eCritCare Podcast

Swapnil Pawar

The landscape of Intensive care is changing. In the era of evidence based medicine, we try to make best possible decision for our patients based on best available evidence. Every fortnight, Dr Swapnil Pawar & Dr Jose Chacko will bring you one hot topic in Critical care. If you want to stay up to date with recent evidence or learn how to critically evaluate the literature in critical care, this podcast is for you.

  1. 1d ago

    #Epi 138 - VASSPR Trial: When to Start Vasopressin in Septic Shock with Dr Ithan Peltan

    When should you add vasopressin in septic shock? It comes up on almost every ward round, and the answer still depends on which ICU you work in. In this episode of the eCritCare Podcast, Dr Swapnil Pawar is joined by Dr Ithan Peltan, intensivist, Associate Professor and Senior Medical Director for Acute Care Research at Intermountain Health in Utah, and lead investigator of the VASSPR trial, published in JAMA in 2026. VASSPR enrolled 3,959 adults with septic shock across 13 hospitals and compared a hospital-level recommendation to start vasopressin at a lower norepinephrine-equivalent dose (0.1 µg/kg/min) with a higher one (0.4 µg/kg/min). In this conversation: Why vasopressin timing is one of the most common unanswered questions on the ICU ward round How VASST, VANISH, VANCS, the Surviving Sepsis guidelines and the cost of vasopressin shaped the trial Why a pragmatic cluster crossover design tests a guideline, not a mandate Monthly crossovers, seasonality and why longer periods carry more risk of bias Getting nurses and teams to follow the "strategy of the month" without EHR alerts The results: no difference in 28-day mortality or kidney replacement therapy-free days Subgroups, the ongoing NOVA trial, and why observational data and target trial emulation still need RCTs A dose threshold is not a time threshold, and the time question remains open Angiotensin II, TRICYCLE and catecholamine-sparing strategies Lessons from ANDROMEDA-SHOCK-2 and early goal-directed therapy, and the next questions: vasopressor and ventilator weaning Read this episode on Substack: https://critcareedu.substack.com/p/vasspr-trial-vasopressin-septic-shock Paper: Peltan ID, Groat D, Jacobs JR, et al. Effect of Vasopressin Initiation Threshold on Septic Shock Mortality: The VASSPR Cluster Crossover Randomized Strategy Trial. JAMA. 2026. doi:10.1001/jama.2026.21333

  2. 5d ago

    Beyond the P Value Ep #2: The Anatomy of an ICU Trial with Prof Paul Young

    You pick up a new ICU trial in a top journal. Before you even look at the result, what should you be checking? And when the headline says "no difference", what does that actually mean for the patient in front of you? In the second episode of Beyond the P Value, the eCritCare sub-series on interpreting RCTs in critical care, Dr Swapnil Pawar and Professor Paul Young, intensivist and clinical trialist from New Zealand, work through the anatomy of an ICU trial: population, intervention, outcomes and analysis, and the common traps for both researchers and clinicians. In this conversation: The first thing Paul looks at in any new trial, and why an outcome has to apply to every randomised patient Function and cognition outcomes that ignore death, and why loss to follow-up is never random Does the trial population look like your patients? The PROSEVA example of a patient you would simply wake, wean and extubate Broad versus targeted populations, and "recruitment, recruitment, recruitment" Pragmatic versus explanatory trials, oxygen targets, and practice misalignment in ARMA and transfusion thresholds Why single-centre trials should be hypothesis generating, not practice changing CRASH-2, PATCH and the dilemma of converting deaths into poor survivors Applying the intervention as tested: ADRENAL hydrocortisone infusions, 16 hours of proning and stopping steroids early Hierarchical composite outcomes and the win ratio, and the trouble with traditional composites Reading SODa-BIC in context, and why journal papers are written like rigid poetry The fragility index, ten years on, and why Paul looks at the effect estimate rather than the P value Previous episode: Beyond the P Value Ep 1, Why RCTs Matter and Why They Mislead Us. Read this episode on Substack: https://critcareedu.substack.com/p/beyond-the-p-value-anatomy-of-an-icu-trial Reference: Ridgeon EE, Young PJ, Bellomo R, et al. The Fragility Index in Multicenter Randomized Controlled Critical Care Trials. Crit Care Med. 2016;44(7):1278-1284. doi:10.1097/CCM.0000000000001670 Please send us your feedback @ icuprimaryprepcast@gmail.com

