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Today's article is about, “Quick Tip for Families in Intensive Care: Post-cardiac Arrest ICU Ventilation, Dialysis, Weaning, and Prognosis – What Families Must Know”

You may also watch the video here on our website https://intensivecarehotline.com/ventilation/quick-tip-for-families-in-intensive-care-post-cardiac-arrest-icu-ventilation-dialysis-weaning-and-prognosis-what-families-must-know/ or you can continue reading the article below.

Quick Tip for Families in Intensive Care: Post-cardiac Arrest ICU Ventilation, Dialysis, Weaning, and Prognosis – What Families Must Know

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’re not a doctor or a nurse in intensive care.

Everything that we do here is written and recorded for families who want honest, evidence-based information and also hope, because I know from my decades of experience as a critical care nurse, intensive care teams are not always good to give you hope. If anything, you get the doom and gloom.

So, Today, I have an email from one of our clients, Angel, who says:

“Hi, Patrik.

My older brother, 40 years of age, had a cardiac arrest a few days ago. I have seen many of your videos on YouTube. He opened his eyes also a few days ago. We haven’t really been shown concrete studies and results of the severity of his condition yet.

Last night before leaving, the nurse suggested to have a conversation with an ICU consultant about options like you say on your videos, it has all been extremely negative. My brother’s case is quite complex due to him also needing dialysis, yet we will not lose faith and hope. He’s a fighter and has endured a lot of hardships and pain. I don’t really have just a question yet, but I have so many. We believe in miracles and the work of God, yet your informative ICU background really helps us.

Thank you so much, and I’m looking forward to speaking with you.”

So, let’s just do a quick summary what happens during cardiac arrest in ICU – what you should be looking for, what questions to ask, what’s the prognosis, what are the outlooks, what are normal timelines in ICU, and so forth.

Immediately after cardiac arrest, the ICU’s job is to stabilize the heart, lungs, and brain, treat reversible causes, and prevent any secondary injury whether it’s to the heart or to any other organs.

They perform many tests and therapies which are also routine from an ICU perspective but they are not routine to you as a family, of course ,which is CT or MRI scan of the brain and ECG (electrocardiogram), check cardiac enzymes in the blood such as troponin or CRP (C-reactive protein), do an echocardiogram, basically an ultrasound of the heart, and potentially do a continuous EEG (electroencephalography) if there is suspicion for an anoxic or hypoxic brain injury, arterial blood gases, invasive blood pressure often targeted temperature to protect other organs, especially the brain in particular. That’s basically cooling therapy for 24 to 48 hours, then with gentle rewarming back to baseline. Evidence says don’t make firm neurological predictions in the first 72 hours after rewarming/ normalization.

Next, if your brother needs dialysis or CRRT (continuous renal replacement therapy), that complicates things, but it’s common and treatable in ICU using continuous modalities for unstable patients such as hemofiltration (also known as CRRT), which supports critically ill patients while the team treats the heart and the lungs.

Next – Mechanical ventilation. Your brother is obviously ventilated. Weaning is a stepwise process, go through spontaneous breathing trials, sedation management (i.e., sedation and opiates need to be weaned and minimized), airway management such as managing the breathing tube. A few days on mechanical ventilation in ICU after cardiac arrest is not a very long time. Many patients simply need time and stepwise trials before extubation or potentially deciding on a tracheostomy.

So, what is the ICU Team doing in the first 24 to 72 hours?

Number 1 – Stabilize breathing and circulation.

If intubated, ventilator settings are chosen to keep oxygen and carbon dioxide in safe ranges and protect the lungs. In your case your brother is intubated, so go check out the ventilator settings and let us know, send us a picture, so that we can help you interpret the ventilation settings so that you are informed and can ask the right questions or we can ask the right questions on your behalf by talking to ICU doctors and nurses directly. That is part of what I do here.

So, if intubated, ventilator settings are chosen to keep oxygen and carbon dioxide levels in safe ranges and protect the lungs. Vasoactive drugs such as noradrenaline (norepinephrine), epinephrine (adrenaline), dobutamine, or milrinone may support blood pressure and cardiac output, which is basically the pump function of the heart to support other organs. But that sometimes can even be vasodilator such as GTN (glyceryl trinitrate) or SNP (sodium nitroprusside) if there is an incidence of high blood pressure, which can also sometimes happen.

Next – Protect the brain.

Targeted temperature management or active fever prevention, avoid fever for at least 72 hours in comatose post-cardiac arrest patients is common practice to reduce secondary brain injury. Neurological examination and prognostication are postponed until sedation and hypothermia are resolved.

Sedation and opiates are used in the first 24 to 72 hours to keep a patient stable on a ventilator with a breathing tube. Then as the patient gets rewarmed, sedation and opiates also need to be reduced.

Next – Look for and fix reversible causes.

