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Anaesthetics & ICU Evidence Rundown

Anaesthetics & ICU Evidence Rundown ·

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Anaesthetics & ICU Evidence Rundown

Week of 12 March 2026 | Issue 1

DAS has overhauled its difficult airway guidelines for the first time in a decade, GPICS V3 redefines the minimum standards for every UK ICU, and an international fasting consensus makes "Sip Til Send" the new benchmark. Meanwhile, a landmark NEJM trial challenges ketamine's haemodynamic superiority in critically ill RSI — and two MHRA device recalls demand an urgent stock check in your department.

Key to badges used in this issue:

RCT SR/MA GUIDELINE CONSENSUS OBSERVATIONAL SAFETY ALERT REVIEW — Evidence type CHANGE PRACTICE — Item likely to change your day-to-day clinical practice Final FRCA — Directly relevant to Final FRCA / FFICM curriculum

IN THIS ISSUE

  1. DAS 2025 Difficult Airway Guidelines CHANGE PRACTICE
  2. EMHG 2025 MH Diagnostic Guidelines CHANGE PRACTICE
  3. Perioperative Fasting Consensus 2026 CHANGE PRACTICE
  4. GPICS V3 — new ICU standards
  5. NEJM RSI Trial: Ketamine vs Etomidate
  6. DESIGNATION Trial: Driving Pressure-Guided PEEP (negative)
  7. ANDROMEDA-SHOCK-2: CRT-Guided Resuscitation
  8. PROSPECT Thoracotomy 2025: TEA/PVB first-line
  9. Aortic Stenosis & Noncardiac Surgery Meta-analysis
  10. TOP Trial: Liberal vs Restrictive Transfusion
  11. MHRA Safety Alerts: Cook Blue Rhino & Armstrong Circuits
  12. 2026 PE Guidelines + PulmCrit critique (Paired Controversy)

GUIDELINES & OFFICIAL UPDATES

DAS 2025: Management of Unanticipated Difficult Intubation in Adults GUIDELINE CHANGE

PRACTICE Final FRCA

BJA, Jan 2026 (136:1, pp 283–307) | DAS website | PubMed

The most comprehensive airway guideline update in over 20 years. Three years of development, 1,241 papers reviewed, 65 evidence-based recommendations via a Delphi process with 36 international experts. The Plan A → B → C → D linear algorithm is retained but with major additions: a new "physiologically difficult airway" concept (shock, hypoxia, obesity, RV failure), continuous oxygen delivery as a core priority, emphasis on maximising first-pass success, and formal incorporation of videolaryngoscopy, POCUS, and human factors.

Why it matters: These guidelines supersede DAS 2015 and are the standard every UK anaesthetist is now expected to practise to. The physiologically difficult airway concept transforms preoperative planning for haemodynamically unstable, obese, and hypoxaemic patients. Directly examinable at Final FRCA.

📢 Tell your department: "The DAS 2025 guidelines are published — we need to update our airway trolley posters, brief the ODPs, and run through the new algorithms at the next departmental teaching."

EMHG 2025 Malignant Hyperthermia Diagnostic Guidelines GUIDELINE CHANGE PRACTICE Final

FRCA

BJA, Feb 2026 (Vol 136, Issue 2) | DOI | PubMed: 41478797

First update in a decade. Introduces a new diagnostic category — MH Genotype (MHG) — for patients with a pathogenic/likely pathogenic RYR1 or CACNA1S variant who have not undergone IVCT. These patients must avoid all MH-triggering agents. Also provides the first consensus definition of a clinical MH event and revised diagnostic pathways that prioritise full genetic panel testing before IVCT.

Why it matters: With cancer genomics and cardiomyopathy workups increasingly identifying incidental RYR1/CACNA1S variants, more patients will be flagged as MHG. Expect an expanding pool of "MH-susceptible" patients — ensure your TIVA competence is current and your department has a trigger-free anaesthesia protocol.

📢 Tell your department: "The new EMHG guidelines create a new MHG diagnostic category — any patient with an incidental pathogenic RYR1 variant now counts as MH-susceptible. Check your MH trolley and review your trigger-free protocol."

International Consensus: Perioperative Fasting in Adults (2026) CONSENSUS CHANGE PRACTICE

Final FRCA

Anaesthesia, 9 Feb 2026 | DOI: 10.1111/anae.70130

International Delphi consensus reaffirms ≥6 h solids, ≥8 h fatty meals, ≥6 h non-clear liquids. The headline: institutions should implement "Sip Til Send" protocols allowing liberal clear fluid intake up to <2 hours before anaesthesia. Clear liquids include water, tea/coffee (≤1/5 milk), clear juices, and carbohydrate drinks. Gastric ultrasound endorsed where clinically indicated. GLP-1 agonist patients require case-by-case assessment.

