eCritCare Podcast

Randomised controlled trials shape almost everything we do in the ICU. So why do so many of them seem to show nothing? And when a trial says "no benefit," what does that actually mean for the patient in front of you? This is the first episode of Beyond the P Value, a new eCritCare sub-series on interpreting RCTs in critical care with Professor Paul Young, intensivist and clinician researcher from New Zealand. Over the coming episodes, Dr Swapnil Pawar and Professor Young go past the abstract and the p-value to unpack how landmark ICU trials should be read, challenged and applied at the bedside. In this conversation: Why the RCT is still the gold standard for causal inference, and the three things to look at first: population, outcome, and plausibility of the treatment effect The two big weaknesses: surrogate outcomes that leave the patient out of the centre, and the gap between average effects and the individual patient Why "negative" trials never really fail, and how a neutral average can hide big benefit for some patients and big harm for others Individualised treatment effects, machine learning on trial datasets, and the coming oxygen target trial built on them Reinforcement learning in the ICU: how the Instagram feed model could one day balance treatments to maximise survival Availability bias at the bedside: why a rising blood pressure after a fluid bolus tells you almost nothing about outcome Heterogeneous populations, disease trajectories, and why you still have to start somewhere The collapsed right upper lobe that fixed itself, and what it says about how clinicians learn Where the practice-changing evidence actually lives: three journals, fewer than 20 papers a year, and the Critical Care Reviews meeting Next episode: how to interpret an RCT, and the anatomy of a trial. Read this episode on Substack: https://critcareedu.substack.com/p/beyond-the-p-value-why-rcts-matter

Conventional platelets last five to seven days. Cryopreserved platelets last two years. So why aren't we using them everywhere? In this episode of the eCritCare Podcast, Dr Swapnil Pawar sits down with Professor Michael Reade, intensivist, researcher and chief investigator of the CLIP-II trial, published in JAMA in 2026. CLIP-II randomised 388 high-risk cardiac surgical patients across 11 Australian hospitals and compared cryopreserved platelets with standard liquid-stored platelets in the 202 who needed a transfusion. The headline result: cryopreserved platelets did not meet the pre-specified 20% non-inferiority margin for chest drain bleeding in the first 24 hours. But as Professor Reade explains, that is only part of the story. In this conversation: Why cardiac surgery was the right population, and the platelet transfusion risk calculator that came out of it How the team achieved double blinding with blood products (and what may have unblinded clinicians anyway) Why 20% was chosen as the non-inferiority margin What "could not conclude non-inferiority" actually means, and why 13% of not very much is not very much The mortality signal and what it does and does not tell us Would he give frozen platelets to a bleeding patient in a regional hospital? Yes. The unpublished New Zealand and US military trials still to come Behind the scenes: training blood bank staff, minus 80 freezers, and running a trial through COVID Paper: Reade MC, Marks DC, Howe BD, et al. Cryopreserved vs Liquid-Stored Platelets for the Treatment of Surgical Bleeding: The CLIP-II Randomized Noninferiority Clinical Trial. JAMA. 2026;335(7):600-608. doi:10.1001/jama.2025.23355

In this episode, Dr Swapnil Pawar sits down with Professor Ian Seppelt, intensivist at Nepean Hospital, Sydney, and one of the lead investigators of the SuDDICU trial, to unpack the decades-long story of Selective Digestive Decontamination (SDD) in intensive care. Ian traces SDD from its haematology origins in the 1970s, through its adoption in the Netherlands, to the extraordinary behind-the-scenes journey of SuDDICU: failed international grants, the pivot from a parallel-group to a crossover cluster design, manufacturing a pharmaceutical-grade SDD preparation from scratch, and navigating ethics approval for a trial without individual patient consent. They discuss: What SDD actually is, and why "selective" matters Why infectious disease physicians resisted a therapy with one of the largest evidence bases in critical care The SuDDICU results: a non-significant mortality benefit, fewer positive blood cultures, fewer resistant organisms, and no signal of emerging resistance The Bayesian view, with a high posterior probability of survival benefit Where SDD goes next: enriched subgroups (neurological injury, pancreatitis), the PREVENT trial of prophylactic ceftriaxone in acute brain injury, and the unanswered question of high-resistance settings Why we adopt some interventions and ignore others: the psychology of evidence in ICU

In this episode, Dr Swapnil Pawar is joined by Dr Ary Serpa Neto to discuss the GUARDS trial, which is testing whether dexamethasone reduces 60-day mortality in patients with moderate to severe ARDS. We cover the rationale for steroids in ARDS, the choice of drug and dose, the expanded eligibility criteria including non-intubated patients, how the sample size was calculated, and the funding and design realities behind running a trial of this scale.

