This Week in Critical Care — Jun 16, 2026

Welcome to This Week in Critical Care. This week we're covering 9 notable papers spanning major trials of interventions in shock and post-cardiac arrest, new approaches to respiratory management, and crucial insights into ICU outcomes and decision-making. Let's dive in.

We begin with a theme of sobering results for several proposed therapies in shock and post-resuscitation care. In *The New England Journal of Medicine*, a pragmatic, double-blind, randomized trial investigated the use of sodium bicarbonate in critically ill adults with metabolic acidosis who were already on vasopressors [6]. Across 55 ICUs, 500 patients were assigned to either sodium bicarbonate or a placebo infusion. The primary outcome was a composite of major adverse kidney events within 30 days, including death, need for renal-replacement therapy, or persistent renal dysfunction. The results were clear: sodium bicarbonate offered no benefit. A major adverse kidney event occurred in 40.2% of patients in the bicarbonate group, compared to 39.4% in the placebo group, a non-significant difference. There were also no improvements in secondary outcomes like 30-day mortality or the use of renal-replacement therapy. This trial provides strong evidence against the routine use of sodium bicarbonate to correct acidemia in this patient population. Similarly, another highly anticipated intervention failed to deliver in the post-cardiac arrest setting. The VITaCCA trial, published in *Intensive Care Medicine*, was a double-blind, multi-center, phase 2 trial looking at high-dose intravenous vitamin C for comatose adults after an out-of-hospital cardiac arrest [1]. Patients were randomized to placebo, a 3-gram daily dose, or a 10-gram daily dose for 96 hours. The primary endpoint was the change in the resuscitation-sequential organ failure assessment, or R-SOFA, score. The results were not just negative, but showed evidence of harm at the highest dose. The 10-gram vitamin C group had significantly less improvement in their organ dysfunction scores compared to placebo. Furthermore, the 10-gram dose was associated with higher troponin release, worse renal function, and worse neurological outcomes. This trial strongly suggests that high-dose vitamin C should be avoided in post-cardiac arrest care. Rounding out this theme is the CLEANSE trial from *Critical Care*, which examined hemoadsorption in patients with septic shock requiring high-dose norepinephrine [9]. This multicenter randomized trial in Thailand assigned 128 patients to either standard treatment alone or standard treatment plus two sessions of hemoadsorption with the HA-330 device. The trial was terminated early due to slow recruitment and funding issues, before reaching its planned sample size. In the available data, adjunctive hemoadsorption did not statistically reduce 28-day mortality, which was 44% in the hemoadsorption group versus 58% in the standard care group. While the hazard ratio suggested a potential trend toward benefit, the result was not statistically significant, and the study was underpowered. A post-hoc analysis suggested a benefit, but this can only be considered hypothesis-generating. For now, hemoadsorption remains an investigational therapy without definitive evidence to support its use.

Next, we turn to advances in respiratory and nutritional management in the ICU. A landmark study in pediatric critical care comes from *JAMA*. The GASTRIC-PICU trial was a large, pragmatic, multicenter randomized trial involving over 4,400 critically ill children on mechanical ventilation [7]. It tested whether forgoing routine assessment of gastric residual volume, or GRV, was non-inferior to the standard practice of checking every six hours. The clinical co-primary outcome was a composite of survival and days free from mechanical ventilation at 30 days. The study found that not checking GRVs was non-inferior, with both groups having a median of 25 ventilator-free days. Importantly, for the nutritional co-primary outcome, the no-GRV strategy was superior. Children in the no-GRV group achieved a significantly higher percentage of their energy requirements by 72 hours. This trial provides robust evidence that the common practice of checking GRVs in critically ill children can be safely abandoned, leading to better nutritional delivery. Shifting to noninvasive ventilation, a study in the *American Journal of Respiratory and Critical Care Medicine* explored better ways to monitor patient effort [4]. In a multicenter study of 60 hypoxemic patients, researchers performed end-expiratory and end-inspiratory airway occlusions to measure parameters like expiratory occlusion pressure, or Pocc, and compared them to gold-standard esophageal manometry. They found that Pocc-derived measurements, when adjusted with a mask-specific conversion factor, provided accurate non-invasive estimates of inspiratory effort and lung stress. These occlusion-based measurements were more reliable than standard ventilator-derived readouts like P0.1 and plateau pressure. This suggests that simple occlusion maneuvers at the bedside could be a valuable tool for identifying patients with excessive respiratory effort on NIV who may be at risk for re-intubation. Also in the *American Journal of Respiratory and Critical Care Medicine*, a post-hoc analysis of several large phase 3 clinical trials offers a new treatment target for COPD [8]. The study defined 'disease stability' as a composite endpoint: having no moderate or severe exacerbations, and no worsening in CAT score or FEV1 from baseline. The analysis showed that more intensive therapies, such as triple therapy over dual therapy, resulted in more patients achieving this stable state. Critically, achieving stability at 28 weeks was prognostic for better long-term outcomes, associated with a 45.7% reduction in the risk of subsequent exacerbations and a 51.7% reduction in the risk of all-cause mortality. This work provides strong evidence for disease stability as a meaningful and achievable treatment goal in COPD that predicts long-term clinical benefits.

