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

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

S01E44: Remote Rehab After the ICU — The iRehab Trial

Surviving the ICU is not the same as recovering from critical illness. In this episode of PRISM Rounds, we discuss the JAMA iRehab randomized clinical trial, which tested whether a 6-week remote, multicomponent rehabilitation program could improve recovery for ICU survivors after hospital discharge. The primary 8-week quality-of-life endpoint was neutral, but the study showed important signals in secondary outcomes, including sit-to-stand performance, fatigue, anxiety, intervention acceptability, and 6-month quality of life. We also discuss the accompanying editorial and what this trial teaches us about post-ICU recovery, telerehabilitation, patient heterogeneity, and why ICU survivorship care cannot be one-size-fits-all. Article: https://doi.org/10.1001/jama.2026.7401 Editorial: https://doi.org/10.1001/jama.2026.5761 Educational content only; not medical advice. Tags Critical Care, ICU, ICU Survivorship, Post-Intensive Care Syndrome, PICS, Rehabilitation, Telerehabilitation, Remote Rehab, iRehab Trial, Mechanical Ventilation, JAMA, Pulmonary Critical Care, Physical Recovery, Quality of Life, Fatigue, Anxiety, Evidence-Based Medicine, PRISM Rounds

S01E43 | EDTA for CVADs: Can a Line Lock Reduce ICU Catheter Complications?

In this episode of PRISM Rounds, we discuss the JAMA 2026 randomized clinical trial by Ornowska and colleagues testing whether 4% tetrasodium EDTA, or t-EDTA, used as a locking fluid for inactive central venous access device lumens, can reduce CVAD-associated complications in adult ICU patients. This pragmatic, triple-blind, multicenter, cluster-randomized crossover trial included 1468 ICU patients across 6 Canadian hospitals. The primary composite outcome—CVAD-associated bloodstream infection, catheter occlusion requiring alteplase, or catheter removal due to occlusion—occurred at 13.1 vs 19.9 events per 1000 catheter-days with t-EDTA versus control. The main signal was fewer catheter occlusions requiring alteplase; infection and thrombosis events were uncommon and should not be overinterpreted. Article link: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2026.6025 [https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2026.6025?utm_source=chatgpt.com] Tags Critical Care, ICU, Central Line, CVAD, EDTA, t-EDTA, CLABSI, Catheter Occlusion, Alteplase, Venous Thrombosis, Infection Prevention, Vascular Access, JAMA, Randomized Trial, Pulmonary Critical Care, FOAMed, PRISMRounds