Dr Swapnil Pawar is joined by Dr Jose Chacko to discuss the LOGICAL trial, published in the New England Journal of Medicine in June 2026. Does limiting oxygen after cardiac arrest protect the brain from reperfusion injury? LOGICAL (the largest randomised trial of oxygen therapy after cardiac arrest to date) randomised 1,840 patients across 53 ICUs in Australia, New Zealand and Ireland to conservative versus liberal oxygen therapy. In this episode: – The pathophysiological rationale: hypoxic-ischaemic encephalopathy, reperfusion injury and free radical damage – Where LOGICAL sits alongside EXACT, ICU-ROX, HOT-ICU and the Danish BOX trial – The Mega-ROX master protocol design, and why the sepsis and non-HIE brain injury arms are still to come – Trial design: SpO₂ upper limit of 95% and FiO₂ down to 0.21 in the conservative arm versus no upper limit and a floor of FiO₂ 0.3 in the liberal arm – The results: no difference in favourable neurological outcome at 180 days (38.2% vs 39.7%), survival, length of stay, quality of life or cognitive function – Strengths, limitations, and what it means at the bedside, including why the hosts have landed in different places on titrating down to room air Reference: The LOGICAL Investigators and the ANZICS Clinical Trials Group. Conservative Oxygen for Unresponsive Patients after Cardiac Arrest. N Engl J Med. 2026 Jun 10. Full summary, outcome tables and references at critcareedu.com.au

In this episode, we discuss the SOHO trial, a large multicentre randomised controlled trial comparing high-flow nasal oxygen with conventional oxygen therapy in patients with acute hypoxaemic respiratory failure. We cover the trial methodology, the key findings on 28-day mortality and intubation rates, and what the results mean for practice in both ICU and ward settings.

In this episode, Dr Swapnil Pawar is joined by Dr Jose Chacko to discuss the 2026 American Heart Association and American College of Cardiology guidelines on the management of pulmonary embolism. We cover the new A to E classification, evaluation and diagnostic algorithms, acute management including the role of PERT teams, advanced reperfusion therapies, and the updated recommendations on anticoagulation and follow-up. Welcome back after two years.

In this episode, we discuss the recently published SWITCH trial which compared the efficacy of decompressive craniectomy with best medical treatment vs best medical treatment alone for deep intra-cerebral hemorrhage.

In this episode, we discuss the etiology of diaphragmatic dysfunction, its management and strategies for prevention. 

In this episode, we discuss the recently published RCT AMIKINHAL, which tested the efficacy of inhaled amikacin in preventing VAP in ICU patients who were ventilated for> 72 hours. Although, this trail demonstrated reduced incidence of VAP in intervention arm, it's premature to adopt these practices widely in intensive care.

In this episode, we discuss recently published RCT in JAMA "NICO trial", which evaluated the role of GCS based intubation vs non-invasive airway management. It is important to understand the nuances before generalising the conclusion of this trial.

In this episode, we discuss the recently published RCT in NEJM, which challenged the current dogma regarding the role of IV thyroxine in potential organ donor patient population. 

In this episode, we discuss the recently published RCT "ECLS-Shock" trial in NEJM. This trial tested the benefit of instituting early extra-corporeal support in cardiogenic shock and suggested more harm in intervention arm compared to control arm. 

In this episode, we discuss recently published landmark RCT which compared the timing for initiation of oral anticoagulation in patients who presented with ischaemic stroke with rapid AF. 

In this episode, we discuss the controversy surrounding the usage of steroids in Community-acquired pneumonia. This controversy arose after the CAPE-COD trial was published recently in NEJM. We discuss the pros and cons of administering steroids as a blanket treatment. We recommend caution and suggest considering the external validity of this trial before changing your practices.

In this episode, we discuss recently published RCT "MERCY Trial" which evaluated the efficacy of continuous infusion vs intermittent dosing strategy of Meropenem.

In this episode, we discuss the recently published RCT "PATCH Trial", which evaluated the efficacy of pre-hospital tranexamic acid in patients with severe trauma. This trial confirmed the results of CRASH-2 trial, which demonstrated 28-day mortality benefit with the use of tranexaic acid in trauma if administered in < 3 hours. However, it failed to demonstrate any significant benefit with favourable neurological output at 6 months. This highlights the importance of Post-ICU care which at this stage is not standardised and varies across the globe.

In this episode, we discuss recenetly published RCT, which compared the role of craniotomy vs decompressive craniectomy in managing acute SDH.

In this episode, we discuss the recently published non-inferiority RCT "PACER Trial", which evaluated the efficacy of prophylactic platelet transfusion in thrombocytopenic patients requiring CVC insertion.

In this episode, Prof Ian Seppelt, one of the lead investigators of SuDDICU, shares his insights and talks about the rationale for SDD in ICU. He also explains the reasons behind the failure to change practices despite the evidence of mortality benefit from the recent meta-analysis. He discusses the future of SDD and the strategy for its widespread adaptation.

