood gas results?
- If your loved one is on ventilation with a mask (BIPAP/CPAP), is it effective? Can ventilation with a breathing tube be avoided?
- If your loved one is ventilated with a breathing tube/endotracheal tube, how far away are they from getting extubated (=removal of the breathing tube)?
- If they are not ready for extubation, what are the next steps? Do they need a tracheostomy?
- If they are having a tracheostomy, how far away are they from weaning off the ventilator and the tracheostomy?
- If your loved one is ventilated with a breathing tube/endotracheal tube or tracheostomy how often do they need suctioning?
4) Gastrointestinal Tract or GI System
The next questions you need to ask are in relation to the gastrointestinal system. When your loved one is critically ill in intensive care, nutrition is often altered because of the inability to take in food and hydration orally.
The need for nutrition and hydration is still there however.
There is the old joke amongst ICU nurses and ICU doctors that as soon as a patient starts to eat and drink orally they are on the verge of leaving intensive care. The minute they start complaining about the food they will need to leave intensive care immediately!
Putting jokes aside, the reality is that as soon your loved one is in intensive care needing mechanical ventilation with a breathing tube/endotracheal tube and intubation they also need a nasogastric tube.
The nasogastric tube is inserted into the nose and is sitting in the stomach. The nasogastric tube can be used for feeding or also for drainage from the stomach if there are issues with reflux etc…
It can also be used to check if food is being digested and absorbed.
A nasogastric tube should be temporary and should be removed when a patient can breathe independently, is awake and alert as well as able to swallow safely.
If for example a tracheostomy is needed, often discussions are being held with families to change from the nasogastric tube to a PEG feeding tube.
A PEG feeding tube has a permanency to it which we think is counterproductive to trying to wean patients off ventilation and tracheostomy and it may foster complacency.
Again, this is where we can help you make the right decisions for your love so they can have the best chance for the best care and treatment.
- WHY DECISION MAKING IN INTENSIVE CARE GOES WAY BEYOND YOUR CRITICALLY ILL LOVED ONE’S DIAGNOSIS AND PROGNOSIS!
- THE 3 MOST DANGEROUS MISTAKES THAT YOU ARE MAKING BUT YOU ARE UNAWARE OF, IF YOUR LOVED ONE IS A CRITICALLY ILL PATIENT IN INTENSIVE CARE!
Next, sometimes food cannot be absorbed when Patients are in ICU or other gastrointestinal issues may prevent your loved one from having nasogastric or PEG feeds.
Next, when your critically ill loved one is in ICU, mobility is automatically decreased, and therefore the peristaltic of the bowels is reduced. Therefore bowel motions and bowel movements are decreased. This is specifically important during an induced coma because again, the sedative and opioid drugs reduce bowel peristaltic and bowel motions. Hence it’s important to manage bowel motions with aperients and laxatives so that regular bowel motions can be maintained.
It’s also important to avoid bowel obstructions because again the risk is increased for a bowel obstruction to occur while in ICU for the reasons mentioned above.
Questions to ask
- Is your loved one eating and drinking orally?
- If not, do they have a nasogastric tube, and are they being fed via the nasogastric tube?
- Is your loved one absorbing their feed?
- Is your loved one opening their bowels?
- Is your loved one having stomach protective medicines such as Pantoprazole (Somach), Ranitidine (Zantac), or esomeprazole (medium) (protons pump inhibitors or PPI’s)? This is to avoid stomach ulcers and stomach or Gastrointestinal bleeds due to stress-induced ulcers whilst being critically ill in intensive care.
5) Renal or Kidney Functions
Next is kidney or renal function. The kidneys have a special role to play when your loved one is in intensive care. If the kidneys are working throughout your loved one’s stay in intensive care that’s great, tick the box and don’t worry about it.
But inevitably you will need to ask if the kidneys are working because often kidney function is impaired when patients are critically ill in intensive care.
If the kidneys aren’t working your critically ill loved one could be in trouble because if urine output is impaired.
If urine output is impaired, issues such as fluid overload come up and those issues may manifest itself with pulmonary edema or fluids in the lungs. This could be detrimental when weaning off a ventilator or when trying to avoid mechanical ventilation and the breathing tube in the first place.
If kidney or renal failure is not an issue, to begin with, and not part if your critically ill loved one’s condition, chances are that it may become an issue throughout your loved one’s journey in intensive care.
The first thing you need to understand about the kidneys is that they are highly sensitive and highly susceptible to sustained low blood pressure. As you would have seen under 2) cardiovascular or hemodynamic system, low blood pressure is a regular occurrence for critically ill patients in intensive care.
