The Latest In Critical Care: June 26, 2025
PROACTIVE trial, 90-year-olds in the ICU, chest tubes for hemothorax, and news
Drug dealers are increasingly cutting street fentanyl with dexmedetomidine instead of xylazine, according to STAT News.
A federal investigation found a Kentucky organ procurement agency pushed hospital workers toward harvesting surgeries despite signs of revival in patients, according to The New York Times.
The American Medical Association called for the Senate to formally investigate RFK Jr after the HHS secretary abruptly removed all CDC’s vaccine advisers and replaced them without a publicly transparent process. —MedPage Today
Prompted by FDA, Zoll issued a Class I recall for its AutoPulse NXT Resuscitation System, because certain units have delivered inadequate chest compressions or stopped entirely. —FDA
Epic Systems, the EMR colossus, is battling another antitrust lawsuit, this one from CureIS. Like Particle Health’s before it, the CureIS complaint alleges anti-competitive practices and illegal interference in its growing business. The company facilitates the movement of data and dollars in the “plumbing” between Epic and managed care insurers. —Fierce Healthcare
Propranolol to reduce the need for sedation in vented patients? (PROACTIVE trial)
Propranolol has anxiolytic properties, and shortages of sedatives during the Covid-19 pandemic provided the opportunity to perform a trial testing the beta-blocker as an adjunct to sedation in the ICU.
Seventy-two ventilated patients were randomized to receive enteral propranolol 20–60 mg every 6 hours or usual care, while also receiving propofol or midazolam infusions.
About a third to one-half of the patients had shock, requiring up to ~11 mcg/min of norepinephrine infusions (0.15 mcg/kg/min).
Patients receiving propranolol required less sedation. However, the trial was small and unblinded, the patients were unbalanced at baseline, and total vasopressor doses were not reported.
—Downar et al, Critical Care Medicine, 2025
90-year-olds in the ICU: Outcomes better than expected
Nonagenarians admitted to ICUs did much better than expected, according to a scoping review of 36 retrospective studies enrolling 16,859 patients aged ≥ 90 years. Despite a ~40% observed rate of mechanical ventilation and ~5-day stays in the ICU, the extreme elderly had only a 26% median hospital mortality. Six-month mortality was 39%, and at one year, 46%. Publication bias should be considered before extrapolating these results.
—Suh et al, Critical Care 2025
Which resuscitation fluid to use in which critical illness (per ESICM)?
The European Society of Intensive Care Medicine (ESICM) suggests that intensivists infuse crystalloid rather than albumin for most critically ill patients, and particularly for those with sepsis, acute respiratory failure, postoperative patients, those at risk for bleeding, and traumatically brain-injured patients.
Balanced crystalloids (like lactated Ringer’s) are preferable to isotonic saline in most critically ill patients, including sepsis and acute kidney injury, suggests ESICM.
Albumin might be preferable for patients with cirrhosis, they say.
These recommendations were all based on low or very low-quality evidence, except for the suggestion for crystalloids over albumin (moderate-quality evidence).
—Arabi et al for the European Society of Intensive Care Medicine (ESICM), Intensive Care Medicine
Small vs large-bore chest tubes for traumatic hemothorax
Large-bore chest tubes (≥24 French) are traditionally considered to be superior for patients with traumatic hemothorax; smaller tubes are anecdotally believed to more often fail after being clogged with clotted blood.
In a review of 9 randomized trials comparing large-bore tubes (≥20 Fr) with smaller-bore tubes (≤14 Fr) placed for traumatic hemothorax, small-bore tubes failed less often, nominally speaking (~18% vs ~22% for larger-bore tubes, non-significant).
Mortality was also nominally lower in the small-bore arms (2.9% vs. 6.1%, p = 0.062), and complication rates were nearly identical (12.3% vs. 12.5%, p = 0.941).
Strangely, though, smaller-bore tubes had higher initial drainage volumes (753 vs. 398 mL, p < 0.001). Small tubes were also removed sooner (4.3 vs. 6.2 days, p < 0.001). Review authors suspected publication or selection bias may have influenced the results. Nevertheless, the review suggests that small-bore tubes might perform better than commonly believed for patients with hemothorax.
—Lyons et al, Journal of Trauma and Acute Care Surgery
