Hi, it’s 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, 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!

You can click on this YouTube link to watch the video for today’s blog post:

https://youtu.be/871gc6V_EdI

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

What are the Right Questions to Ask When Talking to My Daughter’s Doctors & Nurses in the ICU?

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 Dad is on Propofol & Fentanyl in ICU! Should He be on Different Sedatives to Get Out of the Coma Fast?

Dad is on Propofol & Fentanyl in ICU! Should He be on Different Sedatives to Get Out of the Coma Fast?

Welcome to another, Intensive Care Hotline livestream. My name is Patrik Hutzel and I’m your host today for this livestream, in our livestream series for families of critically ill patients in intensive care.

So, in today’s livestream, we want to talk about, “My dad has been on fentanyl and propofol in ICU. Should he be on different sedatives so that he can wake up quicker?” That’s the topic today and this is a question we get quite frequently from our readers and clients. And I could replace my dad with my mom, my spouse, my brother, my sister, my child. I could replace that very easily with another family relation. So, it’s a general question I’m trying to answer today. And I have actually deliberately chosen fentanyl and propofol as an example, because that is quite a common thing in ICU that patients end up on fentanyl and propofol and then should they be changed to something different? And I will elaborate on that in a minute.

Now, before we go into the topic in more depth, you might wonder what makes me qualified to talk about this topic. I have worked in intensive care for over 20 years as a critical care nurse. I have done postgraduate studies in intensive care nursing. And I have worked as a nurse unit manager for over five years in intensive care and I have worked in three different countries. And I have been professionally consulting and advocating for families in intensive care all over the world since 2013. I’m also running and operating an organization called Intensive Care at Home where me and my team are looking after predominantly long-term ventilated patients at home with tracheostomies, but also other clients that would be in intensive care if it wasn’t for an intensive care nurse at home, 24 hours a day. 

So, let’s dive right into the topic. Also, as we go along today, please type your questions into the chat pad. And I can see that Modema is here and Modema, if you want to type in your questions, please keep them to today’s topic. And if you have any other questions that are not related to the topic, I will get to them once we’ve talked about the topic, and then I will get to your questions if you have any others.

So, let’s dive right into what happens when a patient gets admitted to intensive care and they get induced into a coma. They end up on a breathing tube, on a ventilator that is 99% the reason why people end up in a coma because if they need mechanical ventilation with a breathing tube in their mouth, in their throat, it’s very uncomfortable and they would rip it out. And if they ripped it out, they could die. And obviously, there is a reason why they need to be ventilated that could be a pneumonia, it could be ARDS (Acute Respiratory Distress Syndrome), it could be after surgery, it could be brain trauma, it could be chest trauma. It could be a variety of reasons why people are ventilated and I’m not going into too much detail there.

What I will say is this, at the moment a lot of patients are in ICU with COVID, whether it’s a COVID pneumonia or a COVID ARDS, and it does make a difference what sedatives are being used, especially when it comes to proning, when COVID patients are proned or any other patient is proned, because then we are often not only talking about sedatives and pain relief, such as morphine or fentanyl, and I should also say that morphine or fentanyl are classified as opiates. The classification of the drug is called opiates and opiates have a highly addictive nature, which means if patients are on fentanyl and morphine for too long, they get addicted. And then not only do they need to come off the ventilator as part of the recovery process, they often also go through withdrawal from those drugs and that can be a big challenge.

And also, fentanyl and morphine, for example, their main side effect is respiratory depression. So, what that means is on the one hand, you need morphine or fentanyl for tube tolerance, meaning without morphine or fentanyl a patient can’t tolerate the tube. On the other hand, they are also diminishing chances for someone to get off the ventilator. And I will talk more about that in a moment on how that pans out in practice.

So, let’s just take what I refer to as a “straightforward patient in ICU”, pre-COVID, pre-pandemic, patient comes into ICU after open-heart surgery. They need to be ventilated for, let’s just say, 12 to 24 hours in order to make sure they’re stable, they’re not bleeding, and they’re on a little bit of fentanyl and a little bit of propofol for tube tolerance. They’re not bleeding. They’re stable. Their blood pressure is stable. They’re not going into kidney failure. Then, propofol and fentanyl are probably the ideal drugs to manage that situation.