  3. Oct 26

    #Epi 136 - Greening Critical Care Through Medications with Dr Nicole Hunfeld

    IV paracetamol or two tablets? The answer looks the same on the drug chart. In the waste bin and the carbon ledger, it can be six to sixty times different. In this episode of the eCritCare Podcast, Dr Swapnil Pawar is joined by Dr Nicole Hunfeld, ICU pharmacist and Chief Sustainability Officer at Erasmus University Medical Centre, Rotterdam, to open a new pharmacology series. Nicole unpacks the environmental footprint of the medications we give every day in intensive care, how to measure it, and the practical changes any ICU can make. In this conversation: Why spend-based estimates (25% of NHS emissions from medication) can't tell you which drugs matter Life cycle assessment explained: from chemical synthesis and excipients to transport, administration and waste Why IV formulations can carry six to sixty times the footprint of the same molecule as a tablet Material flow analysis of a year of ICU medication, and why CRRT bags top the list Waste audits with a kitchen scale: paracetamol, phosphate and haloperidol Prefilled syringes: fewer errors, a higher bill, and an extra sterilisation step Stopping expiry waste: a small medication room, first in first out, and swapping stock with anaesthesia and ED Ecotoxicity: what happens to drugs after they leave the patient, and the ibuprofen gel problem Bolus injections instead of bags, leaving drugs in the bag instead of drawing up 50 mL syringes IV to oral switches with evidence: paracetamol, phosphate, magnesium, PPIs, cotrimoxazole and metronidazole Vancomycin levels from leftover blood gas samples How to start: one simple change, engaged nurses, and steady and slow Read this episode on Substack: https://critcareedu.substack.com/p/icu-medications-environmental-impact Paper: Uhland C, Mousa A, Montgomery H, Hunfeld N, et al. Greening critical care by harnessing the planetary impact of medications: what fellows need to know. J Crit Care. 2026;95:155672. doi:10.1016/j.jcrc.2026.155672 Please send us your feedback @ icuprimaryprepcast@gmail.com

  4. Oct 15

    #Epi 135 - SODa-BIC Trial: Sodium Bicarbonate for Metabolic Acidosis and Shock, with Prof. Ary Serpa Neto.

    A patient in shock, on noradrenaline, with a pH of 7.22 and a base excess of minus 8. Do you give bicarbonate? Depending on which ICU you work in, the answer ranges from almost never to almost always. In this episode of the eCritCare Podcast, Dr Swapnil Pawar is joined by Professor Ary Serpa Neto of Monash University, lead investigator of the SODa-BIC trial, published in the New England Journal of Medicine in 2026. SODa-BIC randomised 500 critically ill adults with metabolic acidosis receiving vasopressors, across 55 ICUs in seven countries, to sodium bicarbonate or placebo in a double-blind design. In this conversation: Why SODa-BIC was needed after BICAR-ICU, and why it targeted earlier, less severe acidaemia Choosing pH below 7.30, base excess below minus 4 and vasopressor use as entry criteria Why MAKE30 was the primary outcome rather than mortality alone How you blind bicarbonate: 5% dextrose bags, unblinded and blinded investigators at every site Sample size, a blinded re-estimation, and what Ary would do differently with a win ratio The results: faster correction of acidosis but no difference in MAKE30, mortality or persistent renal dysfunction The 4% lower rate of renal replacement therapy, and why a little bicarbonate before a Vascath may be reasonable Cost, sustainability and low and middle income settings Waivers of consent, a five-hour intervention and data minimalism What comes next: MOSAIC, an individual patient data meta-analysis and SODa-BIC sub-studies Read this episode on Substack: https://critcareedu.substack.com/p/soda-bic-trial-sodium-bicarbonate-metabolic-acidosis Paper: Serpa Neto A, McNamara M, White K, et al. Sodium Bicarbonate for Critically Ill Adults with Metabolic Acidosis and Shock. N Engl J Med. 2026. doi:10.1056/NEJMoa2600526

