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.