PRISM Rounds: Pulmonary Critical Care & Sleep Podcast

When should we add vasopressin in septic shock? At a norepinephrine dose of 0.1 mcg/kg/min, or should we wait until 0.4?

In this episode of PRISM Rounds, we examine the VASSPR trial, published in JAMA in October 2026. This pragmatic, cluster-randomized crossover trial enrolled 3,959 patients across 13 hospitals and compared earlier versus later vasopressin initiation strategies.

Earlier initiation increased vasopressin use and reduced the norepinephrine dose at which it was started. However, 28-day mortality was similar between groups (31.8% vs 33.0%), with no significant improvement in kidney replacement therapy-free days.

We explore the trial's strengths, imperfect adherence, implications for current sepsis guidelines, and why a fixed norepinephrine threshold may not capture the complexity of septic shock.

The central question: Should vasopressor management be guided by a number, or by the patient's evolving physiology?

A practical, evidence-based discussion for intensivists, emergency physicians, hospitalists, fellows, nurses, and ICU pharmacists.

Primary article: Peltan ID, et al. Effect of Vasopressin Initiation Threshold on Septic Shock Mortality: The VASSPR Cluster Crossover Randomized Strategy Trial. JAMA. October 14, 2026.

https://doi.org/10.1001/jama.2026.21333

Tags: Septic Shock, VASSPR Trial, Vasopressin, Norepinephrine, Critical Care, Intensive Care, Sepsis, Vasopressors, Hemodynamics, JAMA, Clinical Trials, Evidence-Based Medicine, PRISM Rounds

At PRISM Rounds, we use AI-generated voices to bring you thoughtfully curated medical research in an engaging, conversational format. While we do our best to keep things accurate, occasional errors or mispronunciations may slip through. We hope these episodes spark curiosity and encourage you to explore the original research.

Can stimulating the orexin receptor improve both sleepiness and cataplexy in narcolepsy type 1? In this episode of PRISM Rounds, we examine the First Light and Radiant Light phase 3 trials of oveporexton.

Across two 12-week trials, oveporexton produced substantial improvements in objective wakefulness, patient-reported sleepiness, and cataplexy compared with placebo. We discuss what those changes could mean for patients, why urinary frequency and insomnia matter, and what remains uncertain about long-term safety and comparisons with existing treatments.

Read the trial: https://www.nejm.org/doi/full/10.1056/NEJMoa2601598

Find more episodes at https://www.prismrounds.com and follow PRISM Rounds on Spotify or Apple Podcasts.

Tags

narcolepsy type 1, oveporexton, orexin, hypocretin, cataplexy, excessive daytime sleepiness, sleep medicine, clinical trials, First Light trial, Radiant Light trial, NEJM, PRISM Rounds

Choosing between high-flow nasal cannula, noninvasive ventilation (NIV), CPAP, and conventional oxygen is one of the most common decisions in critical care. The new 2026 American Thoracic Society (ATS) Clinical Practice Guideline provides updated, evidence-based recommendations across the spectrum of acute respiratory failure.

In Season 1, Episode 62 of PRISM Rounds, we examine the guideline published in the American Journal of Respiratory and Critical Care Medicine and explore what its recommendations mean for bedside practice.

We discuss four critical clinical questions:

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Acute hypoxemic respiratory failure: Why is high-flow nasal cannula strongly recommended over conventional oxygen, and when should clinicians consider NIV or CPAP?

•

Acute hypercapnic respiratory failure: Why does NIV remain first-line therapy, and when might high-flow oxygen be a reasonable alternative?

•

Preoxygenation before intubation: How can HFNC and NIV reduce peri-intubation hypoxemia?

•

Postextubation respiratory support: Which patients benefit from preventive NIV or HFNC, and how can we reduce reintubation?

We also examine the strength and certainty of the evidence, important limitations of network meta-analyses, and the distinction between reducing intubation and improving survival.

The central clinical question: Are we choosing the right respiratory support strategy for the right patient, and recognizing early enough when that strategy is failing?

This episode is designed for intensivists, pulmonologists, emergency physicians, respiratory therapists, critical care fellows, and other clinicians managing acute respiratory failure.