  5. Oct 11

    #Epi 134 - GASTRIC-PICU Trial: Stopping Routine Gastric Residual Volume Checks in Ventilated Children with Prof Lyvonne Tume

    Draw back the stomach contents, measure, and hold the feed if the number looks big. It has been routine in paediatric intensive care for decades. But does gastric residual volume tell us anything useful? In this episode of the eCritCare Podcast, Dr Swapnil Pawar is joined by Professor Lyvonne Tume, Professor of Critical Care Nursing and Chief Investigator of the GASTRIC-PICU trial, published in JAMA in 2026. GASTRIC-PICU randomised 4,700 mechanically ventilated children across 23 UK paediatric ICUs and one in Switzerland to routine gastric residual volume (GRV) measurement, or no routine measurement with feed tolerance assessed on clinical signs. In this conversation: Why GRV is such an unreliable number: syringe size, tube lumen, tip position, patient position and breast milk that clumps Why clinicians asked for proof it was safe to stop, and how that forced a non-inferiority design Choosing survival and ventilator-free days over VAP as the primary outcome, and the role of PICANet Sample size, crossover and why per-protocol power matters in a non-inferiority trial Strict non-adherence rules, the bedside education package, and the process evaluation that was cut The results: non-inferior on clinical outcomes, better early nutrition, and far fewer feeds stopped for a "high" GRV Why better nutrition did not shift ventilator days, and the hidden cost in long-stay complex children Cardiac and ECMO patients, generalisability to Australia, and why low and middle income settings differ A message for adult intensivists: de-implementation, not another trial Three months on: attitude change, guideline change and an aggressive implementation plan What comes next: reducing unnecessary fasting in PICU Read this episode on Substack: https://critcareedu.substack.com/p/gastric-picu-trial-gastric-residual-volume Paper: Tume LN, Mouncey PR, Broomhall JM, et al. Gastric Residual Volume Assessment in Critically Ill Children: The GASTRIC-PICU Randomized Clinical Trial. JAMA. 2026. doi:10.1001/jama.2026.10639 Please send us your feedback @ icuprimaryprepcast@gmail.com

  6. Oct 6

    #Epi 133 - The Green ICU: Cutting the Environmental Footprint of Intensive Care with Dr Nicole Hunfeld

    More than one box of gloves per patient, per day. Glass bottles of IV paracetamol filling the waste room. Intensive care saves lives, but at what cost to the planet? In this episode of the eCritCare Podcast, Dr Swapnil Pawar is joined by Dr Nicole Hunfeld, ICU pharmacist and Chief Sustainability Officer at Erasmus University Medical Centre, Rotterdam, associate professor in sustainable healthcare, chair of the Dutch Green ICU Network and co-chair of the ESICM Environmental Sustainability Committee. Nicole shares how a COVID-era frustration became the Green ICU movement, now spread across all 70 ICUs in the Netherlands and beyond. In this conversation: How overflowing plastic waste during COVID sparked the Green ICU project The material flow hotspot analysis, published in Intensive Care Medicine, that gave the team data and a narrative 108 gloves per patient per day, and the journey of a single nitrile glove from Spain to Malaysia to Rotterdam Low hanging fruit: swapping blueys for towels, the "No risk, no glove" campaign, and IV to oral switches Why the paper recycling idea failed completely, and what it taught the team about going slow The paracetamol challenge: a giant tablet, 40 hospitals signing up in one day, and around 18,000 euros saved in a year on one drug Measuring what matters: carbon, cost and nurse workload Building a national network with a mixed nurse and intensivist committee Keeping momentum: green leaf icons in protocols and "oral first" prompts in the EHR Corporate anthropology and why you should embrace the no Where to start in your own ICU Read this episode on Substack: https://critcareedu.substack.com/p/green-icu-sustainable-intensive-care Please send us your feedback @ icuprimaryprepcast@gmail.com

  7. Sep 27

    #Epi 132 - TRICYCLE Trial: Early Triple Vasopressor Therapy in Septic Shock with Prof Giovanni Landoni & Dr Žiga Kalamar