Why are they the ideal drugs? Propofol is short-term acting. Meaning, when you start propofol as a sedative, it knocks people out straight away. And when you stop it, in the ideal world, a patient will wake up pretty quickly. That’s why propofol and fentanyl are very good when it comes to post-surgery. Again, I take open-heart surgery as an example, but you could take any other surgery where a breathing tube and mechanical ventilation are needed, propofol and fentanyl are ideal. And when you stop fentanyl or minimize, patients also tend to be waking up a little bit quicker compared to morphine. It’s just the half-life of the drug is lower. So, in a scenario like this, I would say, “Hey, propofol and fentanyl are great. You stop the propofol, you can very quickly find out, is the patient waking up or not? Is their brain intact?” Good scenario.

Now, next, let’s just say the same patient, instead of open-heart surgery has COVID pneumonia, COVID ARDS, coming into ICU. They need to start off with fentanyl and propofol, they’re using high doses of it. And then they need to be paralyzed as well because for example, they need to be proned. And if they need to be paralyzed, that is a whole different ball game, because then they need more sedatives and more pain relief such as morphine or fentanyl. Again, they need more opiates.

Why is that? When someone is being chemically restrained with a paralyzing agent, such as rocuronium, vecuronium, cisatracurium and the list goes on, they need to be very deeply sedated, because imagine you’re on a breathing tube, someone is paralyzing you chemically with a drug, and you can actually feel things, you can actually feel you can’t move because of the paralyzing agent. So, you really don’t want to go through such an experience. You really need to be deeply sedated. On top of that, a lot of patients that end up being proned can get incredibly uncomfortable and it is very uncomfortable being proned, but it’s often necessary to be proned when it comes to COVID ARDS, COVID pneumonia, it’s often necessary. But there, you also have a problem because if you’re being proned or if your loved one is being proned and is on heavy sedatives and heavy paralytics, it will take them longer to wake up and come out of the induced coma. It’ll take them a lot longer.

Let’s just take someone that’s ICU, again, after cardiac surgery, let’s just say. You wake them up after you switch off the propofol, you switch off the fentanyl, and they’re ready for extubation. Then for whatever reason they need to be re-sedated. Maybe they’re starting to bleed, maybe they’re having heart arrhythmias, maybe their blood pressure plummets, maybe they’re going into kidney failure. The bottom line is this, they need to be re-sedated.

So, coming back to, “What if someone can’t be woken up, they need to stay under sedation for a few more days. Is then propofol and fentanyl still the right thing to take?” So, it really depends. The answer is that it depends. If you think you want to sedate someone for a couple of more days, then I think you should stick with propofol and fentanyl. Because again, you can assess a patient much quicker if their brain is intact, because one of the first things you need to assess when someone comes out of induced coma is, is their brain intact? God forbid, one of the worst-case scenarios is that someone, during an induced coma, is having a stroke or seizures and you can’t even see it because people are in a coma. So therefore, propofol and fentanyl are rather good.

Suggested Links: 

• HOW LONG CAN YOU KEEP A CRITICALLY ILL PATIENT IN INTENSIVE CARE IN AN INDUCED COMA?
• Why is a critically ill Patient not “waking up” from an induced coma?
• What are the side effects of an induced coma?

Now, I’ve talked about the side effects of fentanyl and morphine, which is again, respiratory depression and they’re also addictive in nature. Propofol is not addictive in nature. One of the main side effects of propofol, however, is hypotension, also known as low blood pressure. So, when someone is being started on propofol, and sometimes they’re getting propofol boluses as well. On top of that, they often end up with inotropes or vasopressors, which is considered life support because their blood pressure has dropped because of the use of propofol. So, that in and of itself is not ideal either. You don’t want to have someone on inotropes ideally, because that comes with side effects, such as vasoconstrictions. You’re at higher risk of pressure sores. There’s a whole lot of other issues coming up.

So, then the question is, “Should propofol be changed to another medication?” And the answer often is yes. And that alternative medication is often midazolam, also known as Versed. Now, midazolam or Versed is a common sedative being used in ICU predominantly for long-term sedation. Propofol is predominantly for short-term sedation. Midazolam or Versed is mainly used for a long-term sedation because it’s a little bit smoother to use. It doesn’t have the side effects of dropping the blood pressure quickly and you can use lower doses as well because it’s stronger in the onset.