Why it matters: UK patients fast >9 hours for liquids on average. This consensus provides the mandate to implement institutional "Sip Til Send" protocols — reducing dehydration, hypoglycaemia, and patient discomfort. Use this to advocate for change in your trust.

📢 Tell your department: "The 2026 fasting consensus recommends 'Sip Til Send' as standard — we should update our patient information leaflets and preop fasting protocols."

GPICS V3 — Guidelines for the Provision of Intensive Care Services (3rd Edition)

GUIDELINE Final FRCA

FICM / ICS, 28 Jan 2026 | ICS | FICM | Full PDF

The definitive standard-setting document for UK adult intensive care has been completely restructured. Standards now explicitly labelled "minimum standards" (must-do, non-compliance triggers risk register entry) vs "should-do" recommendations aligned with CQC language. New chapters on sustainability, EDI, ICU ultrasound, airway management in ICU, and enhanced care (Level 1). Patient representatives embedded in the editorial board for the first time.

Why it matters: GPICS V3 is the CQC and Healthcare Improvement Scotland benchmark for rating ICU services. As a senior trainee rotating through ICU, you need to know these standards for governance meetings, business cases, and ARCP. Failure to meet minimum standards now requires formal risk register reporting.

NICE NG24 Blood Transfusion — TXA in Surgery Update GUIDELINE

NICE, 26 Feb 2026 | NICE NG24

NICE reviewed the evidence for tranexamic acid in surgery and added new recommendations to NG24 on TXA use intraoperatively to reduce blood loss and transfusion requirements. Applies to adults, young people, and children ≥1 year. Highlighted by CPOC as clinically significant.

Why it matters: Updated NICE recommendations directly affect consent, patient blood management protocols, and preoperative anaemia pathways. Essential for both clinical practice and FRCA examinations.

ESAIC/ESPA: Neuromuscular Block in Anaesthetised Children GUIDELINE Final FRCA

EJA, 4 Mar 2026 (43:4, pp 295–323) | ESAIC | PubMed

First dedicated European guidelines on NMB management in children. Strong recommendations: quantitative neuromuscular monitoring whenever an NMBA is used; sugammadex preferred over neostigmine for reversal of aminosteroid NMBAs. Unexpectedly favours EMG-based monitoring over acceleromyography in children, citing small hand size limitations.

Why it matters: UK paediatric NMB management has been extrapolated from adult guidelines until now. The sugammadex-over-neostigmine recommendation will prompt formulary reviews in many units. Directly examinable at Final FRCA paediatric anaesthesia stations.

Association of Anaesthetists: Perioperative Blood Pressure Measurement & Management (Updated) GUIDELINE

Anaesthesia, 14 Jan 2026 | AAGBI | PubMed

Updated BP thresholds for planned surgery. Referrals accepted with clinic BP <160/100 or ambulatory/home BP <155/95 mmHg. Patients without prior documentation may proceed if clinic BP <180/120 or ambulatory BP <175/115 mmHg. Covers the full perioperative period through 30 days post-surgery.

Why it matters: Hypertension is among the most common reasons for day-of-surgery cancellations. The shift from absolute thresholds to a more nuanced ambulatory-based approach will change practice at many centres and reduce unnecessary cancellations.

MHRA: Cook Blue Rhino G2 Percutaneous Tracheostomy Kit — Field Safety Notice SAFETY

ALERT

MHRA, 5 Mar 2026 | MHRA FSN listing

SAFETY ALERT: Field Safety Notice issued for the Cook Blue Rhino G2-Multi PCT kit — the most widely used percutaneous tracheostomy kit in UK ICUs — along with related products (Approach CTO wire, Staged Extubation Set, Wayne Pneumothorax Set, Spectrum CVC Set). Check affected lot numbers with Cook Medical and quarantine affected stock. May affect scheduled PCT procedures.

MHRA: Armstrong Medical Anaesthetic Circuit / NIV Circuit — Product Recall SAFETY ALERT

MHRA / NHS Supply Chain, Feb 2026 | NHS Supply Chain

SAFETY ALERT: Full product recall (escalated from FSN) for specific lots of Armstrong Medical anaesthetic circuits, AquaVENT CPAP systems, and NIV circuits. Manufacturing defect causes holes/tears at the purple cuff connector — risk of interrupted ventilation and hypoxia. Eight reports of connector tears. Identify affected lot numbers (FSN CF-1573 v4), quarantine, cease use, and return to manufacturer.

📢 Tell your department: "Check all anaesthetic rooms, ICUs, and airway trolleys for affected Armstrong Medical circuit lot numbers and Cook Blue Rhino kits. Quarantine any affected stock immediately."