Our final theme covers broader ICU outcomes and the complex decisions that shape them. In *Critical Care Medicine*, researchers investigated why some patients experience delayed recovery of consciousness after sedation is stopped [3]. In a retrospective cohort of 784 critically ill COVID-19 patients, they found that a third of patients who eventually recovered consciousness did so well after the time predicted by sedative pharmacokinetics alone. This late recovery was not primarily driven by sedative exposure, but was instead associated with factors reflecting the severity of critical illness, such as older age, hypoxemia, and acute kidney injury. This finding helps clinicians and families set more realistic expectations for awakening after critical illness, suggesting that factors beyond residual drug effect are often at play. A powerful study on end-of-life care comes from the *American Journal of Respiratory and Critical Care Medicine* [5]. This nationwide population-based cohort study from South Korea analyzed over a million ICU admissions to see how the identity of the person signing a Physician Orders for Life-Sustaining Treatment, or POLST, form affected care. The results were striking. When the patient themselves signed the form, it was associated with significantly reduced odds of receiving invasive terminal care. Conversely, when a surrogate signed the form, it was associated with more than double the odds of invasive care. This effect was so strong that it even overrode pre-existing advance directives, a phenomenon the authors termed "AD erosion." Surrogate-led decisions were also linked to higher hospitalization costs. This research critically highlights that the efficacy of POLST in limiting non-beneficial care depends fundamentally on early, patient-led discussions. Finally, from *JAMA Internal Medicine*, we have an update on the effectiveness of the 2024-2025 COVID-19 vaccines in the United States [2]. This large, test-negative case-control study found that vaccination was associated with a reduced likelihood of medically attended COVID-19. While vaccine effectiveness against emergency department or urgent care visits was modest at 26%, it was higher for more severe outcomes. Effectiveness was estimated to be 35% against COVID-19-associated hospitalization and 41% against critical illness, defined as ICU admission or in-hospital death. The protection was similar in adults aged 65 and older. These data underscore the continued importance of COVID-19 vaccination in reducing the burden of severe disease.

If you only have time for one paper this week, make it the GASTRIC-PICU trial in *JAMA* [7]. This large, pragmatic trial provides strong evidence that for critically ill children on mechanical ventilation, abandoning routine gastric residual volume checks is not only safe but also improves nutritional delivery. It’s a clear, actionable finding that should change practice in pediatric ICUs worldwide.

Here are the key takeaways from this week in Critical Care: First: In shock and post-cardiac arrest, several common or proposed therapies failed to show benefit. Neither sodium bicarbonate for metabolic acidosis in shock nor high-dose vitamin C after cardiac arrest improved outcomes; in fact, high-dose vitamin C was associated with harm [6, 1]. Second: For critically ill children on mechanical ventilation, stop routinely checking gastric residual volumes. A large RCT in *JAMA* showed this practice is non-inferior for clinical outcomes and superior for achieving nutritional goals [7]. Third: The identity of the person signing end-of-life orders matters profoundly. A massive cohort study found that when surrogates, rather than patients themselves, finalize POLST forms, it's paradoxically associated with more invasive care and higher costs, even overriding prior advance directives [5]. Fourth: For patients on noninvasive ventilation, airway occlusion maneuvers to measure expiratory occlusion pressure, or Pocc, can provide reliable non-invasive estimates of inspiratory effort and lung stress, outperforming standard ventilator-derived parameters [4]. And finally: The 2024-2025 updated COVID-19 vaccine remains effective at preventing severe outcomes, with an estimated effectiveness of 41% against critical illness in immunocompetent adults [2].

That's your roundup for This Week in Critical Care. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.

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This is an automated summary generated by artificial intelligence, which can make mistakes. Always review the original source materials.