Now, what are the side effects of midazolam? Because everything unfortunate comes with side effects. Now, unfortunately, midazolam or Versed is classified as a benzodiazepine. Other benzodiazepines, for example, are temazepam, diazepam, and Ativan. They’re all benzodiazepines. They’re all tranquilizers, if you will, they all have sedative effects. Problem with those benzodiazepines is that they’re also addictive in nature. And if you have someone on many days, sometimes even many weeks of midazolam or Versed, because it’s given intravenously, and you wake patients up, then they might need to go through a withdrawal as well. And that again is very challenging.

Now, when someone comes out of an induced coma, they are confused. At the best of times, they’re often confused. They can be agitated. They can be aggressive even. And part of that issue is that people are simply going through a withdrawal, but even if they’re not going through a withdrawal, they can still be agitated, confused, potentially aggressive. So, how do you deal with that? It’s a vicious cycle that on the one hand, you need the sedatives and the opiates for someone to be ventilated and tolerate the breathing tube, give the body a rest so that the body can deal with a critical illness. And on the other hand, many of those substances are addictive and have respiratory depression as a side effect. ICU has been around probably since the early 1960s, it’s a shame that no better alternatives have been found, but I do come to that in a moment. There is now an alternative that seems to be working in some instances. And I’ll come to that in a moment.

The other alternative that has been around on the market probably for the last 15, almost 20 years now, is a medication called Precedex or dexmedetomidine. So, when you look at the combination of propofol and fentanyl for sedatives, you’ve got fentanyl on the one hand, which is an opiate for pain relief. You’ve got the propofol on the other hand, which is for sedation. And now, you’ve got Precedex or dexmedetomidine, which apparently is both, it’s giving pain relief and it’s a sedative agent.

Now, what can I say about Precedex or dexmedetomidine? From my experience, it can work in some patients and it’s not working with other patients. Is it the better sedative to use? I think it is, if it works. But my experience has shown me that it doesn’t work in every patient, whereas propofol, fentanyl, morphine, midazolam/Versed, are for pretty much everyone. You’ve just got to choose your preferences and what is appropriate for the individual’s situation.

Now, sticking with the Precedex just for a moment, Precedex or dexmedetomidine is clonidine-based. Now, why is that important? In the “old days”, when I first started out in ICU in the late 1990s, early 2000s, we were using clonidine in ICU to help patients with withdrawal. So, one could argue, because clonidine again has a sedative effect, and it can also be used as pain relief. So, when someone is going through withdrawal and they’re having clonidine or now Precedex, it smoothens out they’re waking up process very often. And now, you could argue using Precedex, in the first place, eliminates that process. If it works, I’m all for it. But again, I haven’t seen it work for too many patients and then often patients go backwards. And they need to use the combination of propofol, fentanyl, or propofol and morphine, or morphine and midazolam/Versed, or fentanyl and midazolam.

So, I’ll give you another clinical situation where you need to worry about, is fentanyl and propofol the right approach? Or do you need fentanyl and midazolam?

Jose, I’ve seen your question. I want to stick with the topic for now and I’ll come to your question at the end. When I’ve talked about today’s topic and then I will answer your questions that are not around the topic. But thanks for joining the call.

So, when someone comes into ICU with a traumatic brain injury, for example, they’re potentially having part of their skull removed, they’re having high intracranial pressures, midline shift. Then, you probably need to start using fentanyl and midazolam, or Versed or morphine, and midazolam or Versed, because this is going to be a longer-term sedation until ICPs (Intracranial Pressures) are under control. Also, you need to then often paralyzes patients again. And if they’re paralyzed, as I said in the beginning, when patients are paralyzed in ICU, you need to go in with the strong guns, if you will. And those strong guns are fentanyl, midazolam/Versed, rather than fentanyl and propofol.

The problem really is then, how long does it take for someone to wake up? And the answer to that is (A) It depends. (B) Sometimes the answer is how long is a piece of string? It can take a long time. And if you get the sedatives right from the very start and you don’t need a prolonged sedation or a prolonged induced coma, people should wake up fairly quickly with fentanyl and propofol. But as you’ve seen now, now that we’ve looked at different conditions, it’s not a one size fits all, unfortunately. It’s not a one size fits all. It really is a situation where it very much depends on the individual. Another thing that could happen is, is someone allergic to several drugs? Are they allergic to morphine? Are they allergic to propofol? Are they allergic to midazolam? Who knows? So, that’s also coming into play here as well.

