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, making sure your loved one always gets the best care and treatment, even if you are not a doctor or a nurse in intensive care.

This is another episode of your questions answered, and today I have an email from David who says:

Hi Patrik,

My brother is in the ICU in a medically induced coma on a ventilator for severe acute pancreatitis. He has been in the hospital 15 days and eight days on the ventilator. He has a chest infection and he is on antibiotics. A scan yesterday showed no change in inflammation of the pancreas. We are seeing the consultant this morning. What questions should I ask the ICU consultant about my brother’s condition? When someone with severe acute pancreatitis has been on a ventilator for over a week with persistent pancreatic inflammation and has now developed a chest infection, what does no change in the inflammation actually mean for my brother’s chances of recovery?

From David.

David, thank you so much for reaching out to intensivecarehotline.com and thank you so much for your question. I am very sorry to hear what your brother and your family are going through right now. This is clearly an incredibly stressful and frightening time for all of you, and I want to help you walk into that meeting with the consultant today as prepared and as informed as possible.

Let me break this down for you, starting with the big picture of what is happening with your brother, what treatment he should be receiving in the ICU, and then the specific questions you need to ask the ICU consultant. I also want to talk about what no change in the inflammation actually means, because it is a phrase that sounds worrying, but it is important to understand it in context.

What Is Severe Acute Pancreatitis and Why Is Your Brother on a Ventilator?

Severe acute pancreatitis is one of the most serious and life-threatening conditions that can land someone in the ICU. When the pancreas becomes severely inflamed, it triggers a massive inflammatory response throughout the entire body what doctors call systemic inflammatory response syndrome (SIRS). This overwhelming inflammation can cause multiple organs to begin failing, including the lungs, kidneys, and cardiovascular system.

This is exactly why your brother is on a ventilator. His lungs have been affected by the inflammation, and the ventilator is there to do the work of breathing for him while his body fights. This is called respiratory failure or acute respiratory distress syndrome (ARDS) secondary to pancreatitis, and it is very common in severe cases. The ventilator in this context is a life-saving tool, not a sign that something extra has gone wrong. It was very likely the right clinical decision to put him on it.

What Does Treatment for Severe Acute Pancreatitis in the ICU Look Like?

There are several key pillars of treatment for severe acute pancreatitis in the ICU, and I want you to know about all of them so you can ask the right questions and make sure your brother is getting everything he needs.

1. Mechanical ventilation and lung protection: Your brother is on a ventilator, and this is expected with severe acute pancreatitis when respiratory failure occurs. The ICU team should be using what is called lung protective ventilation. This means using lower tidal volumes and appropriate pressures to protect the lungs from further damage such as barotrauma, while still keeping him oxygenated. You want to confirm this is being done.
2. Fluid resuscitation: In the early phase of severe acute pancreatitis, aggressive fluid resuscitation is critical to maintain organ perfusion. By this point, 15 days in the acute resuscitation phase should be behind him, and the team should be carefully managing his fluid balance, especially given he is on a ventilator and has a chest infection.
3. Nutrition, including total parenteral nutrition (TPN): This is an extremely important area and one you need to ask about directly. Patients with severe acute pancreatitis in the ICU who are on a ventilator and in an induced coma cannot eat normally, so nutrition needs to be provided artificially. There are two main routes.

Number 1 — enteral nutrition through a feeding tube into the stomach via a PEG (Percutaneous Endoscopic Gastrostomy) tube or into the small intestine via a nasogastric (NG) tube or nasojejunostomy tube, is strongly preferred and is now the gold standard wherever possible. The evidence clearly shows that enteral nutrition, even in pancreatitis, reduces infectious complications, reduces mortality, reduces organ failure, and shortens hospital stay compared to not feeding or feeding intravenously. The ICU team should ideally be giving your brother enteral nutrition via a nasogastric or nasojejunostomy tube.

Number 2 — TPN is intravenous (IV) nutrition feeding directly into a large central vein, bypassing the gut entirely. TPN used to be considered the standard for pancreatitis because the old thinking was that the pancreas needed to quote unquote rest completely. We now know that while TPN is still sometimes necessary for example, when enteral nutrition is not tolerated, causes abdominal distention, or significantly increases intra-abdominal pressure, it is no longer the first choice. TPN carries risks including increased infection risk, liver complications, and gut dysfunction from non-use of the bowels. You need to ask the ICU team what form of nutrition your brother is receiving and why.

