S01E63 | Oveporexton for Narcolepsy Type 1: A New Approach to Wakefulness and Cataplexy

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

In Season 1, Episode 58 of PRISM Rounds, we review the 2025 Society of Critical Care Medicine guideline for the treatment of heat stroke and translate its recommendations into practical bedside decisions for emergency and critical care clinicians. We discuss why active cooling should begin immediately, why cold- or ice-water immersion is preferred when feasible, and why the guideline emphasizes both the speed of cooling and the goal of reaching a core temperature below about 39°C within 30 minutes. We also review what to do when immersion is not practical and how the guideline approaches classic versus exertional heat stroke. The episode also covers therapies that should generally be avoided. Routine acetaminophen, NSAIDs, salicylates, and dantrolene are not recommended for temperature reduction, and prophylactic antibiotics or antiseizure medications should be limited to research settings. An important theme is the strength of the recommendations versus the strength of the evidence. Several recommendations are strong despite very low-certainty evidence, reflecting the practical and ethical difficulty of conducting randomized trials that delay effective cooling in patients with true heat stroke. The bedside message is simple: recognize heat stroke early, start the fastest feasible active cooling strategy, continue simultaneous resuscitation and organ support, and avoid medications that do not address the underlying problem. Read the guideline: https://doi.org/10.1097/CCM.0000000000006551 More PRISM Rounds: https://www.prismrounds.com Available on Apple Podcasts, Spotify, YouTube, and other major podcast platforms. Tags: PRISM Rounds, S01E58, critical care, ICU, heat stroke, heatstroke, hyperthermia, SCCM, Society of Critical Care Medicine, emergency medicine, cooling, cold water immersion, ice water immersion, exertional heat stroke, classic heat stroke, temperature management, dantrolene, antipyretics, heat illness, resuscitation, evidence based medicine, clinical guidelines, guideline review, medical education, FOAMed, pulmonary critical care