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So, let’s just quickly look at some questions that we have here now. So, we’ve got Jose, you’re asking, “My dad just had irreversible damage from a stroke on a ventilator. What’s next?” Jose, I’m very sorry to hear that, but that is also a very general question. And why do I mean it’s a general question? (A) How do you know it’s irreversible? ICUs are very quick in painting doom and gloom pictures, and ICUs are very quick in telling you how negative it all is. How do you know it’s irreversible? How do you know the stroke happened while he was on a ventilator?

So, 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.

Now, why do I say all of that? Now, what you’re telling me here, Jose, is your dad had irreversible damage from a stroke on a ventilator. That is only a fraction of what’s really happening. If your dad is on a ventilator in intensive care, there are dozens of things happening simultaneously, Jose. Dozens of things happening simultaneously. So, it’s very concerning what you’re telling me here, but I have a thousand questions to what you’re telling me. And only then can I tell you what’s next. Now, if you and I would get on a call with a doctor, you would be surprised of the questions that I would be asking. If you could give me access to the medical records, me and my team would be looking at the medical records and we would probably come back with 25 questions to you.

And we would probably say to you, “Okay, we need to talk to the doctors and nurses to find out what else is happening.” And just because the neurologist told you, I would take that very seriously. But again, as a clinician, I would have 25 other questions, what else is happening? What does the CT (Computed Tomography) scan show? What does the MRI (Magnetic Resonance Imaging) scan show? What medications is he on? What ventilation settings is he on? Are pupils equal and reactive? What’s the Glasgow Coma Scale like? I don’t want to overwhelm you here Jose, but you can see, it’s not as simple as what’s next? You want to know what’s next, but before I can give you that answer, I have a million of questions. It’s very complex when someone is in ICU. Very complex, when someone is in ICU. Jose, do you know if it’s a brain bleed or if it’s an ischemic stroke or hypoxic stroke? Do you know? While I’m waiting for your answer, you’re also saying it’s COVID-related Jose. Okay, fair enough.

While I’m waiting for your answer, whether the stroke is an ischemic stroke or hypoxic stroke with a thrombus or a bleeding stroke, I’ll answer the next questionnaire from Areza, “If I’m trying to delay the ICU, if I’m transferring my loved one to LTAC, is it better to avoid case management social worker or to be proactive with them?” Again, Areza, it depends, it really depends. Tell me a little bit more why they are wanting to send your loved one to LTAC. Tell me a little bit more about your loved one’s situation and then I can probably answer your question. How long has he been in ICU? How long has your loved one had the tracheostomy for? Have they got a PEG (Percutaneous Endoscopic Gastrostomy) Tube ? Are they on inotropes or vasopressors? Are they on dialysis? Again, the list is endless of questions and only once I have a good picture, I can advise you what the next steps are.

Jose, you are saying in the meantime, you don’t really know, “Just told me it’s swollen.” Yeah, the brain might be swollen Jose, whether it’s an ischemic stroke or a bleeding stroke, a hemorrhagic stroke. And this is what I mean, the devil is in the detail when someone is in intensive care. Whilst you are saying, ”My dad had a stroke and I’m extremely concerned, what’s next?” I get all of that. If I was the nurse looking after your dad, I would have a million of questions and I would have the same if you and I were to get on the phone. I would have a million of questions that I would want to ask to the team there, to the doctors. And only then can I guide you with the next steps, really.

Oh Areza, if you want to send a booking through, just go to intensivecarehotline.com and there’s a link on the website, on the top of the website where it says, schedule appointment. Maybe you’ve scheduled it already. But yes, you can reserve it for tomorrow, Areza, for sure.

So, coming back, Jose, to your situation, the devil is in the detail. I do understand at the moment, a lot of patients in ICU with COVID end up with strokes for a number of reasons. Everybody in ICU is at higher risk of stroke because they’re (A) At higher risk of a thrombosis, or (B) At a higher risk of bleeding stroke or a bleeding in general. Why is that? They’re at risk of a thrombus because they’re immobile. And on the other hand, they’re getting anticoagulation. Because they are immobile, that puts them at higher risk of a hemorrhagic stroke, of a brain bleed.

Modema, you’re saying, “I wish I found you six months ago.” Sure. Look, it is what it is. You can’t turn back the tide. All I can do is answer questions now and I think that’s what we should be focusing on.