KEY JOURNAL ARTICLES & TRIALS

NEJM RSI Trial: Ketamine vs Etomidate for Emergency Intubation RCT Final FRCA

NEJM, Dec 2025 (n=2,365) | DOI | TBL summary

Largest-ever RCT of induction agents for RSI in critically ill adults. No mortality difference (28.1% ketamine vs 29.1% etomidate). However, cardiovascular collapse was significantly more common with ketamine: 22.1% vs 17.0% (NNH=20), with the excess risk substantially higher in sepsis (NNH=10). Etomidate's putative adrenal suppression harm was not demonstrated.

Why it matters: Challenges the widespread belief that ketamine is haemodynamically superior in critically ill patients. For UK anaesthetists performing RSI on ICU or in the ED: both agents are acceptable, but ketamine's cardiovascular collapse risk must be anticipated. Always have vasopressors drawn up before induction in critically ill patients, regardless of agent.

Anaesthetic angle: This trial used full standard doses (1.5 mg/kg ketamine, 0.3 mg/kg etomidate) in an ED/ICU population. UK practice often uses lower ketamine doses in shocked patients. The key learning is that ketamine does not confer haemodynamic protection — careful dose titration and vasopressor readiness matter more than agent choice.

DESIGNATION Trial: Driving Pressure-Guided PEEP in Open Abdominal Surgery RCT Final

FRCA

JAMA, Feb 2026 (n=1,435, 29 sites, 5 countries) | DOI | PubMed: 41334859

Patients at increased risk for postoperative pulmonary complications undergoing open abdominal surgery: driving pressure-guided individualised high PEEP + recruitment manoeuvres vs standard low PEEP. No reduction in pulmonary complications (19.8% vs 17.4%, P=.23). High PEEP caused significantly more intraoperative hypotension (54% vs 45%) and vasopressor use (32% vs 19%).

Why it matters: The "open lung" approach with aggressive high PEEP and recruitment does not reduce PPCs and causes more hypotension. Standard protective ventilation with lower PEEP remains appropriate. Important for trainees who have been taught to use driving pressure-guided strategies as default.

ANDROMEDA-SHOCK-2: CRT-Guided Personalised Resuscitation in Septic Shock RCT

JAMA, Dec 2025 (n=1,467, 86 centres, 19 countries) | DOI | PubMed: 41159835 | TBL summary

CRT-guided personalised haemodynamic resuscitation (CRT-PHR) vs usual care in early septic shock. Primary hierarchical composite: superior for CRT-PHR (win ratio 1.16, P=.04), driven by shorter vital support duration — not by mortality (26.5% both arms). CRT-PHR group received 251 mL less fluid at 6 hours. CRT normalised at 6h in 86% (CRT-PHR) vs 62% (usual care).

Why it matters: Strengthens the case for CRT as a bedside resuscitation target. The tiered CRT-PHR protocol (pulse pressure → fluid responsiveness → echo → MAP test → dobutamine) is practical, teachable, and achieves better outcomes with less fluid. A paradigm shift from volume-first sepsis resuscitation.

PROSPECT Thoracotomy 2025: TEA and PVB Now Co-First-Line SR/MA Final FRCA

Anaesthesia, Apr 2026 (100 studies) | DOI | PubMed: 41521792

Updated PROSPECT consensus for open thoracotomy pain management. Key change: paravertebral block (PVB) is now equivalent first-line alongside thoracic epidural (TEA) — previous guidelines favoured TEA alone. Second-line: erector spinae plane, rhomboid intercostal, or intercostal nerve block. ESP is NOT elevated to first-line despite clinical enthusiasm. All patients should receive paracetamol + NSAIDs.

Why it matters: PVB as first-line offers flexibility for centres with high anticoagulation rates or limited epidural expertise. ESP block remains second-line — temper enthusiasm with evidence. Multimodal analgesia is mandatory, not optional.

Aortic Stenosis & Noncardiac Surgery: Risk Quantified SR/MA Final FRCA

Anaesthesia, Apr 2026 (19 studies, 100,486 patients) | DOI | PubMed: 41388337

All-cause mortality: 3.8% for any degree AS, 9.6% for severe AS undergoing noncardiac surgery. Relative risk of mortality 1.58 vs non-AS patients. Elevated risk of postoperative MI (RR 1.79) and heart failure (RR 2.06). Approximately 3-fold relative increase in mortality risk with AS.

Why it matters: Quantifies the risk with large numbers. For preoperative planning: consider cardiology review for severe AS; discuss TAVI/valvuloplasty before elective high-risk surgery. Intraoperatively: meticulous haemodynamic management, invasive monitoring, and post-op critical care planning are essential.