Primary Reference:
Goel NN, Ferreyro BL, et al. Noninvasive respiratory support for adult patients with acute respiratory failure: An official American Thoracic Society Clinical Practice Guideline. American Journal of Respiratory and Critical Care Medicine. 2026;212(9):2135–2158.

https://doi.org/10.1093/ajrccm/aamag302

Listen and subscribe to PRISM Rounds on Apple Podcasts, Spotify, Youtube or visit https://www.prismrounds.com.

Evidence reviewed. Clinical decisions informed.

Tags

ritical Care

Pulmonary Medicine

ATS Guidelines

Noninvasive Ventilation

NIV

High-Flow Nasal Cannula

HFNC

CPAP

Acute Respiratory Failure

Hypoxemic Respiratory Failure

Hypercapnic Respiratory Failure

COPD Exacerbation

Mechanical Ventilation

Preoxygenation

Extubation

Intensive Care Medicine

Evidence-Based Medicine

Clinical Practice Guidelines

Respiratory Therapy

PRISM Rounds

Can therapeutic plasma exchange save lives in acute-on-chronic liver failure, or does it simply delay the inevitable?

In Season 1, Episode 61 of PRISM Rounds, we examine a 2026 randomized controlled trial published in Hepatology evaluating therapeutic plasma exchange in 194 patients with acute-on-chronic liver failure (ACLF).

The findings are striking. Plasma exchange reduced 28-day mortality from 63.9% to 44.3%, an absolute difference of nearly 20 percentage points. However, by 90 days, mortality was similar between groups, and more than 40% of patients could not complete the planned treatment.

We examine the trial's methodology, treatment complications, and clinical implications alongside the 2023 EASL guidelines and a 2025 meta-analysis of plasma exchange in ACLF.

The central question: Does plasma exchange meaningfully alter the course of liver failure, or does it provide a temporary bridge to hepatic recovery or transplantation?

Join us as we explore what this trial should, and should not, change in ICU practice.

Read the primary study:
https://doi.org/10.1097/HEP.0000000000001755

Subscribe to PRISM Rounds on Apple Podcasts, Spotify, or YouTube.

Visit https://www.prismrounds.com for more episodes.

Tags

Critical Care, Intensive Care, Hepatology, Acute-on-Chronic Liver Failure, ACLF, Therapeutic Plasma Exchange, Plasmapheresis, Liver Failure, Liver Transplantation, Randomized Controlled Trial, Evidence-Based Medicine, ICU Research, PRISM Rounds

In this episode of PRISM Rounds, we examine a new randomized clinical trial comparing olanzapine with low-dose dexmedetomidine for established delirium in critically ill adults.

The primary outcome was neutral: patients in both groups had a median of 3 days alive without delirium or coma. But the study also found more adverse events with dexmedetomidine and a provocative difference in 90-day mortality that demands careful interpretation.

We place these findings in the context of MIND-USA, AID-ICU, SPICE III, nocturnal dexmedetomidine studies, and the 2025 PADIS guideline update. The key issue is not simply which drug performed better, but whether ICU clinicians are asking medications to do different jobs: prevent delirium, control agitation, or actually treat established delirium.

We discuss what this trial adds, its major limitations, why the mortality signal should remain hypothesis-generating, and what the results should—and should not—change at the bedside.

Primary article:
https://doi.org/10.1093/ajrccm/aamag235

Listen and subscribe on Apple Podcasts, Spotify, YouTube, or at https://www.prismrounds.com

PRISM Rounds, critical care, ICU, delirium, ICU delirium, dexmedetomidine, olanzapine, antipsychotics, sedation, agitation, PADIS, MIND-USA, AID-ICU, SPICE III, mechanical ventilation, intensive care medicine, pulmonary critical care, evidence based medicine, journal club, randomized controlled trial, FOAMcc, FOAMed

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How long should comatose patients remain at 33°C after out-of-hospital cardiac arrest?

In this episode of PRISM Rounds, we examine the icecap randomized clinical trial, which studied 1,158 comatose OHCA survivors who had already been rapidly cooled to 33°C. Patients were assigned to different cooling durations ranging from 6 to 72 hours.

Longer cooling did not improve neurological recovery, mortality, or secondary neurological outcomes. We discuss the adaptive trial design, the separate shockable and nonshockable rhythm cohorts, the meaning of the approximately 50% probability that 6 hours was the shortest optimal duration, and why this does not establish a universal six-hour protocol.