So, if there are no other questions at the moment, I just want to come back to our topic, “What sedatives are best for which situation to get patients out of intensive care quickly?” So, as I said from the outset, propofol and fentanyl are pretty good if you don’t use them for too long. If you use them for too long, no sedative is good, really. The goal should always be to get someone out of induced comas as quickly as possible.

Modema, you are saying, “The virus itself complicates coagulation.” Look, as far as I understand it can complicate coagulation, but again, it varies on the individual. It’s not the primary issue that we see patients having strokes when they’re in ICU with COVID. It’s not the primary issue. What we do see though, is patients in ICU in general, are at a higher risk of unfortunately having a stroke.

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Mohammad, you’re saying, “My father is in ICU. He’s on 55% FiO2 (Fraction of Inspired Oxygen) with tracheostomy done nine days ago. He’s only on fentanyl and noradrenaline for blood pressure support. However, while intubated  and now tracheostomy done, he’s stable at 45 to 55% and the doctors can’t get him off lower. They have never proned him.” Mohammad, why is your dad in ICU? Is he in ICU for COVID? Why is he there? Share a little bit more. If they can’t get him lower, the first reason for that is most likely that the blood gases are pretty poor. What that means is when someone is on a ventilator, they are needing blood gases, arterial blood gases. And if someone is on 55% FiO2, and they can’t lower that, it means that (A) The blood gases are fairly average or poor even, or (B) They might not be able to get him any lower because he might be fighting against the ventilator. Maybe it’s a sedation issue. Maybe he’s not deeply sedated enough, which ties right back in with our original topic that we started off earlier today.

So also, if he’s on noradrenaline in the ideal world, they should get him off that noradrenaline as quickly as possible. But he might be dehydrated. He might have an infection. That could be one of the reasons why he’s needing the noradrenaline. But Mohammad, if you can share with me why your dad is in ICU? And why you think they can’t lower his FiO2? That would be good because then I can hopefully help you with the next step.

While I’m waiting for your answer, Mohammad, Modema, you’re saying your loved one was on ECMO (Extracorporeal Membrane Oxygenation). Look, I’ve done separate videos about ECMO, and I will do other videos about ECMO in the future. Again, it’s not today’s topic.

Mohammad, you’re saying, “He had COVID, and now they have said he has pneumonia. Showing signs of scarring in the lungs. He’s been in ICU for 37 days.” I think now we’re getting closer to the truth here. So, it’s been a big issue across the board, unfortunately, that many patients in ICU with COVID end up with scarring of the lungs, and that is definitely, or can be an obstacle to weaning off the ventilator. And that might be one of the reasons why your dad can’t come off the ventilator yet. Mohammad, how old is your dad? And I will tell you in a minute why I’m asking that question, because age can lead to different treatment options. I’ll just start to elaborate on that a little bit while I’m waiting for your answer, Mohammad, how old is your dad? So, when someone is having scar tissue in the lungs, it’s often irreversible. It obviously depends on the extent, how big is the scarring of the lungs? And then the question is, how old is the patient? Now, if they’re scarring and they can’t get someone off the ventilator, are they a candidate for ECMO?

Mohammad, you’re saying, “65 years of age. He has had four heart bypasses done 10 years ago.” Now, Mohammad, your dad is right on the cusp. What do I mean by that? 65 years of age is the cutoff for someone to have ECMO. And it’s also the cutoff often for a lung transplant. Now, I’m not going into too much detail today about ECMO. I’ve done countless of other videos about ECMO. And I will do future videos about ECMO. Now, basically what ECMO does, it can take over the function of the lungs for a period of time and it can give the lungs time to rest and heal. Now, if there’s scar tissue, the doctors might argue scar tissue is irreversible. But what ECMO can do, is ECMO can buy time whilst your dad might be waiting for a lung transplant. So, that might be an option here. ECMO leading to a lung transplant. There’s no guarantee that your dad will get a lung transplant, but ECMO is often a bridge to a lung transplant.

Now, what probably works against your dad’s situation at the moment is I believe he’s been in ICU for 37 days. They probably should have offered him ECMO very early on. The earlier you get someone on ECMO, if the lungs are failing, the better it is. But I would assume you probably didn’t know that there were alternatives for that. And also, what they might say is, if he’s had four heart bypasses 10 years ago, that might rule him out to go on ECMO because of other risk factors. I wouldn’t know. Again, there are so many details that need to be looked at when someone is in intensive care. Whilst I’m saying he might need ECMO, what else is going on? What other premedical history does he have? Does that potentially exclude him from ECMO? There are so many variables in a situation like that. And bear in mind at the moment, the demand for ECMO is very high.

