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Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COMwhere we instantlyimprove the lives for Families of critically ill Patients 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 makingfast, 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
COVID-19 and ARDS-Proning vs ECMO Therapy which is More Preferred? Live stream!
You can check out last week’s question by clicking on the link here.
In this week’s episode of“YOUR QUESTIONS ANSWERED”, I am here with a live stream today, where I want to answer your questions if you have a loved one in intensive care. And this is one of the most commonly asked questions for families in intensive care and it’s a question that we get all time. And today’s live stream is about My Mother is on Life Support in Intensive Care! What is Actually Considered Life Support in ICU?
My Mother is on Life Support in Intensive Care! What is Actually Considered Life Support in ICU?
Welcome to another Intensive Care Hotline livestream. I’m your host, Patrik Hutzel from intensivecarehotline.com. And in today’s livestream, we want to talk about, “My mother is on life supportin intensive care. What is actually considered life support in intensive care?” And I think it’s about time that we clarify for all families who have a loved one in intensive care what it actually means to be on life support and what are different mechanisms of life support. And I want to dive down deep there today.
Now, just quickly some housekeeping issues. You can type your questions into the chat pad, but please keep them to today’s topic if you can. If you have other questions, I will definitely get to them, but it’ll be more towards the end of today’s topic when I get to those questions.
Now, just quickly what makes me qualified to talk about today’s topic? I am a critical care nurse by background. I have worked in intensive care for over 20 years in three different countries. I have worked for over five years as a nurse unit manager in intensive care. I have professionally counselled and consulted families in intensive care all over the worldsince 2013 here at intensivecarehotline.com. I also own and operate a service Intensive Care at Homewhere we predominantly look after long-term ventilated patients at homethat otherwise would be in intensive care. I am surrounded by intensive care all day every day. We’re employing dozens of intensive care nurses in both of our services. We have lots of expertise in this business that helps again families in intensive care all around the world.
Now, without further ado, let’s dive into today’s topic. So, lots of families in intensive care come to us and they say, “Oh my mom, my dad, my brother, my sister, my spouse, my child is on life support in intensive care. What are their chances of survival? What should I do?” And they don’t actually know what life support in intensive care means. There are different aspects of life support in intensive care. And it’s really important that you distinguish between those different forms of life support, what it means for your loved one? How likely is it if they’re on different forms of life support to survive? What is the outlook going forward? What’s the potential for survival? I really want to break this down today for our viewers.
Now, what makes intensive care different is really that people in intensive care, generally speaking, are on life support because they can’t be looked after on a normal hospital ward or a normal hospital floor. Their critical illness is what gets them into intensive care where often organs need to be supported with medications, with equipment. It requires specialist skills from ICU doctors, ICU nurses, and other support staff in intensive care to make that happen.
The most common form of life support in intensive care that is sort of well-known is mechanical ventilation, breathing tube or endotracheal tubein the throat, but also with the tracheostomy. Now, there are other forms of life support with mechanical ventilation that is probably not as widely known, but there’s also life support such as CPAP (Continuous Positive Airway Pressure)or BIPAP (Bilevel Positive Airway Pressure)ventilation with a mask. And that often requires critical care nursing skills and critical care medical skills as well, depending on the severity of the situation. One of you might say, “Hey, but there’s CPAP, BIPAP at home for sleep apnea.” Yes, that is correct. But that is sort of a milder form when someone needs life support and we’ll break it down a little bit further, why people in intensive care might need life support with a mask such as BiPAP or CPAP?
Now, let’s just quickly look at other mechanisms of life support, and then I will break them down in more detail. We talked about mechanical ventilation. Another very common form of life support in intensive care is inotropes or vasopressors. And you might wonder what are inotropes or vasopressors. And most families in intensive care don’t know that this is actually happening when their loved ones are in intensive care. Because obviously when we ask questions, we’re finding out, oh, they don’t even know what it means, vasopressors or inotropes are life support.
When patients go in intensive care, often they have multiple issues, again, such as breathing issues, but they also often go hand in hand with hemodynamic issues. What that means is there might have high heart rate or low heart rate. They might have high blood pressure or low blood pressure. They might have a high temperature or a low temperature. And that all goes hand in hand with needing to treat that medically with medication. And that’s when inotropes or vasopressors are coming in.