ECG and cardiac enzymes again (such as troponin and CRP), bedside echocardiogram (ultrasound of the heart), and often urgent coronary angiography if a heart attack caused the cardiac arrest. In the angiography you can do the angiogram, where you can see the screen the coronary arteries and look for blockages. If there is a blockage and it’s safe to do, you can do an angioplasty to unblock those coronary arteries. If the coronary arteries can’t be unblocked, cardiac surgery might also be another step.

Treat arrhythmias such as atrial fibrillation or ventricular tachycardia or potentially ventricular fibrillation, which might have led to the cardiac arrest in the first place. Myocardial ischemia which again caused by blocked coronary arteries, severe electrolyte problems, especially potassium, magnesium, calcium, if there is a sepsis treat that as well. And of course, like in your brother’s case, support failing kidneys. If dialysis is needed because of acute kidney injury after the cardiac arrest, ICUs commonly use continuous renal replacement therapy (CRRT) for unstable patients. It buys time while the heart and circulation are stabilized.

Next – Monitor closely.

Continuous ECG, oxygenation, ABGs, urine output, blood tests including lactate and electrolytes, neurological checks (hourly Glasgow Coma Scale assessments), and often continuous or serial EEGs and neuroimaging such as CT scan of the brain or MRI scan of the brain when indicated.

Also, especially with cardiac ultrasound or heart ultrasound, go and look for ejection fraction and see what the pump function of the heart is. Some cardiac arrest patients also end up with a Swan-Ganz catheter or a PA (pulmonary artery) catheter to monitor cardiac output and cardiac index. Also, some patients after cardiac arrest might end up on an intra-aortic balloon pump to support the heart temporarily, or they might even end up with ECMO (Extracorporeal Membrane Oxygenation). I’m not going into too much detail today about ECMO. I’ve made several videos about what ECMO is and how it can support patients after cardiac arrest or other cardiac issues.

Important diagnostics for prognosis and when they should be done:

CT brain early to look for bleed or major injury, same with the MRI (Magnetic Resonance Imaging) scan of the brain.

Next – EEG (electroencephalogram), helpful for seizures and prognostication and is often repeated and interpreted in the context of sedation, opiates, and temperature control. It is not uncommon that after a cardiac arrest, especially if there’s a hypoxic or anoxic brain injury, that there is a higher incidence of seizures occurring for patients and then seizure management needs to happen such as loading patients with phenytoin, also known as Dilantin, or with Keppra.

Look at serum markers. Can contribute to prognosis but must be used later and together with other.

Next – Clinical neurological exam is unreliable for early prognostication if the patient is sedated, on opiates, or potentially even paralyzed or hypothermic, i.e., in temperature cooling. Guidelines recommend delaying definitive prognostic decisions until confounders are cleared and at least 72 hours after return to normal temperature.

Let’s look at mechanical ventilation, weaning, and airway decisions.

Short term, ventilator settings aim for lung protection and adequate oxygenation and management of CO2 (carbon dioxide). ABGs guide adjustments and weaning. ABGs means arterial blood gasses. The evidence-based approach uses protocols and spontaneous breathing trials. When the patient shows improved gas exchange, stable hemodynamics, and reduced or no sedation and reduced or no opiates, liberation from ventilation is a stepwise tested process.

Next – If spontaneous breathing trials fail or prolonged ventilation is expected, the team may discuss a tracheostomy. Timing can be debated, early within 7 to 10 days versus later 10 to 14 days, and the choice depends on the clinical picture, neurological recovery, secretions, airway protection, expected duration, patient and family choices, as well, it’s probably the most important, what are patient and family choices. There is absolutely not a one size fits all, and teams and families balance risks and benefits as per family choice.

So where does dialysis fits into all of this? If the kidneys fail, dialysis or Continuous Renal Replacement Therapy (CRRT) helps control fluids, electrolytes and removes toxins while the ICU treats the primary problem. For hemodynamically unstable patients, which is common after cardiac arrest, continuous modalities such as CRRT are preferred as they are gentler, then intermittent hemodialysis. The presence of dialysis needs careful coordination with ventilation, anticoagulation, and other medications including inotropes and vasopressors.

So, let’s look at realistic timelines why a few days in ICU is not enough.

From admission to 48 hours, lifesaving intervention, stabilization, fever control, many confounders such as sedation, opiates, hypothermia, active, where the prognosis is very uncertain. 72 hours after rewarming and the patient has shown some hemodynamic stability, teams start more reliable neurological assessments and combine exams and EEG and imaging, biomarkers to form a prognosis. Guidelines explicitly caution against early withdrawal of life support while confounders remain.

I mean we caution against any withdrawal of life support unless it’s patient and family driven. When ICUs want to withdraw treatment, it’s often a case of them wanting to free up an ICU bed and save money. And I’ve made blog posts about this, recently and, and in the past.

Days 4 to 14 repeated assessments, spontaneous breathing trials, for ventilation liberation, dialysis or CRRT as needed. Consider tracheostomy if prolonged ventilation is likely, required, and also desired by patients and families.

