The edition · Emergency & Critical Care
Correcting the acidosis did not protect the kidneys, and balanced fluid did not beat saline in 8,482 children with septic shock
SODa-BIC finds sodium bicarbonate makes no difference to major adverse kidney events in vasopressor-dependent metabolic acidosis; PRoMPT BOLUS settles the crystalloid question in paediatric septic shock; low-dose ketamine trims opioid requirement in ventilated adults; atropine vials are recalled for particulate contamination.
The edition in brief
SODa-BIC randomised 500 adults in 55 ICUs across seven countries with metabolic acidosis (pH under 7.30) receiving vasopressors to a titrated sodium bicarbonate infusion or 5% dextrose placebo for up to five hours. Major adverse kidney events at 30 days occurred in 40.2% versus 39.4% (adjusted difference 1.2 percentage points, 95% CI -7.1 to 9.4); renal-replacement therapy 16.8% versus 20.9%; in-hospital mortality by day 30 25.4% versus 24.0%. PRoMPT BOLUS randomised 9,041 children aged 2 months to under 18 years with suspected septic shock at 47 emergency departments in five countries to balanced fluid or 0.9% saline: major adverse kidney events at 30 days were 3.4% versus 3.0% (risk ratio 1.10, 95% CI 0.88-1.40), with hyperchloraemia in 31.4% versus 49.0%. A double-blind trial of 120 mechanically ventilated adults in two Melbourne ICUs found low-dose ketamine 0.15 mg/kg/hr reduced median hourly opioid dose from 77 to 64 microgram/hr fentanyl equivalents (median difference -13.0, 95% credible interval -26.6 to 2.4; probability of benefit 95.1%), with no difference in delirium. In 1,028 emergency department patients with acute nontraumatic headache, adding 2 g intravenous magnesium sulfate to paracetamol raised treatment success from 65.1% to 78.9% and halved rescue analgesia, though all pain-score differences fell below the accepted threshold for clinical importance. The FDA has recalled atropine sulfate injection for particulate contamination.
Balanced fluid did not beat 0.9% saline in paediatric septic shock, in a trial big enough to settle it
Use whichever crystalloid is immediately available in paediatric septic shock; the choice did not change death, dialysis or kidney dysfunction across 8,482 children.
Low-dose ketamine cut hourly opioid requirement in ventilated adults without more delirium
Low-dose ketamine at 0.15 mg/kg/hr reduces opioid requirement in ventilated adults and did not increase delirium — a reasonable adjunct, not yet a proven benefit.
Intravenous magnesium for acute headache: more patients met the success threshold, but the pain scores barely moved
Intravenous magnesium added to paracetamol halves the need for rescue analgesia in acute headache, but do not promise the patient a large fall in pain.
Class II recall of atropine sulfate injection for particulate contamination
Audit resuscitation trolleys and airway boxes against the recalled atropine lots; the pharmacy shelf is not where this drug is stored.
When a patient on vasopressors suddenly deteriorates, look at the line before you turn up the dose
Before escalating a vasopressor for sudden hypotension, trace the line by hand — delivery failure looks identical to refractory shock and is commoner.
Sodium bicarbonate corrected the acidosis and changed nothing that mattered
Stop giving sodium bicarbonate to correct metabolic acidosis in vasopressor-dependent patients; it did not reduce death, dialysis or renal dysfunction.
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