For example, for low blood pressure, that is not compatible with life, so let’s just say someone has a blood pressure, 85/40, and it drops even further. Now, it goes down to 70/30. That is a blood pressure that is often not compatible with life and therefore inotropes or vasopressors need to be used. So, what are inotropes or vasopressors? You might have heard of medications such as epinephrine or norepinephrine or phenylephrine, vasopressin, dobutamine, dopamine, milrinone, and isoprenaline. Those are different types of inotropes or vasopressors. What they do is they increase blood pressure. They might increase contractility of the heart. What that means is it increases the pump function of the heart. Isoprenaline increases the conductivity of the heart so that the electrical rhythm flows through the heart. There are different classifications of inotropes but the bottom line is this, without inotropes or vasopressors often blood pressure cannot be maintained that is compatible with life.
Now, on the other hand, if someone has a high blood pressure, let’s just say has a blood pressure of 200/100 and increasing, you may use vasodilators, such as SNP (Sodium Nitroprusside) or GTN (Glyceryl Trinitrate), which are vasodilators that’s the exact opposite of a vasopressor, it dilutes the vessels of vasopressor, constricting the vessels, increases blood pressure, dilating the vessels, decreases blood pressure.
They are all mechanisms of life support that you need to be aware of. And sometimes it can be small doses, but nevertheless, it’s life support. And outside of intensive care, those medications can’t really be managed. It needs close monitoring. It needs a one-to-one nurse-to-patient ratio. It needs constant monitoring. Often requires regular blood testsas well to monitor the bigger picture of a patient and so forth.
Now, other mechanisms of life support can be for example, dialysis. Dialysis or hemofiltration for kidney failure. That is also considered life support because again, takes specialist skills. Kidney failure, in the long run, is not compatible with life if it’s not managed with life support, if it’s not managed medically. So that’s another mechanism of life support.
Next, ECMO is a big one in this day and age. ECMO is a bypass machine that can be used temporarily for heart failureor for lung failurewhere conventional treatment is no longer working. Also, ECMO can be used as a bridge to a heart transplantor a lung transplant. It’s another mechanism of life support. Challenge with all of these mechanisms of life support is simply that it requires specialist medical skills and specialist nursing skills to manage all of that. And those skills are in high demand, they’re rare because it takes years of training to get to that point where you can look after someone on a ventilator, where you can look after someone on ECMO, where you can look after someone with inotropes or vasopressors, where you can look after someone on dialysis or ECMO.
Now, other mechanisms of life support that are not often mentioned when you talk about life support, but I think it’s important to know are things like a nasogastric tube, things like a PEG (Percutaneous Endoscopic Gastrostomy) tube. Because at the end of the day, without a nasogastric tube or without a PEG tube, one can’t maintain nutrition especially in intensive care. That could be considered life support as well. But it’s not often mentioned in that context. You could also argue that a central venous lineor a peripheral intravenous line is also considered life support because none of the treatments can be done without those lines.
You could argue that an arterial line or an arterial catheteralso falls under life support. Because again, none of the treatments that I mentioned can be offered without close monitoring, so you could break it down even further into even other categories. But I think to look at it strictly from an intensive care perspective and why people go into intensive care in the first place, I really want to keep it to mechanical ventilation, inotropes, vasopressors, dialysis, and ECMO. They are the main components of life support in intensive care, what’s considered life support in intensive care.
One more thing that I’d like to mention is for example for a traumatic brain injurypatient, you might end up with an ICP, also known as an intracranial pressure monitoror an EVD (Extra Ventricular Drainage), without that the brain might burst because of pressures and that could be lethal, could end up with a patient dying as well. So, you could almost argue even an ICP or an EVD could be considered life support.
But if you look at the literature in general, it’s mainly the things that I mentioned at the beginning, ventilation, inotropes, vasopressors, vasodilators, dialysis, ECMO (Extracorporeal Membrane Oxygenation), which are the main forms of life support. I also should mention that, I mentioned norepinephrine, phenylephrine, epinephrine earlier. In countries like Australia or the U.K., those drugs are called noradrenaline, adrenaline and vasopressins, so a slight difference in terminology in different countries, but at the end of the day, they’re the same drugs.
Now, and as much as I said in the beginning that patients on life support can only be looked after in intensive care, but it’s not 100% accurate because now with our service Intensive Care at Home, you can also look after patients on life support at home, predominantly with ventilation and tracheostomy. But I know you could also do inotropes or vasopressors at home such as dobutamine or milrinone or dopamine could be happening at home as well. Certainly, as intensive care progresses on, there are more variations coming out of where you can support someone on life support. And that is, for example, one way is Intensive Care at Homewhere we can look after patients at home with tracheostomy and ventilation just to name a few.
