This Week in Critical Care — Jul 22, 2026

Welcome to This Week in Critical Care. This week we're covering 5 notable papers spanning metabolic resuscitation, extracorporeal support, mechanical ventilation weaning, and health equity in intensive care. Let's dive in.

We begin with metabolic resuscitation and extracorporeal organ support. Two recent studies highlight the complexities of managing acid-base balance and blood purification in critically ill patients. Writing in Critical Care, Fosset and colleagues performed an individual patient data meta-analysis of the BICAR-ICU and BICAR-ICU2 trials, evaluating intravenous sodium bicarbonate in over one thousand adults with severe metabolic acidemia and a pH of 7.20 or lower [1]. While sodium bicarbonate therapy did not significantly reduce overall 90-day mortality compared to control at roughly 58% versus 61%, it did significantly reduce the initiation of renal replacement therapy, dropping it from roughly 51% down to about 35% [1]. This corresponded to a number needed to treat of roughly 6.3 and an increase in dialysis-free days [1]. Furthermore, a significant interaction was observed based on acidemia depth [1]. In patients with a pH of 7.10 or lower, sodium bicarbonate reduced 90-day mortality, whereas no survival benefit was seen in patients with a pH above 7.10 [1]. These findings suggest that timely correction of profound metabolic acidemia may help avoid renal replacement therapy in select patients [1]. Conversely, when looking at extracorporeal membrane oxygenation, Xie and colleagues published an updated systematic review and meta-analysis in Critical Care evaluating the addition of hemoperfusion in over 8,000 adult patients receiving extracorporeal membrane oxygenation [2]. Overall, extracorporeal membrane oxygenation combined with hemoperfusion did not significantly reduce all-cause mortality compared to extracorporeal membrane oxygenation alone [2]. In fact, mortality was significantly higher with the addition of hemoperfusion in randomized controlled trials, and trial sequential analysis indicated that the current evidence remains insufficient to confirm any survival benefit [2]. The authors conclude that current evidence does not support the routine use of hemoperfusion in intensive care unit patients receiving extracorporeal membrane oxygenation [2].

Turning next to mechanical ventilation, lung protection, and weaning strategies. In Intensive Care Medicine, Ehrmann and colleagues reviewed the evolution of prone positioning in acute respiratory distress syndrome [3]. Originally used primarily as a rescue therapy, prone positioning is now an integral component of lung-protective ventilation, applied early in intubated patients with a partial pressure of arterial oxygen to fraction of inspired oxygen ratio below 150 millimeters of mercury [3]. Beyond improving oxygenation, prone positioning mitigates ventilator-induced lung injury by reducing lung stress and strain, while also conferring favorable hemodynamic effects [3]. The review highlights how the coronavirus disease pandemic expanded these concepts to non-intubated patients through awake prone positioning, though routine application in non-coronavirus populations requires further confirmation [3]. For patients successfully navigating the recovery phase, prolonged mechanical ventilation remains a major clinical and economic challenge. Writing in Critical Care Medicine, Pietzsch and colleagues conducted a health-economic evaluation of transvenous diaphragm neurostimulation in ventilator weaning [4]. Using clinical data from the RESCUE-3 randomized trial alongside real-world claims data, the authors modelled short-term and lifetime economic implications in a United States setting [4]. Under base case assumptions, transvenous diaphragm neurostimulation achieved a 2.8-day reduction in mechanical ventilation utilization and a 10.5% greater weaning success rate [4]. This translated to projected acute setting cost savings of roughly $12,102, alongside long-term care hospital savings of roughly $11,999, before factoring in device costs [4]. With quality-adjusted life-year gains ranging from 0.10 to 0.68 over patients' remaining lifetimes, the analysis suggests that improved weaning rates with transvenous diaphragm neurostimulation can render it a high-value, cost-effective intervention depending on therapy costs [4].

Finally, we examine structural disparities in critical care outcomes. In Critical Care Medicine, de Kok and colleagues investigated socioeconomic disparities and the role of comorbidity in hospital mortality across a Dutch nationwide cohort of over 588,000 intensive care unit admissions [5]. Unadjusted odds ratios demonstrated higher hospital mortality among patients with lower socioeconomic status [5]. Even after rigorous multivariable adjustment for age, sex, year of admission, acute physiologic derangement, and seven specific major comorbidities—including respiratory and renal insufficiency, cancer, cardiovascular disease, diabetes, cirrhosis, and immunological insufficiency—socioeconomic disparities persisted [5]. The association was most pronounced in the lowest socioeconomic quintile and remained evident regardless of underlying comorbidity status [5]. These findings emphasize that intensive care unit patients with lower socioeconomic status face poorer survival prospects independently of their comorbid burden, highlighting the need to account for socioeconomic factors when interpreting outcome measures and targeting health equity interventions [5].

If you only have time for one paper this week, make it the individual patient data meta-analysis by Fosset and colleagues on sodium bicarbonate therapy in severe metabolic acidemia, published in Critical Care [1]. This synthesis clarifies conflicting trial data by demonstrating that while overall 90-day mortality was unchanged, targeted sodium bicarbonate use significantly curtailed the need for renal replacement therapy and offered a clear survival advantage in patients presenting with a pH of 7.10 or lower [1].

Here are the key takeaways from this week in Critical Care. Sodium bicarbonate therapy for severe metabolic acidemia with a pH of 7.10 or lower reduces ninety-day mortality and substantially lowers the initiation of renal replacement therapy. Combining hemoperfusion with extracorporeal membrane oxygenation does not improve survival and is not currently supported for routine intensive care unit use. Prone positioning remains a cornerstone of lung-protective ventilation in severe acute respiratory distress syndrome, improving oxygenation and reducing lung stress. Transvenous diaphragm neurostimulation reduces mechanical ventilation duration, increases weaning success, and offers favorable health-economic value. Socioeconomic deprivation independently predicts higher intensive care unit mortality, persisting even after extensive adjustment for underlying patient comorbidities.

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.