There were a handful of big name critical care studies published the last few weeks (LOGICAL, ARISE FLUIDS, SODa-BIC to name a few) but many of you probably already saw those so we're gonna stick with something a little more off the beaten path.
A retrospective observation trial was published recently by Gastanadui et al in Journal of Intensive Care looking at the mortality impact of corticosteroids in cardiogenic shock. They looked at 167,721 patients from the Vizient database admitted with cardiogenic shock (excluded patients with other indications for steroids). The unadjusted mortality was a whopping 48.8% in the steroid group and 29.6% in the non-steroid group. They did Inverse Probability Treatment Weighting (IPTW), which attempts (imperfectly, but best as you can retrospectively) to control for treatment selection bias, and still found a roughly 3% mortality increase in the steroid group.
Bottom Line: Corticosteroids were already controversial (at best) in cardiogenic shock, but this further adds to the reasons to avoid them in this condition. Of note, this trial excluded patients with classic hard-indications (e.g. adrenal insufficiency, COPD exacerbation, etc) and steroids should still be given to those groups, but in my opinion if you feel cardiogenic is the primary driver of the patient's shock and they do not have another indication, I would consider avoiding steroids solely for the shock.
Bottom Line: Lactate is a useful but imperfect marker of critical illness. Below are some key points to consider when interpreting lactate.
Sodium bicarbonate significantly reduced the need of renal replacement therapy (risk ratio [RR] 0.69; 95% CI, 0.61–0.78) but not mortality (RR, 0.84; 95% CI, 0.55–1.30). However, there was not enough sample size to support the outcome of mortality.
There was still significant heterogeneity between studies as the sources of metabolic acidosis were different between different studies in this meta-analysis study of randomized control trial. One study recruited patients with septic shock only, while other studies enrolled patients with different disease states.
There was also heterogeneity in the threshold for pH to enter the study.
Not all patients with an acute PE will be crashing and critically ill, but it seemed worthwhile to remind everyone that there are new guidelines and recommendations from AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN/XYZLMNOP about the management of patients with acute pulmonary embolism in the 2026 AHA/ACC Joint Committee statement. A few key takeaways, with highlights for the sicker PE patients:
Highlights for the sicker PE patients, i.e. Categories C+:
For a great breakdown and further discussion of the new guidelines, I recommend checking out the Life in the Fast Lane blogpost here.
Should we give a dose of antibiotics after intubating to reduce risk of VAP down the line? A multicenter RCT conducted in 2024 - the PROPHY-VAP Trial - found that a single dose of 2g ceftriaxone administered within 12 hours of intubation reduced VAP within the first week of hospitalization for patients intubated for airway protection due to TBI, stroke or SAH, with a VAP rate of 14% in the CTX group vs 32% in the VAP group (HR 0.60; 95% CI 0.38-0.95).
Click the link below for details and additional discussion
PaO2 to FiO2 (P:F) ratios, are often considered the gold standard in critical care for assessing the degree of oxygen-refractory hypoxia in various pathologies, particularly ARDS. P:F does have some limitations, including not accounting for the PEEP, but probably the most limiting is that it requires collecting an ABG, which is invasive and not always feasible or a top priority when resuscitating a critically ill hypoxic patient. On the other hand, SpO2 (pulse ox saturation) is routinely available, and of course the FiO2 should be known, so many have suggested perhaps using an SpO2 to FiO2 (S:F) ratio instead. But how S:F maps to P:F and how well they correlate is not fully known. Chaudhuri et al recently conducted a meta-analysis, published in Critical Care Medicine this month, which reviewed the literature on this.
Bottom Line: Yes, S:F ratios correlate well with P:F ratios, especially when the SpO2 is less than 97%, but you can't just substitute the S:F for P:F, you have to use one of the accepted formulas. See additional info on the website for the actual formula to apply and how a given S:F translates to P:F.
Summary:
The recent ARISS (Albumin Resuscitation in Septic Shock) trial showed no difference in 90-day mortality or other secondary outcomes, similar to other trials comparing albumin and crystalloid. Notably however, the trial did not meet its predetermined enrollment requirement of patients (in the setting of the COVID-19 pandemic) and had a large portion of its intervention group failing to meet goal serum albumin level.