The episode places icecap in context with TTM, TTM2, and HYPERION while keeping clear that these trials addressed different temperature-management questions.

Read the study:
https://jamanetwork.com/journals/jama/fullarticle/2852508

Subscribe to PRISM Rounds on Apple Podcasts, Spotify, or YouTube, and visit:
https://www.prismrounds.com

Tags:
icecap, cardiac arrest, out-of-hospital cardiac arrest, OHCA, targeted temperature management, therapeutic hypothermia, post-cardiac arrest care, neuroprotection, neurological recovery, TTM, TTM2, HYPERION, critical care, intensive care, emergency medicine, resuscitation, ICU, fever prevention, modified Rankin Scale, PRISM Rounds

In Season 1, Episode 58 of PRISM Rounds, we review the 2025 Society of Critical Care Medicine guideline for the treatment of heat stroke and translate its recommendations into practical bedside decisions for emergency and critical care clinicians.

We discuss why active cooling should begin immediately, why cold- or ice-water immersion is preferred when feasible, and why the guideline emphasizes both the speed of cooling and the goal of reaching a core temperature below about 39°C within 30 minutes. We also review what to do when immersion is not practical and how the guideline approaches classic versus exertional heat stroke.

The episode also covers therapies that should generally be avoided. Routine acetaminophen, NSAIDs, salicylates, and dantrolene are not recommended for temperature reduction, and prophylactic antibiotics or antiseizure medications should be limited to research settings.

An important theme is the strength of the recommendations versus the strength of the evidence. Several recommendations are strong despite very low-certainty evidence, reflecting the practical and ethical difficulty of conducting randomized trials that delay effective cooling in patients with true heat stroke.

The bedside message is simple: recognize heat stroke early, start the fastest feasible active cooling strategy, continue simultaneous resuscitation and organ support, and avoid medications that do not address the underlying problem.

Read the guideline:
https://doi.org/10.1097/CCM.0000000000006551

More PRISM Rounds:
https://www.prismrounds.com

Available on Apple Podcasts, Spotify, YouTube, and other major podcast platforms.

Tags:
PRISM Rounds, S01E58, critical care, ICU, heat stroke, heatstroke, hyperthermia, SCCM, Society of Critical Care Medicine, emergency medicine, cooling, cold water immersion, ice water immersion, exertional heat stroke, classic heat stroke, temperature management, dantrolene, antipyretics, heat illness, resuscitation, evidence based medicine, clinical guidelines, guideline review, medical education, FOAMed, pulmonary critical care

Should we wait for a patient with intermediate-high-risk pulmonary embolism to deteriorate before pursuing reperfusion—or intervene before the right ventricle fails?

In this episode of PRISM Rounds, we examine PRAGUE-26, a multicenter randomized trial published in the New England Journal of Medicine comparing conventional catheter-directed thrombolysis with low-dose alteplase plus anticoagulation against anticoagulation alone in patients with intermediate-high-risk acute pulmonary embolism.

The headline result is striking: the 7-day composite of death, recurrent pulmonary embolism, or cardiorespiratory decompensation or collapse occurred in 0.7% with catheter-directed thrombolysis versus 6.8% with standard care. But the interpretation requires nuance. The benefit was driven primarily by fewer episodes of cardiorespiratory deterioration, not a demonstrated mortality reduction. Overall major bleeding was not clearly increased, yet two intracranial hemorrhages occurred in the thrombolysis group and none with anticoagulation alone.

We break down patient selection, the low-dose alteplase strategy, the composite endpoint, rescue reperfusion, early RV recovery, bleeding risk, and the limitations of an open-label trial conducted in experienced tertiary cardiovascular centers. Most importantly, we ask what prague-26 should change at the bedside: Does this trial support routine early catheter-directed thrombolysis, or does it help us identify the selected patient who should undergo reperfusion before overt hemodynamic collapse?

The article was published online in the New England Journal of Medicine on August 31, 2026, DOI 10.1056/NEJMoa2608012.

