The Latest in Critical Care: October 13, 2025
EVIDENCE trial post-cardiac arrest; Lateral positioning to prevent postop hypoxemia; European IV fluids guideline; antibiotic prophylaxis for variceal bleeds; volatile anesthesia in the PACU
Expedited transfer to expert centers after out-of-hospital cardiac arrest (EVIDENCE trial)
In observational studies, outcomes after out-of-hospital cardiac arrest are better when patients are treated at more advanced centers, with cardiac catheterization, cardiac ICU, and ECMO capacities, for example. For this reason, AHA guidelines advise cardiac arrest patients be transported to such centers whenever feasible.
New CPR guidelines: What changed?
New guidelines on cardiopulmonary resuscitation in adults were published in Circulation in November 2024. They’re 187 pages long.
The EVIDENCE trial took this principle to its logical endpoint. From 2021 to 2024, almost 200 patients with OHCA (of any rhythm type) lasting ≥15 minutes in Sydney, NSW, Australia were randomized to either receive continued resuscitation at the scene (usual care) or expedited transfer to an expert center where cardiac cath and/or extracorporeal CPR (ECMO) could be performed.
Investigators assumed a 10% neurologically favorable survival rate with usual care and 25% survival with good neurologic outcome in the intervention group–a 15% absolute difference. This provided the customary 80% power to detect a difference at a sample size of 200.
But at six months of follow-up, the two arms had near-identical outcomes: survival with good neurologic function was 15% in the expedited transport group, and 16% with usual care (with a wide 95% CI spanning -12% harm to +10% benefit).
Lateral positioning to reduce postoperative hypoxemia in the PACU*
*in China.
Prone positioning improves oxygenation (and may also improve survival in ARDS), but it’s uncomfortable for patients and inconvenient for staff. Lateral positioning is more comfortable and feasible both for patients and care teams.
At 14 tertiary hospitals in China, ~2100 patients waking up from anesthesia were randomized to supine or lateral positioning. The laterally-positioned patients experienced less hypoxemia (5% vs 15%), severe hypoxemia (~1% vs ~5%), and airway interventions (~6% vs ~14%).
The study was unblinded. Mean BMI was ~24, precluding broad application of the findings to the U.S. and Europe, where patients are broader.
European guideline on fluid removal after the acute phase of critical illness
The leading European critical care society issued a three-part advisement for the use of fluids in critical illness.
In part 3, they advise that for patients who have received aggressive fluid resuscitation during the acute phase of critical illness, protocolized administration of diuretics may lead to a lower need for renal replacement therapy, without an increased risk of acute kidney injury from over-diuresis.
This advisement was based on the pooled results of 10 randomized trials.
Protocolized diuretics also tended to reduce ventilator days and ICU length of stay.
Dialysis catheters should not be inserted routinely to perform ultrafiltration in patients who do not otherwise require RRT, the panel advised.
Prophylactic antibiotics for variceal bleeds: evidence for guideline-advised care is lacking
Historically, as many as half of variceal bleeds were complicated by bacterial infections, leading to the conventional practice of providing antibiotic prophylaxis to cirrhotic patients with variceal hemorrhages.
A systematic review and meta-analysis reveals that (unsurprisingly?) the evidence base for this practice is weak (~14 small, heterogeneous, randomized trials) and no mortality benefit could be demonstrated. There was a suggestion of reduced bacterial infections.
Despite the included studies’ high risk of bias, forgoing antibiotic prophylaxis would carry potentially significant and unknown risks. Unless large randomized trials are performed, standard practice and guidelines are unlikely to change.
Continuing volatile anesthetics from the cardiac O.R. into the PACU
Standard practice at the end of cardiac surgery in the U.S. is to stop volatile anesthetics and start or continue a sedative like propofol until the patient is ready for extubation in the ICU. Continuing the volatile anesthetic is another option, but requires specialized closed-circuit gas delivery systems so as not to anesthetize ICU staff.
In a meta-analysis of five randomized trials, continuing volatile anesthesia reduced time to extubation by about an hour compared to propofol, on average, without meaningfully impacting other outcomes.
Physiology Flashback!
ICU Physiology in 1000 Words: Airway Pressure Release Ventilation – Part 2
Jon-Emile S. Kenny MD [@heart_lung]