Beyond 2 weeks rehabilitation planning, transfer discussion, or palliative care pathways only if patients and families agree with that and if the prognosis is really poor. But each patient’s course is highly individual, highly individual.

So, what to watch for, including red flags, and do not panic.

New severe hemodynamic instability, refractory arrhythmia such as AF (atrial fibrillation), uncontrolled multi-organ failure – these certainly worsen prognosis. Recurrent seizures not controlled by medication affect brain recovery, but slow improvement in wakefulness, ability to follow commands, attempts at spontaneous breathing trials, urine output returning, and decreasing vasopressor/inotrope needs are good signs even if they are small.

And another very important aspect here is, one of the reasons that many patients in ICU after cardiac arrest go into kidney failure is if the heart stops for a period of time. Basically, all organs lose perfusion, and if organs lose perfusion, even if it’s for a short period of time, or minimally perfused, they have a higher risk of going into what’s an organ shock. Like the kidneys are not perfused, they’re not getting any blood to the kidneys, i.e., they stop working. That’s why patients often end up in a with acute kidney injury after cardiac arrest.

So, questions to ask the ICU team, and copy this list to your phone if you like:

• What exactly caused the cardiac arrest? Was it a myocardial infarct, arrhythmia, or anything else? 
   
• Is my brother receiving targeted temperature management or active fever control? 
   
• When will rewarming be complete? 
   
• Which neurological tests have been done or planned, CT scan of the brain, MRI scan of the brain, EEG? 
   
• Biomarkers, when is meaningful prognostication possible? Ask about the 72-hour rule after rewarming, sedation, and opiate clearance. 
   
• Is he intubated? You’ve already indicated in your question that he is intubated, but it’s just for anyone else watching this, it’s a question for you to ask. 
   
• What are the ventilator settings and the plan for weaning? 
   
• Spontaneous breathing trials. When will the first spontaneous breathing trial be attempted? 
   
• Is the plan to wean off sedation and opiates step by step? 
   
• Does he need dialysis or CRRT now and what does that mean for mobility and rehabilitation? Do they think that dialysis or CRRT is ongoing or temporary? 
   
• Are there reversible causes we can treat – blocked coronary artery, treatable infection, electrolytes, if recovery appears limited? 
   
• What decisions might be needed and when will you involve palliative care and what are our options? 
   
• Can we have daily family updates and a single point of contact, i.e., this particular nurse or doctor for clarifying questions?

Number 9 – Get access to all medical records so that you can have someone else professional look over them like we do here at intensivecarehotline.com, where we can give you that second opinion.

So, how can you help right now?

Document events when collapse happen, bystander CPR, initial rhythm – useful for clinicians. Keep a concise list of questions and ask for one clinician to summarize progress each day. Advocate for time. Ask the ICU team to wait until the confounders are cleared before major decisions are being made.

Also very important, spiritual and emotional support. Your beliefs and presence matters. Liaise with your pastor, with your church, with your spiritual guides, if you want.

Now, words on hope and honesty. ICU clinicians balance aggressive, evidence-based care with realistic prognostication. Many patients surprise families. Some recover significantly; others don’t. The most important principle is to avoid premature decisions while sedation, opiates, hypothermia, dialysis, and organ instability are active. The guidelines are clear. Prognostication is multimodal and delayed until confounders are removed.

Now, and if you feel overwhelmed by all of this, which I know it can be. If you don’t understand intensive care inside out like I do, it can feel overwhelming, and therefore, you need to reach out to us so that we can help you break this down step by step, ask the questions on your behalf or set you up with the right questions to ask. Get access to all medical records so that we can help you get results, get outcome, making sure your loved one gets best care and treatment, always.

I have worked in critical care nursing for 25 years in three different countries where I worked as a nurse manager for over 5 years in intensive care. I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. I can very confidently say that we have saved many lives with our consulting and advocacy because of our insights. You can verify that on our testimonial section at intensivecarehotline.com. You can verify it on our intensivecarehotline.com podcast section where we have done client interviews because our advice is absolutely life changing.

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.

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 best care and treatment always. 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.

That’s why I do one on one consulting and advocacy over the phone, Zoom, WhatsApp, whichever medium works best for you. 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. 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 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 eBooks and 21 videos that I have personally written and recorded. 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 best care and treatment always.

All of that you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or simply send us an email to support@intensivecarehotline.com with your questions.

If you like my videos, subscribe to my YouTube channel for regular updates for families in intensive care. Click the like button, click the notification bell, share the video with your friends and families, and comment below what you want to see next, what questions and insights you have from this video.

I also do a weekly YouTube live where I answer your questions live on the show. You will get notification for the YouTube live if you are a subscriber to my YouTube channel or my intensivecarehotline.com email newsletter at intensivecarehotline.com.

Thank you so much for watching.

This is Patrik Hutzel from intensivecarehotline.com and I will talk to you in a few days.

Take care for now.
 

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