In this episode, we dive deeper into the controversy surrounding using high-flow nasal cannula vs NIV in high-risk patients to prevent reintubation. The recently published trial raised some crucial questions and forced us to reconsider our overall approach to extubation in this subset of patients. 

In this episode, we discuss recently published RCT, which demonstrated the mortality benefit in Community-acquired pneumonia.

In this episode, we discuss the recently published RCT in NEJM, which evaluated the efficacy of ECMO CPR ( eCPR) in patients with OHCA secondary to a shockable rhythm. 

In this episode, we discuss the recently published CLOVERs trial, which compared fluid dominant vs vasopressor-dominant resuscitation strategies for patients in septic shock. 

In this podcast, we discuss another RCT which evaluated the efficacy of restrictive Vs liberal oxygenation targets in comatose OHCA survivors.  The trial showed no difference between the two groups w.r.t 90-day mortality or discharge from hospital 

In this episode, we discuss the recently published DOSE VF trial, which evaluated the efficacy of early double sequential defibrillation strategy over vector change and standard defibrillation strategies. This trial has demonstrated that this innovative strategy has the potential to improve mortality and is likely to change our practices.

In this episode, we discuss the recently published RCT "TEAM trial", which evaluated the role of early mobilisation in mechanically ventilated intensive care patients. 

In this episode, we discuss the SETPOINT 2 trial, which evaluated the controversy around the timing of tracheostomy. 

In this episode, we discuss a recently published randomised controlled trial evaluating the role of aggressive fluid resuscitation strategy in mild acute pancreatitis. 

Join us in this episode to discuss the evidence behind the use of tranexamic acid for various indications in intensive care. 

In our landmark 100th episode, we discuss the controversy around one of the most commonly used drugs in intensive care, i.e. Oxygen. In this episode, we dive deeper into the available evidence and recommend our approach for using oxygen in critically ill patients. 

In this episode, we discuss the role of therapeutic hypothermia and targeted temperature management in severe TBI. We dive deeper into the available literature on this topic and share our recommendations on this controversy. 

In this episode, we discuss the controversies around the definitions, diagnostic criteria, investigations and management of ventilator-associated pneumonia.

In this episode, we discuss the recently published trial evaluating the efficacy of liberal vs restrictive fluid resuscitation strategy in patients with septic shock. 

In this episode, we discuss the recently published RCT evaluating the role of IV Vitamin C in patients with septic shock.  This trial has given us a clear answer on the future of vitamin C in these patients. We discuss the available evidence on this topic so far and suggest our approach to this toopic. 

In this episode, we discuss the evidence behind each target used in resuscitating a patient with septic shock. 

In this episode, we discuss the landmark trial published in JAMA, which evaluated the efficacy of eCPR over standard strategy. We believe although a well-conducted trial, it's still not enough evidence to decide one way or the other w.r.t performing eCPR in patients with out of hospital cardiac arrest. 

In this episode, we discuss the evidence behind the choice of adrenaline vs noradrenaline in patients who achieved ROSC (return of spontaneous circulation) after OHCA(out of hospital cardiac arrest). 

In this episode, we discuss the controversy surrounding the use of NIV in hypoxemic respiratory failure in severe COVID-19. The results of the RECOVERY-RS trial has provided us with significant evidence on this topic.

In this episode, we discuss the recently published trial on long term outcomes in COVID patients. 

In this episode, we discuss a recently published PLUS study comparing saline solution with Plasmalyte-148. This study demonstrated no significant mortality difference between the saline group and the plasmalyte-148 group.

In this episode, we discuss the recently published RCT evaluating the role of extended thromboprophylaxis in COVID-19.

In this episode, we discuss the challenges faced by healthcare systems and the patterns emerging from the current COVID-19 pandemic wave caused by the Omicron variant. 

In this episode, we discuss a recently published trial comparing conventional oxygen therapy and high flow nasal oxygen therapy. 

In this podcast, we discuss the controversy surrounding glycemic control in intensive care. We discuss the target range, the ideal amount of time spent in the target range and the utility of continuous glycemic monitoring in critically ill patients.

In this episode, we discuss the CONTROLLING study which compared the novel strategy of individualised glycemic control vs conventional glucose control. 

In this episode, we dive deeper into the controversy around the timing of initiation of RRT in Intensive Care. 

The controversy around the dose of steroid dose in COVID-19 still exists. In this podcast, we discuss the recently published RCT COVID Steroid 2 and dive deeper into this controversy. 

In this episode, we discuss some of the key recommendations and the rationale behind them from recently published SSCG 2021. 

Hyperventilation has been used to control raised ICP for decades. However, the evidence behind it is very weak. In this podcast, we discuss the recently published study by CENTRE-TBI to address this controversy. 

In this episode, we discuss the evidence behind the dogmatic practice of routinely using ICP monitoring in patients with traumatic brain injury admitted to ICU.