The Latest in Critical Care: October 1, 2025
PROMIZING trial, Danger-Shock post hoc, How do you nudge?, Sotanercept benefits, Mortality risk calculators
Fancy ventilator mode (PAV+) did not improve weaning success (PROMIZING trial)
Proportional-assist ventilation tailors the delivered flow to a patient’s respiratory efforts, theoretically reducing respiratory muscle atrophy and weakness and improving weaning success.
In one promoted form called “PAV+”, the clinician sets the “gain” (the percentage of work for the ventilator to perform), rather than a fixed tidal volume or pressure. Each respiratory effort is amplified by the ventilator, which frequently measures respiratory mechanics (resistance and compliance) and adjusts the delivered pressure to keep the patient’s respiratory work within the normal range.
In the PROMIZING trial, among 573 patients in 23 centers in 7 countries, critically ill adults randomized to PAV+ were not weaned off the ventilator faster or in higher proportions than those receiving pressure support ventilation. Mortality at 90 days was high and similar between groups (30% with PAV vs 27% with PSV).
Patients receiving PAV required less sedation than those receiving PSV, although this was not a prespecified outcome.
Although PROMIZING was conducted at academic centers, clinicians frequently reported unfamiliarity with PAV and may have often switched patients to PSV as a result.
The PROMIZING trial contrasts with an earlier randomized trial testing neurally adjusted ventilatory assist (NAVA), a related form of PAV. In that trial, among 306 adults, those randomized to NAVA had 4 more ventilator-free days than those receiving usual care.
The PROMIZING authors noted that the pressure support ventilation (control) group received careful ventilator adjustments to reduce their work of breathing, a level of attention they would likely not receive outside a randomized trial, and that this may have contributed to the null result.
Bosma et al, Proportional-Assist Ventilation for Minimizing the Duration of Mechanical Ventilation | New England Journal of Medicine (PROMIZING trial)
Impella® response associated with BP level (DanGer-Shock post hoc)
The DanGer-Shock trial tested the Impella® microaxial flow pump, a temporary left ventricular assist device in patients with cardiogenic shock from STEMI, and found a mortality benefit.
In a post hoc analysis of the DanGer-Shock trial, only patients with significant hypotension (a systolic blood pressure less than 82 mmHg) experienced a mortality benefit; those with higher blood pressures before randomization and insertion of the microaxial flow pump did not experience a benefit.
The findings are only hypothesis-generating, but one possibility would be that Impella’s high complication rates (limb ischemia, bleeding, and renal failure) create a heterogeneity of treatment effect, with a net benefit for patients with more severe cardiogenic shock, and a net harm for those with less severe shock.
Intensivists are conflicted about ‘nudging’ patients and families, but feel obligated to do it
Intensivists must routinely provide information to guide surrogate decision-makers, and as human beings, they will inevitably present it in a non-neutral way.
In a qualitative study, 54 intensivists at three Harvard-affiliated centers in Boston were interviewed, and their narrative responses were analyzed and distilled into themes.
Intensivists reported commonly nudging patients or their families toward a particular option, and considered this a necessary part of their role as the treating physician.
At the same time, they felt ethically ambiguous about doing so in some instances. Younger physicians reported greater ethical concerns and hesitancy over nudging compared to more experienced physicians.
Soled et al, Critical Care Physicians’ Perspectives on Nudging in Communication | Ethics | JAMA Network Open
Mortality risk calculators work better in combination
Mortality risk calculators have thus far been too crude for practical use, both in the ICU and generally.
A study in JAMA Network Open suggests that combining multiple scales, the Good Outcome Following Attempted Resuscitation Score (GO FAR), Clinical Frailty Scale, and Charlton Comorbidity Index, could significantly improve the accuracy of prediction of all-cause mortality in adults.
Although such calculations will not be practical for individual clinicians, it is easy to foresee their automated calculation and integration into the electronic medical record, to help guide counseling decision-making and administrative nudges for palliative care, for example.
Even at the higher level of accuracy (e.g., ~0.85 AUC), however, the tools leave considerable ambiguity for all but the frailest patients. At very high levels of frailty and chronic disease burden, the combined tools’ accuracy increased significantly.
Sotarecept proves useful in earlier PAH, too
Sotarecept, an injectable activin-signaling inhibitor, was shown to improve outcomes (in a composite endpoint) for patients with recently diagnosed pulmonary arterial hypertension who were already receiving multiple other agents. The drug was already FDA-approved for PAH based on earlier trial results demonstrating its benefits in patients with longer-standing PAH.
McLaughlin et al, Sotatercept for Pulmonary Arterial Hypertension within the First Year after Diagnosis, NEJM September 2025
