S01E50: The MARCH Trial, When ICU Mucoactives Cause Harm Without Benefit

S01E50: The MARCH Trial, When ICU Mucoactives Cause Harm Without Benefit

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 [https://www.nejm.org/doi/10.1056/NEJMoa2603406?utm_source=chatgpt.com] 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

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