The Latest In Critical Care: June 5, 2025
Guidelines on fluid resuscitation targets; early vs late tracheostomy confusion; Vitamin C in the ED
European guidelines on intravenous fluids in critical illness
The leading European critical care society issued guidelines on the amount of intravenous fluids to provide to critically ill patients with indications for volume resuscitation.
Their absence of novelty or certainty provides a soothing effect to the anxious clinician.
For sepsis and septic shock, the committee suggested delivering up to 30 ml/kg of crystalloid at the time of presentation.
Patients in cardiogenic shock due to left ventricular failure should not receive volume resuscitation, authors advised.
Cardiac tamponade patients should be given fluid “cautiously … until definitive treatment.”
In acute pulmonary embolism, they advised fluids might be harmful in patients with right heart congestion as detected by elevated jugular venous pressure, venous excess ultrasound (VEXUS) testing, echocardiography (e.g., right ventricle larger than left ventricle), or other surrogate measures of right heart congestion.
For traumatic hemorrhagic shock, a restrictive approach was advised.
For hemorrhagic shock not due to trauma, individualized patient management was advised.
All the recommendations were based on low or very low certainty evidence, except for a restrictive resuscitation strategy in hemorrhagic shock due to blunt trauma (moderate certainty).
That recommendation was powered largely by a single trial in NEJM 1994 in which 598 patients with penetrating chest trauma randomized to permissive hypotension (delayed resuscitation with MAP 50-60) had an 8% absolute improvement in mortality compared to immediately-resuscitated patients. The finding of benefit with permissive hypotension was weakly replicated in a meta-analysis of subsequent smaller studies of patients with hemorrhagic shock due to blunt trauma.
Early versus late tracheostomy in critically ill patients
Dozens of randomized trials and systematic reviews have tested “early” vs. “late” tracheostomy, with highly variable methodologies and discordant results.
Worse, according to a new meta-analysis combining data from 19 RCTs, most studies were of “critically low quality,” precluding any confidence in their aggregated results.
Although the pooled results suggested a decrease in ventilator-associated pneumonia with early tracheostomy (OR 0.65 [0.47 to 0.89], 95% CI; p=0.007) and no significant difference in mortality (OR 0.85 [0.70 to 1.03], 95% CI; p=0.09), the conclusions were considered unreliable by the authors.
Brain-injured patients are most likely to get early tracheostomies, but meta-regression did not suggest that patients with neurologic conditions were more likely to benefit from early tracheostomy. This could not be determined with confidence, either.
Perhaps the most applicable and persuasive of the RCTs in the MICU population was TracMan, published in 2013. Although underpowered, TracMan suggested there was no benefit to early tracheostomy in most medical ICU patients. We reviewed that trial here:
Early tracheostomy does not improve survival or other outcomes (TracMan trial)
Early Tracheostomy Does Not Help in Large "TracMan" Trial
The meta-analysis authors argue that the low quality of the evidence overall should preclude any reliance on aggregations of the existing data. Instead, they called for a new, larger, better-conducted trial with a well-defined study population.
Boni et al, BMJ Open Respiratory Research, April 2025
Early vitamin C for sepsis, given in emergency departments (C-EASIE trial)
Vitamin C was shown to be ineffective or even harmful as a treatment for sepsis after multiple randomized trials refuted earlier studies with questionable methodology, certain of whose authors later crossed over from mainstream medicine into fervid Covid crankology.
But what if—just maybe—vitamin C wasn’t given early enough in those refuting trials, which enrolled patients after ICU admission?
In the C-EASIE trial, ~300 patients in the emergency departments at eight hospitals in Belgium with “sepsis” (high NEWS score plus suspected infection) got 1.5 g intravenous vitamin C or placebo saline every 6 hours for 4 days.
There was a trend toward benefit in the vitamin C-treated patients! They had nominally 9% lower average organ failure scores (SOFA) on days 2 to 5 (ratio 0.91, 95% CI 0.77 to 1.08, P = 0.30)—the primary outcome.
The sickest patients (SOFA scores ≥6) did have a statistically significant reduction in organ failure scores (ratio 0.76, 95% CI 0.86 to 0.99, P = 0.04), in a prespecified subgroup analysis!
Three trials that will further test the use of vitamin C for sepsis are currently recruiting patients, according to clinicaltrials.gov.
We’ll let you know.
Bad news: there is no evidence for anything we do.
Good News: We are the last true artists in the hospital.