Number 3 — Antibiotics and the chest infection: Your brother now has a chest infection what is likely ventilator-associated pneumonia (VAP) or hospital-acquired pneumonia which is a common complication in patients who have been on a ventilator for more than a few days. He is already on antibiotics, which is appropriate. However, you need to ask whether the antibiotics are targeted based on cultures taken from his airway secretions, because using broad-spectrum antibiotics without knowing the specific bacteria involved can lead to resistant organisms and harder-to-treat infections down the track.

It is also worth knowing that in severe acute pancreatitis, prophylactic antibiotics, that is, antibiotics given just in case are no longer routinely recommended. Antibiotics should be targeted at confirmed or strongly suspected infections like the chest infection your brother now has.

Number 4 — Monitoring for infected pancreatic necrosis: This is a critical area. When the scan shows no change in inflammation, one of the things the ICU team must be watching for is whether any areas of the pancreas have become necrotic, meaning whether there is dead tissue and whether that necrotic tissue has become infected. Infected pancreatic necrosis is one of the most serious complications of severe acute pancreatitis, and it significantly increases the risk of death. It needs to be treated aggressively, sometimes with drainage or surgical debridement. You need to ask directly whether the scan shows any evidence of necrosis and whether any necrotic areas show signs of infection.

Organ support — kidneys, heart, and liver: Severe acute pancreatitis can affect multiple organs simultaneously. Ask the ICU team which organs have been affected and what support is in place. Is your brother on vasopressors or inotropes  which are medications to maintain a physiologically compatible blood pressure? Does he require kidney support or dialysis? These are all very important pieces of the picture.

What Does No Change in Inflammation Actually Mean?

David, I know no change sounds alarming, especially when someone is critically ill on a ventilator in the ICU. You want to see improvement, and I know you want to see it fast. When the scan shows the same level of inflammation after all these days, it feels like nothing is working. But here is what I need you to understand.

No change in the context of severe acute pancreatitis is not necessarily bad news. In fact, in the acute and subacute phase of this condition, the expectation is not that inflammation resolves quickly. Severe acute pancreatitis is known to be a prolonged illness. The pancreas can take weeks to months to recover. Radiological, also known as scan-based, evidence of improvement often lags significantly behind clinical improvement. In other words, your brother might be stabilizing or even slowly improving in terms of his overall condition, but the scans might not show that yet.

What no change does tell you is that the inflammation has not significantly worsened on imaging, and that in itself has some value. The more concerning scenario would be if the scan showed new areas of necrosis, spread of inflammation, abscesses, or new fluid collections.

You need to ask the consultant specifically, does no change mean no worsening, or does it mean the inflammation is truly static with no sign of improvement at all? Because the answer to that question is really important.

The Critical Importance of Having Access to All Medical Records

David, before you go into that meeting with the ICU consultant, I want to stress something that families often overlook, and it can make a massive difference. You need to have access to all of your brother’s medical records, his observations, his blood results, his medication charts, his nursing notes, his scan reports, his care plans, his ventilation charts, his lab results, his fluid balance charts. Leave no stone unturned.

Why does this matter? Because without the full picture, you are going in blind. You are being given selective information in a brief meeting, and you do not have the ability to ask the right follow-up questions, understand the trajectory of his condition, or spot things that do not add up. Medical records are your brother’s records. As his family and advocate, you have every right to request them, and I strongly encourage you to do so.

When our team at intensivecarehotline.com or myself does a consulting call with a family, one of the very first things we want to see is the medical records, because that is where the real story of what is happening to your loved one is being told. It allows us to review the clinical picture properly, formulate the right questions, help you advocate powerfully and effectively with the ICU team, and in particular, see whether any crucial information is potentially being withheld from you.

David, if you want real personalized support going into this meeting or any future meetings with the ICU team, myself or one of my team members at intensivecarehotline.com is here for you. A consulting call will allow us to review your brother’s medical records with you, help you understand exactly what is happening with his condition, formulate the right questions to ask the ICU team, question and advocate on your brother’s behalf with the ICU team, make sure no stone is left unturned when it comes to your brother’s care and treatment options, and give you peace of mind, control, power, and influence over decisions that affect your brother’s life.

You can visit intensivecarehotline.com to find out more and get in touch with us. You can also call us on one of the numbers listed on the top of our website or send us an email to [email protected]. We are here to help you.

