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

Neuro Cases- Janz

Pdf Summary

This presentation by Dr. David Janz addresses managing physiologic parameters in ICU patients with brain injury, focusing on hemoglobin, temperature, oxygen saturation, and ventilation goals. It highlights the challenges of critical care where definitive evidence-based answers are often lacking, requiring clinicians to balance expert opinion and individualized patient management.<br /><br />Key themes include targeting "normal" values—termed "making the numbers look normal"—such as normothermia, normoxia, normocarbia, normotension, normovolemia, normoglobinemia, and normoglycemia. Cases illustrate common ICU dilemmas, such as fluid resuscitation and hemoglobin transfusion thresholds in traumatic brain injury (TBI) patients with complications like hyponatremia or bleeding. Evidence on transfusion thresholds is mixed, but recent data suggest that higher hemoglobin goals (around 10 g/dL) may improve neurologic outcomes in moderate/severe TBI compared to restrictive strategies (hemoglobin around 7 g/dL).<br /><br />Temperature management in stroke patients, including those post-thrombectomy or with comorbid pulmonary embolism, often involves maintaining normothermia and actively treating fever to reduce secondary brain injury, though clinical outcome improvements remain uncertain. Ventilation strategies prioritize lung-protective approaches (low tidal volumes, moderate PEEP) and maintaining normocarbia (PaCO2 35-38 mmHg) to prevent cerebral blood flow alterations and secondary injury. Blood pressure targets differ by brain injury type—for example, systolic BP under 180 mmHg post-stroke thrombectomy, 150 mmHg for intracerebral hemorrhage, and MAP goals adapted to injury specifics.<br /><br />Oxygenation goals are conservative to avoid hyperoxia and hypoxia harms, with SpO2 targets typically around 90%, even in severe cases requiring prone positioning and high PEEP. The decision to escalate to extracorporeal support depends on balancing cerebral and pulmonary risks.<br /><br />Overall, the talk emphasizes individualized, evidence-informed goal-setting in ICU brain injury care, acknowledging ongoing controversies and the need for multidisciplinary input.

Keywords

ICU brain injury management

hemoglobin targets

temperature management

oxygen saturation goals

ventilation strategies

traumatic brain injury

normothermia

fluid resuscitation

blood pressure targets

lung-protective ventilation