The longer critically ill patients go without sufficient or adequate blood supply to the kidneys the higher the risk for the kidneys being damaged or “taking a hit”.
The first sign of the kidneys being impaired is usually a low urine output. As a rule of thumb, normal or physiological urine output should be between 30- 80 ml/hr.
Anything less than 30 ml/hr for a few hours raises alarm bells in intensive care and it usually needs investigations and/or medical management.
Daily fluid balances in intensive care are normal where fluid input and fluid output are calculated at midnight.
The fluid balance as well as hourly checks and documentation of urine output and fluid intake are critical to keeping the balance in check, quite literally.
Hourly checks of urine output can be done with an indwelling urinary catheter. Most critically ill patients in intensive care have an indwelling catheter inserted in their bladder.
If fluid balances are too positive, I.e. higher fluid input than urine output, pulmonary edema might be one of the signs, plus peripheral edema or fluid swelling might be visible in hands, feet, belly, etc…
Next, blood tests such as urea, creatinine, GFR, and BUN levels are also indicators for kidney or renal impairment.
The first-line treatment for low urine output is usually diuretics such as Lasix or Frusemide. Sometimes Spironolactone is being used to as a Potassium saving diuretic.
If the cause of low urine output is dehydration, then a fluid challenge might be indicated.
If the cause of the kidney failure is simply that the kidneys are failing then hemodialysis or hemofiltration is the next step.
Here the dialysis machine is taking over the function of the kidneys and is removing fluids and other toxins.
Over time the kidneys may recover with dialysis but it’s not guaranteed. In the short term, dialysis is the best option to deal with failing kidneys.
Daily checks of urea, creatinine, BUN, and GFR in the blood are necessary to keep an eye on kidney function.
Another sign of dehydration vs fluid overload besides checking urine output hourly are sodium levels. High sodium levels indicate dehydration and low sodium levels indicate potential fluid overload.
Again as you can see, the devil is in the detail.
So questions to ask are
- What is the fluid balance like?
- What is the hourly urine output?
- Sodium levels
- Urea, creatinine, BUN and GFR levels
- If your loved one is on hemofiltration or hemodialysis, how many ml per hour are being removed?
- Electrolyte levels such as Potassium and Magnesium. High volumes of fluid removal either via drug-induced diuretics such as Lasix (Frusemide) or via hemofiltration or hemodialysis can reduce Potassium and Magnesium levels to a point where the heart or cardiac function can be impaired. On the other hand, when the kidneys are failing Potassium is elevating and again can cause heart or cardiac disturbances.
6) Endocrine System (blood sugar regulation)
The endocrine system in intensive care can be important in some but not in all situations.
We are just covering the basics here of the endocrine system and we won’t go into too much detail. Most other aspects of intensive care are more important.
Many non-diabetic patients in intensive care can become temporarily hyperglycemic, meaning they can have a high blood sugar temporarily.
This is a side effect of critical illness and stress response.
High blood sugars in intensive care can be treated with the temporary administration of insulin intravenously or IV.
If your loved one in intensive care has a premedical history of diabetes, their blood sugars are most likely to be higher than usual and again, higher doses of insulin are needed.
If your loved one is diabetic and wasn’t on insulin before the ICU admission, they most likely will be needing insulin now.
In most cases Insulin can be ceased eventually, just know that blood sugars are likely to go up during the critical illness.
They can also increase sometimes secondary to certain medications being used such as steroids (I.e. hydrocortisone, dexamethasone, Methylprednisolone).
Questions to ask about the endocrine system
- Is your loved one’s blood sugar within normal levels?
- If the blood sugar is high, is your loved one on insulin?
- Do they think that high blood sugar is a stress response secondary to the critical illness or drug-induced from steroid use?
7) General aspects of being a patient in intensive care
This is also a very important and often neglected aspect of your loved one being critically ill in intensive care.
- THE 10 THINGS YOU DIDN’T KNOW ARE HAPPENING BEHIND THE SCENES IN INTENSIVE CARE THAT HOLD YOU BACK FROM HAVING PEACE OF MIND, CONTROL, POWER AND INFLUENCE, WHILST YOUR LOVED ONE IS CRITICALLY ILL IN INTENSIVE CARE!
- INTENSIVE CARE’S HIDDEN SECRETS AND MYTHS BEHIND THE SCENES, THAT THE INTENSIVE CARE TEAM KEEPS AWAY FROM YOU AT ANY COST AND OTHER FAMILIES OF CRITICALLY ILL PATIENTS HAVE NO CLUE ABOUT THOSE HIDDEN SECRETS!