The Bottom Line:
There remains no evidence-based mortality benefit of albumin over crystalloid in patients with septic shock that do not have additional indications for albumin (such as hepatorenal syndrome). Crystalloid resuscitation remains a staple of appropriate and cost-effective care in septic shock. Albumin can be considered on a case-by-case basis after standard crystalloid resuscitation in this clinical setting.
In a large, randomized trial conducted in 42 ICUs in France, high-flow oxygen did not reduce 28-day all-cause mortality in adult patients with acute hypoxemic respiratory failure when compared to standard oxygen support.
The 2026 Acute Pulmonary Embolism Guidelines recommend a new approach to risk stratification of patients with acute PE, including measurement of at least one cardiac biomarker and serum lactate, evaluation of RV size and function with CTA or echo (preferred when feasible), and multidisciplinary PERT assessment for all patients with acute PE and elevated clinical severity scores to assist with further risk stratification.
Bottom Line: Swimming-Induced Pulmonary Edema (SIPE) AKA Immersion Pulmonary Edema is a rare, though life-threatening pathology associated with water-based activities, especially among athletes or military personnel. Caused by physiologic effects of immersion, not from aspiration/ingestion. Consider in any patient with respiratory distress or chest discomfort onset during water activities such as swimming, diving, etc. Diagnose with physical exam and POCUS. Manage supportively, potentially including positive pressure ventilation. Screen for alternative diagnoses.
See the link for more thorough review of assessment diagnostics, pathophysiology, pharmacological options, risk factors, and long-term considerations.
Click the link for below to read the bulleted, abridged version of the Executive Summary of the Updated SSC Guidelines for Adults with Sepsis and Septic Shock 2026…
Beta-blocker is used for tachycardia among patients with sepsis. Landiolol, a new beta-blocker with highly selective B1-agonist (ratio of B1:B2 250:1) has recently been approved for use. In a network meta-analysis comparing landiolol with esmolol (B1:B2 ratio 30:1), landiolol was associated with increased 28-day mortality (relative risk [RR], 1.57; 95% CI, 1.08–2.30). This result carried low certainty as there were not as many studies using landiolol and there was no direct comparison between landiolol versus esmolol.
Similarly, landiolol was associated with higher norepinephrine requirements (mean difference [MD], 0.17 ?g/kg/min; 95% CI, 0.02–0.32). Again, there was no direct head-to-head comparison between landiolol versus esmolol.
It is a common scenario in the ICU, and occasionally in the ED, to be asked which pressor you would like to wean first, norepinephrine or vasopressin. This is mostly an “art not science” question, but is there a right answer? Does picking one vs the other to wean first lead to less hypotension?
Bottom Line: This meta-analysis doesn't suggest that either the norepi-first or vasopressin-first strategies for vasopressor wean are associated with an increased incidence of hypotension, although the literature is mixed. Whatever your current practice is, it's probably reasonable to stick with that. See the additional information for my personal approach.
Bottom Line: Hypertonic sodium bicarbonate (8.4%) can be used judiciously as an alternative hyperosmolar therapy in the setting of increased intracranial pressure (ICP) or cerebral edema with impending herniation, particularly in setting of concomitant metabolic acidosis. Two 50 mL ampules of hypertonic sodium bicarbonate is the equivalent of approximately 200 mL of 3% sodium chloride (hypertonic saline).
Diagnostic Errors in the Critically Ill
Etomidate is often a go-to agent for RSI because it is considered relatively hemodynamically neutral. However, lab studies have shown an association with transient adrenal suppression, and some observational studies and meta-analyses have suggested that patients intubated with etomidate face higher risk of cardiovascular collapse and in-hospital mortality than those intubated with ketamine.
The RSI trial was a pragmatic open-label multi-center randomized control trial conducted in 6 EDs and 8 ICUs across the US and compared induction with ketamine 1-2mg/kg versus etomidate 0.2-0.3mg/kg for RSI of critically ill adults (excluding trauma patients). They found no significant difference in overall 28 day hospital mortality across the cohort. They found an increased risk of cardiovascular collapse during intubation in the ketamine group. This increased risk was more pronounced in patients with sepsis or septic shock and patients with APACHE II ?20.
Some details:
Overall - this was a well conducted randomized control trial that - at the very least - suggests that etomidate is likely as safe (if not safer) than ketamine with respect to 28d mortality and peri-intubation cardiovascular collapse, even among patients with critical illness or septic shock.