    Norepinephrine first, titrate up, add vasopressin when the dose gets high, reach for a third agent when things get desperate. That stepwise approach is how most of us treat septic shock. What if all three went in together, early? In this episode of the eCritCare Podcast, Dr Swapnil Pawar is joined by Professor Giovanni Landoni (San Raffaele Hospital, Milan) and Dr Žiga Kalamar (Medical ICU, University Medical Centre Maribor, Slovenia) to discuss the TRICYCLE trial, published in Critical Care in 2026. TRICYCLE randomised 79 patients with septic shock to early simultaneous norepinephrine, vasopressin and angiotensin II at balanced starting doses, or to conventional stepwise vasopressor escalation. In this conversation: Why septic shock involves several broken vasoconstrictor pathways at once, and why one drug titrated to high doses may not be the answer Why a phase II mechanistic trial chose renin, not blood pressure or mortality, as its primary outcome The results: faster falls in renin and lactate, a 3-point SOFA improvement at 72 hours, and numerically lower mortality The striking drop in tachyarrhythmias, and the beta-adrenergic explanation behind it What went hard: strict inclusion criteria and running three infusion pumps to protocol A post hoc hint that high-renin patients may benefit most, and why phenotyping is still a long way off Angiotensin II cost and access, and what that means for resource-limited settings Next steps: a bigger trial powered on AKI or arrhythmias, and the idea of a meta-trial run across many small sites Read this episode on Substack: https://critcareedu.substack.com/p/tricycle-trial-multimodal-vasopressors-septic-shock Paper: Kalamar Ž, Landoni G, Gorenjak M, et al. Early multimodal vasopressor strategy in septic shock: results of the TRICYCLE randomized controlled trial. Crit Care. 2026. doi:10.1186/s13054-026-06323-z

  8. Sep 22

    #Epi 131 - T4P Trial: Platelet Transfusion Thresholds Before ICU Procedures with Prof Peter Watkinson & Prof Simon Stanworth

    A platelet count of 40 and a central line to put in. Transfuse first, or go ahead? Right now the answer depends on which ICU you work in, and nobody actually knows which is right. In this episode of the eCritCare Podcast, Dr Swapnil Pawar is joined by Professor Peter Watkinson (Professor of Intensive Care Medicine, University of Oxford, and Chief Investigator) and Professor Simon Stanworth (Professor of Haematology and Transfusion Medicine, University of Oxford) to discuss the T4P trial, Threshold for Platelets. T4P is a Bayesian adaptive randomised trial across five platelet transfusion thresholds, from below 10 to below 50, in critically ill patients undergoing low bleeding risk invasive procedures. It is recruiting 2,550 patients across the UK, Australia and Canada and has just passed the halfway mark. In this conversation: Why platelet transfusion practice in critical care was borrowed from blood cancer patients, and why the evidence never caught up The UK survey that showed thresholds anywhere from under 10 to under 50 for the same procedure The risks side of the ledger: a biological product, transfusion reactions, unknown effects, and around £290 per unit before lab and administration costs Why five thresholds instead of two: drawing the threshold-response curve so the optimum does not have to be one of the arms Which procedures are specified (central lines, pleural aspiration, paracentesis) and which are at clinician discretion The adherence question, and why even the below-10 arm is being followed The haematology confusion: why a patient's daily platelet threshold does not stop them being in T4P Rotating trainees, cross-specialty equipoise, and asking clinicians to step outside a comfort zone they have practised in for years Operator experience, ultrasound-guided lines, and what PACER did and did not show in critical care What success looks like: the biggest platelet transfusion study in critical care, and a practice-changing curve Read this episode on Substack: https://critcareedu.substack.com/p/t4p-trial-platelet-transfusion-thresholds Trial registration: ISRCTN79371664. Funded by the NIHR Health Technology Assessment Programme (NIHR131822).

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About

The landscape of Intensive care is changing. In the era of evidence based medicine, we try to make best possible decision for our patients based on best available evidence. Every fortnight, Dr Swapnil Pawar & Dr Jose Chacko will bring you one hot topic in Critical care. If you want to stay up to date with recent evidence or learn how to critically evaluate the literature in critical care, this podcast is for you.

Information

  • Creator
    Swapnil Pawar
  • Years Active
    2019 - 2026
  • Episodes
    100
  • Rating
    Clean
  • Copyright
    © @eCritCare Podcast
  • Show Website
    eCritCare Podcast

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