Article 1
Prehospital Postintubation Hypotension and Survival in Severe Traumatic Brain Injury. Price J, Lachowycz K, Major R, et al. JAMA Netw Open. 2025 Nov 3;8(11):e2544057.
Prehospital post-intubation hypotension (PIH) may be an underappreciated, potentially modifiable contributor to secondary brain injury after severe traumatic brain injury (TBI). The current study aimed to determine the frequency of PIH after prehospital rapid sequence induction (RSI) in patients with severe TBI and to test whether PIH is independently associated with 30-day mortality — a clinically important and patient-centered outcome for this population.
This was a retrospective multicenter cohort of adults with severe TBI who underwent prehospital RSI in a UK helicopter EMS network from 2015–2022. PIH was defined a priori as a new systolic blood pressure (SBP) <90 mmHg within 10 minutes after induction. The primary endpoint was 30-day mortality; analyses adjusted for key confounders (age, GCS, ISS, head AIS and other baseline variables) and included planned subgroup analyses for isolated severe TBI versus polytrauma.
Of 555 patients included, 106 (19.1%) developed PIH within 10 minutes of induction, and overall 30-day mortality was 30.5%. After multivariable adjustment, PIH was independently associated with higher 30-day mortality in the polytrauma + severe TBI group (adjusted odds ratio 1.70; 95% CI 1.01–2.86). The effect estimate was dramatically larger but imprecise in the isolated severe TBI subgroup (adjusted OR ~13.6; 95% CI 3.65–61.66), based on smaller numbers. These associations persisted despite adjustment for injury severity and other measured covariates.
The results identify PIH as a frequent event after prehospital RSI and a robust predictor of death after severe TBI, supporting biological plausibility: even brief drops in MAP/SBP reduce cerebral perfusion pressure and may worsen secondary ischemic brain injury. The notably large point estimate in isolated TBI is hypothesis-generating but limited by small subgroup size and wide confidence intervals; it should be interpreted cautiously.
Clinical implications are immediate but measured. This study argues for treating the peri-intubation window as high-risk: anticipate and attempt to prevent PIH by optimizing preload when possible, minimizing hemodynamically deleterious induction strategies, and having vasopressors immediately available (or started preemptively in selected high-risk patients). However, causality is not proven — residual confounding and measurement limitations in the prehospital setting remain — so widespread guideline changes should await prospective interventional data. Nevertheless, protocolized per-intubation hemodynamic management (checklist: assess volume status, plan induction doses, vasopressor readiness, immediate post-intubation monitoring) is a low-risk, high-potential-benefit step that services can reasonably adopt while randomized trials are planned.
In short, prehospital PIH after RSI occurs in about one in five severely injured TBI patients and is independently associated with increased 30-day mortality; these findings justify both immediate attention to perintubation hemodynamic practice and prioritized randomized trials of preemptive vasopressors and hemodynamic bundles to determine whether preventing PIH improves survival.
Article 2
Risk factors and outcomes of ventilator-associated pneumonia in patients with traumatic brain injury: A systematic review and meta-analysis. Serra R, Dominguez-Rivera C, Moreno J, et al. Injury. February 2025.
This systematic review and meta-analysis evaluated risk factors for ventilator-associated pneumonia (VAP) in patients with traumatic brain injury (TBI) and examined the association between VAP and key clinical outcomes. Using PRISMA methodology, the authors searched five major databases and included 13 observational studies in the qualitative synthesis, with 12 studies comprising 2,883 total patients pooled for quantitative analysis.
Across studies, several consistent predictors of VAP emerged. Male sex (OR 1.58) and severe head injury (head AIS ≥3; OR 2.79) were significantly associated with increased VAP risk, suggesting that both biological susceptibility and injury severity contribute to pneumonia development. Additional risk factors identified in subgroup analyses, after eliminating studies that might cause heterogeneity using the leave-one-out strategy, included blood transfusion on admission (OR 1.97) and barbiturate infusion (OR 3.55), both of which likely reflect management strategies in more severely injured patients. Younger age appeared protective, and prophylactic antibiotic use demonstrated a modest protective association (OR 0.67), though the authors caution that this observation may be vulnerable to selection bias.
The development of VAP was associated with substantial increases in morbidity. Patients with VAP had longer durations of mechanical ventilation (mean +5.8 days), prolonged ICU length of stay (mean +7 days), and extended overall hospitalization (mean +11.9 days). Despite these impacts on resource utilization and recovery trajectory, VAP did not confer a statistically significant increase in mortality among TBI patients.
These findings reinforce that VAP remains a common and clinically meaningful complication in ventilated TBI patients. The identified risk factors—particularly severe head injury, may be markers of physiologic vulnerability and treatment intensity rather than modifiable drivers of pneumonia. The strong association between VAP and increased ICU and hospital stay underscores the importance of rigorous VAP-prevention strategies in this population, especially given the lack of mortality signal that could otherwise justify more aggressive or invasive prophylaxis.
The analysis is limited by heterogeneity in VAP definitions, diagnostic criteria, and timing across included studies. All included data were observational, raising the possibility of residual confounding, particularly for treatment-related variables such as transfusion and barbiturate use. Reported protective effects of prophylactic antibiotics should be interpreted cautiously, as these findings may reflect institutional practices rather than biological benefit.
In TBI patients requiring mechanical ventilation, VAP is associated with predictable risk profiles and significant morbidity but not increased mortality. This review highlights the need for standardized diagnostic criteria, prospective studies to clarify causal pathways, and targeted approaches to VAP prevention in high-risk neurocritical care populations.
Article 3
Deferring Arterial catheterization in Critically Ill Patients with Shock. Muller G, Contou D, Ehrmann S, et al. N Engl J Med. 2025 Nov 13;393(19):1875-1888.
This was a multicenter noninferiority trial in which the EVERDAC trial group randomized ICU patients from 9 French hospitals in shock to undergo “early” (<4hrs from randomization) arterial line or noninvasive BP monitoring. Shock was defined as SBP<90mmHg are MAP <65mmHg for >15minutes or initiation of vasopressors therapy, plus one sign of tissue hypoperfusion. Obese patients and patients on “high” dose vasopressors, in addition to other criteria, were excluded. The primary outcome was all-cause death at 28 days with a noninferiority margin set at 5%. 1010 patients were enrolled; though arterial catheterization was permitted at a later time point in the noninvasive group, only 14.7% got an arterial line at any point. The safety criteria that permitted arterial line in these patients included: inability to get NIBP, need for ABG with 5 failed attempts, ECMO, or the development of the need for high dose pressors. The authors found that the noninvasive strategy was noninferior with regard to the primary endpoint, with 34.3% in the noninvasive group and 36.9% in the invasive group dying by day 28.
On one hand, one may question the primary outcome in this study. It does not seem terribly surprising that NIBP was noninferior for death. But, a) this is not evidence that we previously had and b) secondary outcomes were equally as convincing. Median SOFA score was similar at the time of randomization and a week later. There was some signal (p=0.07) for more pain and discomfort with NIBP than with arterial line. There was more arterial line site hematoma/hemorrhage in the invasive group. One downside to the study was a lack of description of the etiologies of shock (i.e. septic, hemorrhagic) and one could question the generalizability of the findings to a surgical population. Regardless, these findings are strong evidence that arterial catheterization can be deferred in shocked ICU patients.
