Master Class 2025: Critical Care: Cutting Edge and Beyond the Evidence (MC)-Challenging Cases

Challenging Cases - Janz

Pdf Summary

The presentation "Challenging Cases" by Dr. David Janz addresses complex critical care scenarios encountered in the ICU that lack clear evidence-based solutions, encouraging expert panel and audience discussion.

Three main cases are explored:

1. <strong>"The Straw of Life"</strong> focuses on a 38-year-old patient with pulmonary arterial hypertension (PAH) secondary to scleroderma who requires parenteral therapy initiation. The patient develops massive upper gastrointestinal bleeding and hemodynamic instability. The case raises questions about timing and preparation for endotracheal intubation prior to urgent endoscopy, including sedation approach, use of neuromuscular blockade, vasopressor strategy (prophylactic vs reactive), choice of proceduralist, and airway devices.

2. <strong>"Outside Hospital"</strong> describes a 26-year-old pregnant patient at 36 weeks gestation admitted to a remote hospital with influenza-induced ARDS requiring intubation. Despite optimal ventilator settings, profound hypoxemia persists. The case prompts discussion regarding management prior to and during interfacility transport, including sedation drips, proning attempts, driving pressure considerations, and potential initiation of ECMO cannulation onsite versus rapid transfer.

3. <strong>"When Bivalves Attack"</strong> involves a 67-year-old septic shock patient with a Vibrio vulnificus infection from oyster exposure. Despite surgical debridement and broad-spectrum antibiotics, he remains on high-dose vasopressors and steroids. Queries focus on whether to escalate vasoactive medications, narrow antimicrobial therapy based on culture results, and optimal antibiotic duration.

The session’s format highlights that these common ICU presentations have no definitive right answers. Panelists offer bedside opinions, fostering interactive debate and audience polling to engage clinicians in tackling these challenging clinical dilemmas. The goal is to enhance critical thinking and patient-tailored approaches when evidence is limited.

Keywords

Critical Care

ICU Challenges

Pulmonary Arterial Hypertension

Scleroderma

Upper Gastrointestinal Bleeding

Endotracheal Intubation

Pregnancy and ARDS

Interfacility Transport

Vibrio vulnificus Infection

Septic Shock Management