PRISM Trials / PRISM Rounds:
Visit PRISM Trials

Journal article:
Read “Catheter-Directed Thrombolysis in Intermediate-High-Risk Pulmonary Embolism” in NEJM

Tags:
#PRISMRounds #PRISMTrials #CriticalCare #CriticalCareMedicine #ICU #PulmonaryCriticalCare #PulmonaryMedicine #Pulmonology #PulmonaryEmbolism #PE #IntermediateHighRiskPE #SubmassivePE #CatheterDirectedThrombolysis #CDT #Thrombolysis #Alteplase #Anticoagulation #Reperfusion #PERT #PulmonaryEmbolismResponseTeam #RightVentricle #RVFailure #RightHeartStrain #HemodynamicCollapse #CardiorespiratoryDecompensation #Shock #VTE #VenousThromboembolism #EmergencyMedicine #Cardiology #InterventionalCardiology #IntensiveCare #ClinicalTrials #RandomizedTrial #RCT #EvidenceBasedMedicine #MedicalEducation #JournalClub #NEJM #FOAMed #FOAMcc #MedEd #EvidenceBasedCriticalCare

In this episode of PRISM Rounds, we discuss the SAVE-O2 AI randomized clinical trial, which tested autonomous closed-loop oxygen titration versus usual manual oxygen adjustment in 300 hospitalized adults receiving supplemental oxygen.

The autonomous system kept patients in the target SpO2 range much more often, 85% vs 63%, while also reducing time spent in hypoxemia and, even more strikingly, hyperoxemia. We break down what the trial shows, what it does not show, the importance of pulse oximetry accuracy and skin pigmentation, and whether improved oxygen control is enough to justify broader implementation.

We also discuss the accompanying editorial by Weingart and Matthay, which explores the potential impact on clinician workload, oxygen stewardship, resource-limited settings, and the next generation of implementation and outcomes studies.

SAVE-O2 AI trial, JAMA Internal Medicine
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/jamainternmed.2026.4023
DOI: https://doi.org/10.1001/jamainternmed.2026.4023

Invited Commentary: Potential Transformative Impact of Autonomous Oxygen Delivery in Hospitalized Patients
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/jamainternmed.2026.4038
DOI: https://doi.org/10.1001/jamainternmed.2026.4038

Find more episodes at http://www.prismrounds.com and subscribe on Apple Podcasts or Spotify.

Tags
#PRISMRounds #SAVE02AI #CriticalCare #ICU #PulmonaryCriticalCare #OxygenTherapy #Hypoxemia #Hyperoxemia #PulseOximetry #ClosedLoopControl #ArtificialIntelligence #DigitalHealth #ClinicalTrials #RandomizedTrial #JAMAInternalMedicine #RespiratoryCare #FOAMcc #MedEd

Does video laryngoscopy improve first pass success for routine tracheal intubation, and does blade geometry matter?

In this episode of PRISM Rounds, we discuss the COVALENT randomized clinical trial, which compared direct laryngoscopy, Macintosh style video laryngoscopy, and hyperangulated video laryngoscopy in more than 2,400 perioperative intubations.

We review the higher first pass success with video laryngoscopy, why the hyperangulated strategy performed best, the important role of stylet use, and what the accompanying editorial adds to the interpretation.

We also discuss how COVALENT builds on the DEVICE trial in critically ill adults and why the airway conversation may now be shifting from simply video versus direct toward which video strategy, blade, and adjunct work best in different clinical settings.

Find PRISM Rounds on Apple Podcasts, Spotify, and https://prismrounds.com

Tags:
Critical Care, ICU, Airway Management, Video Laryngoscopy, Direct Laryngoscopy, COVALENT Trial, DEVICE Trial, Tracheal Intubation, First Pass Success, Emergency Airway, Anesthesiology, Pulmonary Critical Care, Evidence Based Medicine, Journal Club, PRISM Rounds, FOAMcc, FOAMed

Description
We obsess over the paralytic, but are we giving enough of it?

In this episode of PRISM Rounds, we review a new AJRCCM secondary analysis of 1,822 critically ill adults from the DEVICE and PREOXI trials examining whether rocuronium dose is associated with first-attempt intubation success.

Patients receiving more than 1.2 mg/kg had higher first-attempt success overall, with the strongest signal in ICU patients. But rocuronium dose was chosen by clinicians rather than randomized, so residual confounding matters.

We break down the study, the accompanying editorial, the pharmacologic rationale for higher dosing, the ICU versus ED findings, and the key bedside question: Should this change how we dose rocuronium during emergency intubation?

