S01E40 | Balanced Fluids vs Saline in Pediatric Septic Shock: Why Adult ICUs Should Care

S01E49: VICTORY Trial, High-Dose Vitamin C in Severe Burns

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 [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 Tags

S01E48 | Bicarbonate During In-Hospital Cardiac Arrest : The BIHCA Trial

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,

S01E47 | SODa-BIC: Sodium Bicarbonate for Metabolic Acidosis and Shock

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 [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

S01E46 | ARISE FLUIDS: Early Vasopressors or More Fluids in Septic Shock?

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 [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

S01E45: PROMINE Trial: Ketamine vs Propofol for ICU Intubation

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 [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