S01E48 | Bicarbonate During In-Hospital Cardiac Arrest : The BIHCA Trial

Can stimulating the orexin receptor improve both sleepiness and cataplexy in narcolepsy type 1? In this episode of PRISM Rounds, we examine the First Light and Radiant Light phase 3 trials of oveporexton. Across two 12-week trials, oveporexton produced substantial improvements in objective wakefulness, patient-reported sleepiness, and cataplexy compared with placebo. We discuss what those changes could mean for patients, why urinary frequency and insomnia matter, and what remains uncertain about long-term safety and comparisons with existing treatments. Read the trial: https://www.nejm.org/doi/full/10.1056/NEJMoa2601598 Find more episodes at https://www.prismrounds.com and follow PRISM Rounds on Spotify or Apple Podcasts.

Choosing between high-flow nasal cannula, noninvasive ventilation (NIV), CPAP, and conventional oxygen is one of the most common decisions in critical care. The new 2026 American Thoracic Society (ATS) Clinical Practice Guideline provides updated, evidence-based recommendations across the spectrum of acute respiratory failure. In Season 1, Episode 62 of PRISM Rounds, we examine the guideline published in the American Journal of Respiratory and Critical Care Medicine and explore what its recommendations mean for bedside practice. We discuss four critical clinical questions: Acute hypoxemic respiratory failure: Why is high-flow nasal cannula strongly recommended over conventional oxygen, and when should clinicians consider NIV or CPAP?

Can therapeutic plasma exchange save lives in acute-on-chronic liver failure, or does it simply delay the inevitable? In Season 1, Episode 61 of PRISM Rounds, we examine a 2026 randomized controlled trial published in Hepatology evaluating therapeutic plasma exchange in 194 patients with acute-on-chronic liver failure (ACLF). The findings are striking. Plasma exchange reduced 28-day mortality from 63.9% to 44.3%, an absolute difference of nearly 20 percentage points. However, by 90 days, mortality was similar between groups, and more than 40% of patients could not complete the planned treatment. We examine the trial's methodology, treatment complications, and clinical implications alongside the 2023 EASL guidelines and a 2025 meta-analysis of plasma exchange in ACLF. The central question: Does plasma exchange meaningfully alter the course of liver failure, or does it provide a temporary bridge to hepatic recovery or transplantation? Join us as we explore what this trial should, and should not, change in ICU practice. Read the primary study: https://doi.org/10.1097/HEP.0000000000001755 Subscribe to PRISM Rounds on Apple Podcasts, Spotify, or YouTube. Visit https://www.prismrounds.com for more episodes.

In this episode of PRISM Rounds, we examine a new randomized clinical trial comparing olanzapine with low-dose dexmedetomidine for established delirium in critically ill adults. The primary outcome was neutral: patients in both groups had a median of 3 days alive without delirium or coma. But the study also found more adverse events with dexmedetomidine and a provocative difference in 90-day mortality that demands careful interpretation. We place these findings in the context of MIND-USA, AID-ICU, SPICE III, nocturnal dexmedetomidine studies, and the 2025 PADIS guideline update. The key issue is not simply which drug performed better, but whether ICU clinicians are asking medications to do different jobs: prevent delirium, control agitation, or actually treat established delirium. We discuss what this trial adds, its major limitations, why the mortality signal should remain hypothesis-generating, and what the results should—and should not—change at the bedside. Primary article: https://doi.org/10.1093/ajrccm/aamag235 Listen and subscribe on Apple Podcasts, Spotify, YouTube, or at https://www.prismrounds.com PRISM Rounds, critical care, ICU, delirium, ICU delirium, dexmedetomidine, olanzapine, antipsychotics, sedation, agitation, PADIS, MIND-USA, AID-ICU, SPICE III, mechanical ventilation, intensive care medicine, pulmonary critical care, evidence based medicine, journal club, randomized controlled trial, FOAMcc, FOAMed Tags

How long should comatose patients remain at 33°C after out-of-hospital cardiac arrest? In this episode of PRISM Rounds, we examine the icecap randomized clinical trial, which studied 1,158 comatose OHCA survivors who had already been rapidly cooled to 33°C. Patients were assigned to different cooling durations ranging from 6 to 72 hours. Longer cooling did not improve neurological recovery, mortality, or secondary neurological outcomes. We discuss the adaptive trial design, the separate shockable and nonshockable rhythm cohorts, the meaning of the approximately 50% probability that 6 hours was the shortest optimal duration, and why this does not establish a universal six-hour protocol. The episode places icecap in context with TTM, TTM2, and HYPERION while keeping clear that these trials addressed different temperature-management questions. Read the study: https://jamanetwork.com/journals/jama/fullarticle/2852508 Subscribe to PRISM Rounds on Apple Podcasts, Spotify, or YouTube, and visit: https://www.prismrounds.com Tags: icecap, cardiac arrest, out-of-hospital cardiac arrest, OHCA, targeted temperature management, therapeutic hypothermia, post-cardiac arrest care, neuroprotection, neurological recovery, TTM, TTM2, HYPERION, critical care, intensive care, emergency medicine, resuscitation, ICU, fever prevention, modified Rankin Scale, PRISM Rounds