Here I’m talking more about the nursing care aspect when patients are critically ill in intensive care.
Nothing is happening without excellent ICU nursing care.
Here is a list of things that are part of excellent nursing care in ICU. You will need to ask for those things.
- Daily bed bath, including regular backwashes, when patients change position to freshen them up as well as getting the blood circulation going when being immobile.
- Regular mouth care, eye care, and nose care- at least 6 hourly when in an induced coma, twice daily and as per patient request when awake and not induced into a coma.
- Regular pressure area care. Changing position every two to three hours in order to prevent skin breakdown and pressure sores.
- Mobilization. As soon as your critically ill loved one can get mobilized, in a chair and out of bed, it needs to happen. Early mobilization is saving lives and it helps weaning patients off ventilation. If ICU’s are not mobilizing patients, it’s complacency and not lack of resources. There are situations where a patient can’t be mobilized such as ECMO, ARDS, trauma, patients on neuromuscular blockers, etc… but there are plenty of patients that can be mobilized even on ventilation with a breathing tube and a tracheostomy.
- Especially for patients on ventilation with either a breathing tube/endotracheal tube or tracheostomy they will also need to have chest Physiotherapy or physical therapy. This will help with ventilation weaning.
- Quality ICU’s will also offer patients a shower, in a shower trolley when necessary, especially for long term ICU patients, including for patients on ventilation. Or as soon as a patient can get mobilized, sit in a chair, they should also have the opportunity to have a shower, as long as they are hemodynamically stable. Having a shower works wonders for patients in intensive care, the positive effect it has cannot be underestimated.
In closing, now that you have read through this list of explanations and questions, you know and understand why I always say that the biggest challenge for families in intensive care is that you don’t know what you don’t know.
This is a comprehensive list of questions for families in intensive care, but it doesn’t stop there. It’s like going down a rabbit hole. Once you’re in there you can’t stop. I could have gone into more detail, but for now, if you ask those questions, the intensive care team will inevitably know that you are talking to someone who understands intensive care inside out.
This is the first step in making informed decisions, get peace of mind, control, power, and influence. The intensive care team will look at you differently and you will be a “one percent” as opposed to the 99% of families of critically ill patients who will never know what they don’t know because they either trust intensive care teams blindly or they don’t do their own research.
How can you become the best advocate for your critically ill loved one, make informed decisions, get peace of mind, control, power and influence quickly, whilst your loved one is critically ill in Intensive Care?
You get to that all important feeling of making informed decisions, get PEACE OF MIND, CONTROL, POWER AND INFLUENCE when you download your FREE “INSTANT IMPACT” report NOW by entering your email below!
In Your FREE “INSTANT IMPACT” report you’ll learn quickly how to make informed decisions, get PEACE OF MIND, real power and real control and how you can influence decision making fast, whilst your loved one is critically ill in Intensive Care! Your FREE “INSTANT IMPACT” Report gives you in-depth insight that you must know whilst your loved one is critically ill or is even dying in Intensive Care!
Sign up and download your FREE “INSTANT IMPACT” REPORT now by entering your email below! In your FREE “INSTANT IMPACT” REPORT you’ll learn how to speak the “secret” Intensive Care language so that the doctors and the nurses know straight away that you are an insider and that you know and understand what’s really happening in Intensive Care! In your FREE report you’ll also discover
- How to ask the doctors and the nurses the right questions
- Discover the many competing interests in Intensive Care and how your critically ill loved one’s treatment may depend on those competing interests
- How to eliminate fear, frustration, stress, struggle and vulnerability even if your loved one is dying
- 5 mind blowing tips & strategies helping you to get on the right path to making informed decisions, get PEACE OF MIND, control, power and influence in your situation
- You’ll get real world examples that you can easily adapt to you and your critically ill loved one’s situation
- How to stop being intimidated by the Intensive Care team and how you will be seen as equals
- You’ll get crucial ‘behind the scenes’ insight so that you know and understand what is really happening in Intensive Care
- How you need to manage doctors and nurses in Intensive Care (it’s not what you think)
Thank you for tuning into this week’s YOUR QUESTIONS ANSWERED episode and I’ll see you again in another update next week!
Or you can call us! Find phone numbers on our contact tab.
Also check out our Ebook section where you get more Ebooks, Videos and Audio recordings and where you can also get 1:1 counselling/consulting with me via Skype, over the phone or via email by clicking on the products tab!
This is Patrik Hutzel from INTENSIVECAREHOTLINE.COM and I’ll see you again next week with another update!
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