The Questions You Need to Ask the ICU Consultant Right Now

About the scan and the inflammation:

• Does no change mean the inflammation has not worsened, or does it mean there is no sign of improvement at all and what is the difference clinically for my brother’s prognosis?
• Does the scan show any areas of pancreatic necrosis, and if so, is there any evidence that the necrosis is infected?
• Are there any new fluid collections, abscesses, or pseudocysts forming?
• When do you plan to do the next scan and what are you specifically looking for?

About the ventilator and the chest infection:

• Have you taken cultures from my brother’s airway to identify the specific bacteria causing the chest infection, and are the antibiotics being targeted to those specific results?
• What are his current ventilator settings and are you using a lung protective ventilation strategy?
• What do his oxygen requirements look like right now, and have they been improving, staying the same, or worsening?
• What is his current plan to wean him off the ventilator and what needs to happen before weaning can begin?
• Is my brother still on sedation and opiates, and if yes, why?

About nutrition:

• Is my brother currently receiving enteral nutrition through a nasogastric or nasojejunostomy tube, or TPN intravenously? If he is on TPN only, why? And when do you plan to transition to enteral feeding?
• What are his current caloric and protein targets, and is he meeting them?
• What about his blood sugars, is he on insulin? Because even non-diabetic patients often require insulin with pancreatitis.

About organ function:

• Which of my brother’s organs have been affected beyond his lungs and pancreas?
• Is he on any vasopressors, inotropes, or blood pressure support?
• What are his kidney function markers and does he require any form of renal support?

About prognosis and the bigger picture:

• What clinical scoring systems are you using to assess my brother’s severity and prognosis, such as Acute Physiology and Chronic Health Evaluation II (APACHE II) or the Revised Atlanta Classification?
• What is your current assessment of his trajectory, is he stable, improving, or deteriorating?
• What would you need to see over the next 48 to 72 hours to feel more confident about the direction he is heading?
• What is the worst-case scenario from here and what would trigger a change in the treatment plan?
• What is the realistic timeframe for recovery from severe acute pancreatitis at this stage, given how long he has been ventilated?

About the longer term:

• If my brother is unable to be weaned off the ventilator in the coming weeks, would a tracheostomy be considered, and at what point would that discussion take place?
• What is the plan if the chest infection does not respond to the current antibiotic treatment?

What If Your Brother Needs Long-Term Ventilation?

I want to make sure, David, you know about something that is very relevant to your brother’s situation if his recovery takes longer than expected. While the goal is always to wean a patient off the ventilator as quickly as it is clinically safe to do so, some patients with severe acute pancreatitis, especially those who have been ventilated for a prolonged period can become difficult to wean. In those cases, a tracheostomy may be performed to make long-term ventilator management safer and more comfortable.

If that situation arises for your brother, or even if you simply want to plan ahead and understand what options are available, I want you to know about intensivecareathome.com. Intensive Care at Home is a long-term option that can allow ventilator-dependent patients whether they are on invasive mechanical ventilation with a tracheostomy or non-invasive ventilation such as BiPAP (Bilevel Positive Airway Pressure) or CPAP (Continuous Positive Airway Pressure) to be cared for at home rather than spending months or sometimes even years in an ICU or hospital setting. This service can help to keep patients out of the ICU predictably and permanently, provide them with dignity, privacy, and quality of life, and give families the ability to be together at home rather than in a hospital environment. This also applies to patients requiring palliative care who want to spend their remaining time at home with their loved ones. Visit intensivecareathome.com to find out more, even if it is just so you know what options exist further down the track.

What I Want You to Do Right Now

1. Go into that meeting with the consultant as prepared as possible using the questions I have given you above. Do not be afraid to ask them. You are not being difficult. You are being an advocate for your brother. That is exactly what he needs right now.
2. Request access to all of your brother’s medical records so that you have the full picture of what has been happening over the last 15 days.
3. f you want help understanding those medical records, preparing for the next meeting, questioning the ICU team, or advocating for your brother, reach out to us at intensivecarehotline.com. Call us on one of the numbers on the top of our website or email us at [email protected]. We are here for you and your family.

Your brother is very lucky to have someone like you asking these questions and fighting for him. Keep going, David. Do not give up.

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 intensivcarehotline.com and I will talk to you in a few days.

Take care.