Why is the demand for ECMO very high? Previously, pre-pandemic, pre-COVID, many patients in ICU had ECMO because of ARDS/lung failure or heart failure. So now, ARDS cases have gone through the roof because of COVID. So, the demand for ECMO has gone through the roof. So now, it’s even more difficult to get ECMO. There’s a staffing shortage everywhere, a staffing crisis. It’s very difficult at the moment to get the right treatment in a timely manner because of COVID, because of staff shortages, because of equipment shortages. But also, if someone is on ECMO, staff, doctors, nurses, need to have done specialist training to look after patient on ECMO. So, it’s a whole lot of complicating factors.

Now, I am conscious of the time. I usually keep those sessions to about 30 or 40 minutes. And I want to answer as many questions as I can, but I want to give you the option to ask other questions while I’m still here, but I will wrap this up in about 5 or 10 minutes, but I absolutely want to make sure all your questions are answered while I’m still here. So, please type your questions away so I can carry on answering them.

Just quickly while I’m waiting for your questions to come through, I just quickly want to go back again to our initial topic, and maybe combine that also with the question around ECMO. When someone is on ECMO and they have a tracheostomy, they often don’t need sedation, or they need minimal sedation because the tracheostomy is much more comfortable to tolerate compared to a breathing tube. So, there could be numerous advantages for your dad, Mohammad, if he can end up on ECMO. Is your dad awake? That’s another question. I don’t know if your dad is awake. Just coming back to our initial topic, the longer someone is in an induced coma, the more you want to use long-term sedatives, such as midazolam rather than propofol because of the side effects and also you can use lower doses. Propofol, sometimes you need to use 200 milligrams an hour and so forth.

Mohammad, what are you saying? “If you get a chance, can I pay you to be a consultant for my father and call the ITU just to see if they’re giving him every right treatment? The doctors change every two days.” Yeah, for sure. You can absolutely reach me. It sounds to me like you are in the U.K., Mohammad, because you’re talking about ITU (Intensive Therapy Unit), that’s a U.K.-specific term. “They’re very short-staffed and don’t know the patient properly. I had to fight hard just to get him to have a tracheostomy.” Yeah, I can appreciate that. It’s very difficult. It’s very difficult at the moment. And to me, it looks like you might be in the U.K., Mohammad. And the U.K. system is probably the worst system out of all. Yes, you’re in the U.K.

Mohammad, either sent me an email to support@intensivecarehotline.com, that is support@intensivecarehotline.com. Or you can call me on my U.K. number, which is 0118-324-3018. That is again, U.K., 0118-324-3018. But you will also find that number on our website intensivecarehotline.com. It’s right on the top of the website or on our contact page. So, you can contact me there.

So, look, I really want to wrap this up here if there are no other questions. I do really appreciate you coming on to this call, to this livestream. Thank you for your support. Thank you for your questions.

And I will do another livestream in about a week’s time at the same time, 7:00 PM on a Saturday, Eastern Standard Time. 6:00 PM, Central Time, 5:00 PM Mountain Time, 4:00 PM Pacific Time. That’s 11:00 AM on a Sunday in Sydney, Melbourne, and it’s unfortunately in the middle of the night in the U.K., but the recording will go up later today and then you can watch the replay, of course. And it’ll be there for a long time to come.

Thanks, Modema for your kind words, “I highly recommend that you do, Mohammad.” Thank you for your kind words, Modema.

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• CAN ECMO BE A BRIDGE TO A HEART TRANSPLANT OR A LUNG TRANSPLANT?
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• 1:1 Email counselling and consulting with Patrik
• 7 days unlimited 1:1 phone consulting and advocacy
• Membership for families in Intensive Care
• 1:1 phone and email counselling and consulting with Patrik  

Thank you, Mohammad for your kind words, “You’re great at what you do. Every single person appreciates your content. Thank you. Saving one life is like saving humanity.” Yeah, thank you.

Thanks for your encouragement.

Thank you for coming on to this livestream. This is Patrik Hutzel from intensivecarehotline.com  and I’ll talk to you next time.

Take care.

• Email counselling/consulting with Patrik
   
• One on One phone/ Skype counselling/consulting with Patrik