Now, let’s break down this even further in terms of multi-organ failureand how long you can support someone in life support. Let’s just say someone is in intensive care on a ventilator with a breathing tube or with a tracheostomy and has no other forms of life support. You could argue that someone is in single organ failure. Compare that to someone who is in multi-organ failure. You might hear, and you would’ve seen some of my videos or blog posts where I talk about, well, intensive care teams talk about multi-organ failureand patients being unable to survive because they are in multi-organ failure.
Now, I’ve seen plenty of patients over the years in ICU that are in multi-organ failure that do survive as long as you can support the organs with life support such as again, mechanical ventilation or ECMO or inotropes, vasopressors or dialysis, or a combination of all of it. And it’s not uncommon that patients are in multiple forms of life support in intensive care, which means they are in often multi-organ failure which is often temporary. But as long as you can manage them with life support, they have a chance of survival.
Depending on how much research you’ve done, you would’ve heard me say before, approximately 90% of patients in intensive care survive, they stay in intensive care. And it doesn’t really matter whether they are in multiple forms of life support or just on one form of life support. In intensive care, you can support organs for a period of time, whether it’s with equipment. And sometimes it is with medications. For example, start from the top, you can support the brain, as I mentioned before, maybe temporarily with an ICP monitor with an EVD drain, with medications especially for high ICPs. You can use 3% saline. You can use sedation, you can use drainage of CSF (Cerebrospinal Fluid). There are a number of things you can do with the brain. You can use paralyzing agent. You can use mannitol. There are a number of things you can do to support the brain for a period of time.
Next, moving down, the lungs. If someone is in lung failure, pneumonia, ARDS (Acute Respiratory Distress Syndrome), COVIDat the moment, still you can support their fading lungs with a mechanical ventilator. You can support them with a breathing tube, endotracheal tube or tracheostomy. You can also support them with ECMO.
Next, heart, let’s say the heart is failing. You can temporarily support the heart, a failing heart with inotropes or vasopressors. ECMO potentially also with vasodilators, if blood pressure is too high. You can support the heart potentially with surgery. There are a number of things you can do while someone is going into heart failure. If you get them on ECMO, that could also be used as a bridge to a heart transplant. And the same is applicable for lung failure, ECMO can be used as a bridge to a lung transplant. If the lungs are failing to a degree where they think the lungs can’t recover at all.
Now, moving downwards to another organ, which is the liver. Now, the liver is one of those organs that cannot be supported with equipment. It can mainly be supported with medications if people are in liver failure. And I’m not going into too much depth there now, the only other option for liver failure is obviously a liver transplant.
Next, the kidneys. Kidneys can be supported by dialysis or hemofiltration if someone is in kidney failure. So, you can see that the major organs can be supported for periods of time. For example, you take dialysis. Many patients are on dialysis for the rest of their lives. And that is definitely a possibility. It’s more difficult for the heart and for the lungs, but then again, with services likeIntensive Care at Homenow, you can support the lungs for a very long time as well.
Now, before I go into more detail with life support in intensive care, I just want to find out if there are any questions up to this point about life support in intensive care. I want to open the floor of course and I want to answer your questions if you have any.
While I wait for your questions to come through, I’ll just quickly keep talking. So, if you look at the digestive system in intensive care separately, you could also argue again that by feeding someone with a nasogastric tube or with a PEG tube or with an oral gastric tube, one could argue that is considered life support as well. And with a feeding tube, that can be managed outside of intensive care as well. Once someone is “only on feeding” and otherwise, they’re stable, no other mechanisms of life support, they can then go to a hospital floor or hospital ward with a feeding tube. And again, that I think it is considered life support, or I would consider it as life support. And that is one of the mechanisms of life support that can be managed outside of intensive care.