Original article:
https://academic.oup.com/ajrccm/article/212/8/1740/8679093

Accompanying editorial:
https://academic.oup.com/ajrccm/article/212/8/1680/8706698

Educational use only. This is not medical advice.

Tags
Critical Care, ICU, Airway Management, Tracheal Intubation, Emergency Intubation, Rocuronium, Neuromuscular Blockade, Rapid Sequence Intubation, RSI, First Pass Success, First Attempt Success, Video Laryngoscopy, DEVICE Trial, PREOXI Trial, AJRCCM, Pulmonary Critical Care, Emergency Medicine, Anesthesiology, Evidence Based Medicine, Journal Club, Medical Education, PRISM Rounds

Could a bedtime pill become a meaningful treatment for obstructive sleep apnea?In PRISM Rounds Season 1, Episode 53, we examine “Aroxybutynin and atomoxetine (AD109) for obstructive sleep apnea: a randomized phase 3 trial (SynAIRgy).”This randomized, double-blind, placebo-controlled trial evaluated AD109, an investigational combination of aroxybutynin and atomoxetine, in adults with obstructive sleep apnea who could not or would not use positive airway pressure therapy.AD109 improved the apnea-hypopnea index and measures of oxygenation over 26 weeks. However, the average placebo-adjusted reduction was four respiratory events per hour, fatigue did not significantly improve compared with placebo, and approximately one in five participants discontinued treatment because of adverse effects.We discuss:• How AD109 is intended to improve upper-airway muscle function• The trial design and primary findings• Relative versus absolute reductions in the apnea-hypopnea index• Intention-to-treat versus on-treatment results• Hypoxic burden and changes in sleep architecture• Insomnia, dry mouth, tachycardia, and treatment discontinuation• Which patients might benefit if AD109 is approved• Why CPAP remains the most effective and best-established treatment for most patientsDoes SynAIRgy represent the beginning of oral precision therapy for sleep apnea, and can better phenotyping identify patients whose benefits outweigh the adverse effects?Primary article: https://doi.org/10.1093/ajrccm/aamag215Accompanying editorial: https://doi.org/10.1093/ajrccm/aamag243PRISM Rounds is intended for education and discussion and does not provide medical advice.Tags: PRISM Rounds, SynAIRgy, AD109, aroxybutynin, atomoxetine, obstructive sleep apnea, OSA, sleep apnea treatment, sleep medicine, CPAP, positive airway pressure, apnea-hypopnea index, AHI, hypoxic burden, randomized clinical trial, phase 3 trial, AJRCCM, pulmonary medicine, clinical research, medical education, FOAMed#PRISMRounds #SynAIRgy #AD109 #SleepApnea #OSA #SleepMedicine #CPAP #ClinicalTrials #PulmonaryMedicine #MedicalEducation #FOAMed

Should oxygen be aggressively limited after cardiac arrest to reduce reperfusion injury?The LOGICAL trial randomized 1,840 unresponsive, mechanically ventilated adults after cardiac arrest to conservative or liberal oxygen therapy. Favorable functional outcomes at 180 days occurred in 38.2% versus 39.7%, with no significant difference between strategies.In this episode, we examine the trial design, oxygen targets, treatment separation, protocol deviations, key results, limitations, and practical implications for post-cardiac arrest care.Read the article in the New England Journal of Medicine:https://doi.org/10.1056/NEJMoa2513814Educational use only. This is not medical advice.Tags:LOGICAL trial, cardiac arrest, post cardiac arrest care, oxygen therapy, conservative oxygen, hyperoxemia, hypoxemia, reperfusion injury, critical care, intensive care, ICU, mechanical ventilation, resuscitation, neurocritical care, NEJM, Mega-ROX, evidence based medicine, journal club, pulmonary critical care, PRISM Rounds

Can early in-bed cycling plus intravenous amino acids improve recovery after critical illness?

The NEXIS trial randomized 115 adults with acute respiratory failure to protocolized cycling plus higher amino acid delivery or usual care. The intervention substantially increased rehabilitation time and protein intake, but did not improve six-minute walk distance at hospital discharge, strength, duration of ventilation, length of stay, mortality, or six-month recovery.

This episode examines the trial design, intervention delivery, safety findings, limitations, and bedside implications. The discussion also addresses why a biologically plausible intervention may fail to produce better patient-centered outcomes, and why the results should not be interpreted as an argument against individualized ICU rehabilitation.