A crucial part of cardiac arrest management is identification of the underlying rhythm, with key aspects of management diverging depending whether shockable (pulseless ventricular tachycardia/pVT or ventricular fibrillation/VF) or unshockable (pulseless electrical activity/PEA or asystole).
A recent study prospectively evaluated adult atraumatic out-of-hospital-cardiac-arrests (OHCAs) presenting to the ED, to determine what percentage of cases had “Occult VF” – VF found point-of-care echocardiogram but not by ECG. The researchers only included cases with simultaneous ECG and echo assessments for the initial 3 pulse checks. Echo and ECG determinations for the study were adjudicated by research team members.
They found that:
Major limitations:
Bottom Line: Point-of-care echocardiogram continues to have value in the management of cardiac arrest, potentially changing management and affecting post-ROSC decisions. Ensuring high-quality CPR, with appropriate defibrillation and anti-arrhythmic strategies, remains paramount in management of shockable OHCA.
Settings: Secondary analysis of the Crystalloid Liberal or Vasopressors Early Resuscitation in Sepsis (CLOVERS) trial.
Participants:
1368 patients who survived on day 28 after enrollment, and were retrospectively assigned different subtypes:
Low risk, barriers to care. Younger patients with few comorbidities, less severe disease,
Unhealthy baseline with severe illness: Previously healthy with severe illness and complex needs after discharge, barriers to care.
Multimorbidity. Older patients with more comorbidities and are frequently readmitted.
Low functional status: Poor functional status. Older patients with high prevalence of frailty at discharge and high functional needs who are often discharged to a facility.
Unhealthy baseline with severe illness: Existing poor health with severe illness and complex needs after discharge. Older patients with severe comorbidities, more severe illness, high functional needs, prolonged hospital stay,
Outcome measurement:
A) 90-day mortality,
B) 6-month and 12-month EuroQol 5D five level score
Study Results:
A) 90-day mortality:
Unhealthy baseline with severe illness (37.6%) > low functional status (45.5%) > multimorbidity (17.4%) > unhealthy baseline, severe illness (13.2%) > Low risk (5.1%).
B) 6-month EuroQol 5D-Five Level: lower score, lower functional outcomes)
Unhealthy baseline with severe illness (0.53) > unhealthy baseline, severe illness (0.68) > low functional status (0.69) > multimorbidity (0.78) > Low risk (0.80).
Discussion:
a) The framework, readily available to clinicians provides good prognostic tools for mortality.
b) Although there was prediction of poor functional outcomes at 6-month and 12-month, the differences between subtypes in their EuroQoL 5D-5L did not seem to correspond to 90-day mortality. Low functional status group had 2nd-highest rate of mortality, but only 3rd in their EuroQoL 5D-3L score. Thus, there needs to be more studies in these nuances.
Conclusion:
Sepsis survivor subtypes—assigned using only three routinely available discharge variables—are strongly associated with 3-month mortality and long-term disability and HRQOL up to 12 months
Recall that MAP = (cardiac output) x (systemic vascular resistance)
Consequently, a patient can be normotensive due to increased SVR despite a very low cardiac output and shock. In fact, normotensive shock may have worse outcomes compared to patients with isolated hypotension.
Take home points:
Yet another study (this time ED focused) has shown benefits to patients and hospital systems when implementing a Phenobarbital-based treatment algorithm. Shorter ED LOS, fewer admissions, and treatment with phenobarbital alone was independently associated with discharge when compared to mixed treatment regimens. Higher age and heart rate, as well as treatment with benzodiazepines alone were independently associated with hospitalization.
Cautions/contraindications include: pregnancy, cirrhosis with history of hepatic encephalopathy (consider dose reduction in hepatic dysfunction), acute intermittent porphyria, and prior chronic phenobarbital use.
Phenobarbital has a long half life (one of its benefits in AWS) and works synergistically with benzodiazepines, so should be used preferentially as monotherapy in patients where the diagnosis is relatively certain and who have not received high doses of benzos. Once the diagnosis is made, go with phenobarbital and stick with it.
PulmCrit has an excellent in-depth article on this and also see Dr. Flint's pearl describing another centers experience in a hospital-wide rollout (links below).