I want to quickly hone in on BIPAP, CPAP ventilation with a mask as well, because again, some people might say that, “Oh, this is not intensive care specific.” And I’d say, “Yes, it is intensive care specific.” Because if it’s not for sleep apnea, other conditions maybe, pneumonia, maybe
ARDS, maybe COVID pneumonia, COVID ARDS. If you need BIPAP or CPAP it is absolutely considered life support because the goal is to keep them off ventilation, off the breathing tube or the endotracheal tube. And therefore, you need the intensive care nursing skills to keep that patient safe and off the breathing tube and the endotracheal tube. What that means is when someone goes on BIPAP or CPAP in intensive care, that also means when they go off BIPAP or CPAP, they often go on high flow nasal prongs, and they often go on oxygen with the high flow nasal prongs, high concentrated flows with oxygen, and one needs to check ABG or arterial blood gasesin order to manage the ventilation side of things and keep the patient safe.
The reason that is important is you can’t do arterial blood gases outside of intensive care, which is why it is a specialist skill. Also, you need to change ventilation settings as you go along if you want to keep a patient off the endotracheal tube and breathing tube. A BIPAP machine or CPAP machine or anything related to that, again, should not be used by non-intensive care professionals. Again, the only exception there is sleep apnea, even in a home care environment at Intensive Care at Home, we are looking after patients owned BIPAP or CPAP at home. And there’s a clear indication that only intensive care nurses should be doing that and nobody else.
That’s why it’s important. And you will see that, especially in the current environment that people on BIPAP are on CPAP will be on high levels of oxygen, 80%, 100% of oxygen in intensive care. And that means it definitely needs intensive care nursing skills, intensive care medical skills. Those patients could not be looked after at home. They often have high PIPs (Peak Inspiratory Pressure), again, high FiO2s (Fraction Of Inspired Oxygen), and it can be very distressing for patients to be on BIPAP or CPAP in intensive care, while they’re gasping for oxygen, gasping for air, can be very frightening for patients. And they often need a little bit of sedation to be able to tolerate the BIPAP or the CPAP rather than the breathing tube or the endotracheal tube.
Next, so with the breathing tube or endotracheal tube, if people can’t be weaned off the ventilator, they often then end up with a tracheostomy, which sometimes ends up with long-term ventilation, which means that people might perceive that patients need to stay in intensive care for long periods of time. The perception might be that people never come off the ventilator, that is often not the case, people can be weaned off the ventilator with a tracheostomy, but it can take some time. Or if they can’t be weaned off the ventilator, if it’s prolonged, you should absolutely be checking out Intensive Care at Home, because there’s a solution for you and for your loved one to go home with Intensive Care at Homeservices.
I also want to quickly look again at the inotropes or vasopressors in more detail. Again, adrenaline, noradrenaline are vasoconstrictors, basically meaning it constricts the veins and it, therefore, increases blood pressure, dobutamine, dopamine, or milrinone work more on the cardiac contractility, improves the cardiac contractility and what that means is it more or less increases the pump function of the heart and cardiac output and cardiac index should improve and it should support the heart and the vascular system in general, whilst it’s people are in intensive care.
Now, and I just quickly want to hone in on ECMO again, because when someone is on ECMO, most of the time all other mechanisms of life support kick in as well, even though ECMO can be used for heart failure and for lung failure, most other organs often need to be supported when someone is on ECMO, including the kidneys. Patients are often so sick that there’s a high risk of them going into kidney failure at least temporarily that all major organs need to be supported while someone is on ECMO. Because the heart and the lungs are often failing, sometimes it’s a combination of both.
I hope that gives you a good overview today about what life support is in intensive care. And if there are no other questions, I do want to wrap this up here and I do want to move along and type in your questions if you have any. If not, I want to thank you so much for coming on to this livestream and I want to thank you for your support.
If you have a loved one in intensive care, go to intensivecarehotline.com. Call us on one of the numbers on the top of our website, or simply send us an email to [email protected].
Also, like this video, give it a thumbs up, subscribe to my YouTube channelfor updates for families in intensive care. Comment below what you want to see next, or what questions you have and click the notification bell. I do offer one-on-one professional consulting and advocacy for families in intensive care, services that we provide are also reviewing medical records. Part of the professional consulting and advocacy is for you and for me to talk to the doctors, talk to the nurses, review medical records and consult you one-on-one with other family members if that’s what you prefer. There are all sorts of things we can help you with when you have a loved one in intensive care.
I urge you to not fly blind because 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 where I can help you with very, very fast.
Thanks again for watching today’s livestream and I will talk to you next week again, next Saturday 7:00 PM Eastern Standard Time, 4:00 PM Pacific Time, 11:00 AM Sydney, Melbourne time.
This is Patrik Hutzel from intensivecarehotline.comand I’ll talk to you next time.
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