Tags

PRISM Rounds, NEXIS trial, critical care, intensive care, ICU rehabilitation, ICU acquired weakness, early mobility, in-bed cycling, cycle ergometry, amino acids, protein supplementation, acute respiratory failure, mechanical ventilation, six-minute walk distance, physical function, critical illness recovery, post-intensive care syndrome, nutrition in critical illness, AJRCCM, randomized clinical trial, pulmonary critical care, evidence-based medicine, journal club, medical education

Should mechanically ventilated patients with difficult-to-clear secretions routinely receive carbocisteine or nebulized hypertonic saline?

In this episode of PRISM Rounds, we examine the MARCH randomized trial, which enrolled 1,956 patients across 71 UK intensive care units. Neither intervention shortened mechanical ventilation or improved major clinical outcomes. However, carbocisteine increased clinically important gastrointestinal bleeding, while hypertonic saline increased bronchoconstriction and hypoxemia during nebulization.

We discuss the trial’s factorial design, the absence of a number needed to treat, and the approximate numbers needed to harm: 88 for gastrointestinal bleeding with carbocisteine, 51 for bronchoconstriction with hypertonic saline, and 26 for hypoxemia during nebulization. We then translate these findings into practical de-implementation strategies for airway care in the ICU.

Article:
https://www.nejm.org/doi/10.1056/NEJMoa2603406

Educational use only. This podcast is not medical advice.

Tags
MARCH trial, carbocisteine, hypertonic saline, mucoactive agents, mechanical ventilation, acute respiratory failure, airway secretions, mucus clearance, hypoxemia, bronchoconstriction, gastrointestinal bleeding, critical care, intensive care, ICU, respiratory therapy, pulmonary medicine, evidence-based medicine, randomized clinical trial, de-implementation, NEJM, PRISM Rounds

In this episode of PRISM Rounds, we review the VICTORY randomized clinical trial, published in JAMA on June 10, 2026, testing high-dose intravenous vitamin C in patients with severe burn injury.

The trial randomized adults with deep second- or third-degree burns involving at least 20% total body surface area to high-dose IV vitamin C or placebo. VICTORY was stopped early for futility and harm. Vitamin C did not improve death or persistent organ dysfunction and raised concerning mortality signals.

We discuss how the trial was conducted, why vitamin C was biologically appealing, what the results showed, and what this means for medical ICU patients with shock, sepsis, ARDS, and inflammatory critical illness.

Article: https://doi.org/10.1001/jama.2026.10616

Educational content only; not medical advice.

Critical Care, ICU, Medical ICU, Burn ICU, Severe Burns, Vitamin C, High-Dose Vitamin C, Ascorbic Acid, VICTORY Trial, JAMA, Randomized Clinical Trial, Organ Dysfunction, Shock, Sepsis, ARDS, Mortality, Evidence Based Medicine, Pulmonary Critical Care, Emergency Medicine, Pharmacy, Nursing, Respiratory Therapy, PRISM Rounds

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In this episode of PRISM Rounds, we discuss the JAMA randomized clinical trial BIHCA, which tested whether routine sodium bicarbonate improves outcomes during adult in-hospital cardiac arrest.

Granfeldt and colleagues randomized adults with in-hospital cardiac arrest who had received epinephrine to sodium bicarbonate or placebo. Sustained return of spontaneous circulation occurred in 39% with bicarbonate vs 37% with placebo, with no significant difference. Survival and favorable neurologic outcome were also not clearly improved, while alkalosis and hypernatremia were more common with bicarbonate.

We also discuss the accompanying editorial by Clifton Callaway, which asks whether this high-quality trial will change practice, given how deeply bicarbonate remains embedded in code culture despite guideline recommendations against routine use.

Bottom line: bicarbonate changed the blood gas, but it did not change the patient-centered trajectory. Routine sodium bicarbonate should not be reflexive during in-hospital cardiac arrest, but targeted use remains appropriate for specific indications such as hyperkalemia or toxicologic sodium-channel blockade.

Source article: https://doi.org/10.1001/jama.2026.10628
Editorial: https://doi.org/10.1001/jama.2026.10508

Tags

critical care, ICU, cardiac arrest, in-hospital cardiac arrest, sodium bicarbonate, bicarbonate, BIHCA, resuscitation, ACLS, code blue, epinephrine, return of spontaneous circulation, ROSC, neurologic outcome, JAMA, clinical trials, randomized trial, evidence-based medicine, emergency medicine, hospital medicine, pulmonary critical care, PRISM Rounds, FOAMed, medical education, CriticalCare, ICU, CardiacArrest, Resuscitation,

In this episode of PRISM Rounds, we discuss the NEJM SODa-BIC trial, a pragmatic, double-blind randomized trial of sodium bicarbonate versus placebo in critically ill adults with metabolic acidosis receiving vasopressors.

The trial asked a common ICU question: when a patient in shock has a low pH, does bicarbonate improve outcomes or mainly improve the blood gas?

SODa-BIC found that sodium bicarbonate improved acid-base parameters and reduced recurrent acidosis, but did not reduce major adverse kidney events at 30 days, mortality, renal replacement therapy dependence, or organ-support–free days.

For bedside clinicians, the message is practical: bicarbonate may still have a role in selected scenarios, but routine use for moderate metabolic acidosis in vasopressor-dependent shock should not be expected to improve patient-centered outcomes.

Article: https://doi.org/10.1056/NEJMoa2600526

This episode is for educational purposes only and is not medical advice.

Tags
Critical Care, ICU, Shock, Metabolic Acidosis, Sodium Bicarbonate, SODa-BIC, NEJM, Renal Replacement Therapy, Acute Kidney Injury, Vasopressors, Sepsis, Acid Base, Nephrology, Emergency Medicine, Hospital Medicine, Pulmonary Critical Care, PRISM Rounds, FOAMed, Medical Podcast

This week on PRISM Rounds, we discuss ARISE FLUIDS, a pragmatic NEJM trial asking a question every ICU and emergency department team faces: after initial fluid resuscitation in septic shock, should we give more crystalloid or move earlier to vasopressors?

In adults with early septic shock, restricted fluids with early vasopressors changed the process of care and was associated with less pulmonary edema, but did not improve days alive and out of the hospital at 90 days compared with a more fluid-forward strategy.

We place the trial in context with prior sepsis resuscitation evidence and discuss what it means at the bedside: not reflexive liters, not reflexive pressors, but thoughtful reassessment of perfusion, fluid responsiveness, pulmonary edema risk, and shock physiology.

Listeners may also want to revisit PRISM Rounds Episode 35 on choosing fluids in sepsis and Episode 40 on the PRoMPT BOLUS study for related discussions.

Article: Vasopressors or Fluids in Early Septic Shock. New England Journal of Medicine. Published June 11, 2026. https://doi.org/10.1056/NEJMoa2516225

Tags:
Critical Care, ICU, Sepsis, Septic Shock, ARISE FLUIDS, Vasopressors, Norepinephrine, IV Fluids, Fluid Resuscitation, Emergency Medicine, Pulmonary Critical Care, NEJM, Evidence Based Medicine, PRISM Rounds, Medical Podcast, FOAMed, Clinical Trials, Shock, Pulmonary Edema

In this episode of PRISM Rounds, we discuss the PROMINE trial, a randomized trial comparing ketamine versus propofol for rapid sequence intubation in critically ill adults.

Ketamine produced a modestly higher early mean arterial pressure in the first 10 minutes after induction, but the effect was transient and did not translate into a sustained hemodynamic advantage or clear improvement in patient-centered outcomes. We unpack what this means at the bedside, why sedative “reputation” can oversimplify ICU physiology, and why airway safety depends on the whole peri-intubation bundle—not just the induction agent.

Article discussed: “Propofol versus ketamine in rapid sequence intubation in critically ill patients: a prospective, randomized, controlled trial.” Intensive Care Medicine, 2026.
https://doi.org/10.1007/s00134-026-08351-3

Educational only; not medical advice.

Tags
Critical Care, ICU, Pulmonary Critical Care, Emergency Intubation, Rapid Sequence Intubation, RSI, Airway Management, Ketamine, Propofol, PROMINE Trial, Intensive Care Medicine, Hemodynamics, Hypotension, Vasopressors, Mechanical Ventilation, Emergency Medicine, Anesthesia, FOAMed, MedEd, Journal Club