TOP Trial: Liberal vs Restrictive Transfusion in High-Cardiac-Risk Surgery RCT

JAMA, Dec 2025 (n=1,424, 16 VA medical centres) | DOI

High-cardiac-risk patients with postoperative anaemia (Hb <10 g/dL): liberal (trigger <10) vs restrictive (trigger <7) transfusion. No significant difference in 90-day composite of death, MI, revascularisation, AKI, or stroke (9.1% vs 10.1%; RR 0.90). Secondary signal: fewer non-MI cardiac events with liberal strategy (5.9% vs 9.9%) — needs further investigation.

Why it matters: Restrictive transfusion (Hb <7 g/dL) appears safe even in high-cardiac-risk surgical patients. Supports current NICE/AAGBI recommendations. For individual patients with active ischaemia, a higher trigger may still be appropriate — but routine liberal transfusion is not justified.

PCT/CRP-Guided Antibiotic Discontinuation in ICU Sepsis SR/MA

Anaesthesia, Apr 2026 (21 studies, 6,382 patients) | DOI | PubMed: 41505903

PCT-guided protocols reduced antibiotic therapy by 2.0 days (moderate certainty evidence) with no increased mortality (RR 0.95). CRP-guided protocols had very low to low certainty evidence — insufficient to support CRP-guided antibiotic discontinuation.

Why it matters: PCT-guided antibiotic de-escalation in ICU sepsis is safe and effective — supports antimicrobial stewardship. CRP alone should not drive antibiotic discontinuation in critical illness. Where serial PCT is available, use declining PCT to guide de-escalation at 5–7 days rather than completing fixed courses.

POPPY Studies: Pain Burden in UK Day-Case Surgery OBSERVATIONAL

Anaesthesia, Apr 2026 (7,839 patients, 199 UK sites) | Part 1: DOI | Part 2: DOI

Striking baseline data: 39% of day-case patients had existing pain at the surgical site, 30.5% with chronic pain, and 1 in 9 used opioids daily preoperatively. Unplanned admission rate was 11.8% — exceeding NHS targets. Part 2 identifies pre-existing chronic pain and day-1 postoperative pain as key predictors of chronic post-surgical pain at 97 days.

Why it matters: Day-case surgery carries a far greater burden of chronic pain and opioid use than commonly appreciated. Routine preoperative opioid review and multimodal analgesic planning should be standard. Acute pain at 24 hours is a modifiable predictor of CPSP — target it aggressively.

DPE vs Standard Epidural for Labour Analgesia — Meta-analysis SR/MA

BJA, 2025 (18 RCTs, 2,144 parturients) | PROSPERO: CRD42024602115

Dural puncture epidural (DPE) had 3.4 minutes faster onset, fewer unilateral blocks (OR 2.02), reduced motor block (OR 1.95), and better sacral coverage (NNT≈6) compared to standard epidural. No difference in Caesarean/instrumental delivery or PDPH rates. High heterogeneity in multiple outcomes.

Why it matters: DPE offers faster onset and more reliable bilateral sacral coverage. DPE does NOT inject intrathecal medication (distinct from CSE). The reduced troubleshooting from fewer unilateral blocks may offset the modest extra cost of a spinal needle. Relevant for trainees developing obstetric anaesthesia unit protocols.

FOAMED & CRITICAL APPRAISAL HIGHLIGHTS

EMCrit 420: Dynamic LVOTO — The Diagnosis You're Missing on ICU REVIEW Final FRCA

EMCrit, 8 Mar 2026 | emcrit.org/emcrit/dlvoto

Comprehensive educational review of dynamic LVOT obstruction. Incidence up to 22% in septic ICU patients. Triggered by hypovolaemia, low afterload, and increased contractility. POCUS diagnostic criteria: "late-peaking dagger" Doppler waveform, SAM on 2D echo, posterior MR. Management: increase preload (fluids), increase afterload (phenylephrine/vasopressin), decrease contractility (stop inotropes → esmolol), HR control 55–70 bpm.

Why it matters: dLVOTO is underdiagnosed, often mistaken for cardiogenic shock — leading to harmful inotrope escalation. The POCUS framework is immediately applicable. Critical distinction: RV-driven dLVOTO (massive PE, post-cardiotomy) requires fundamentally different management targeting RV afterload. Essential knowledge for cardiac anaesthetists and ICU trainees.

⚖️ Paired Controversy: 2026 PE Guidelines

AHA/ACC 2026 PE Guidelines: New A–E Risk Classification GUIDELINE

AHA/ACC/ACEP, Feb 2026 | DOI | St Emlyn's review

New A–E clinical categories replace "massive/submassive" terminology. Categories A–B may be managed outpatient. Categories C–E require hospitalisation with escalating care. CTPA remains first-line. DOACs preferred over VKAs. Formal PERT team recommendation. Supports proactive escalation to advanced therapies before overt haemodynamic collapse.

PulmCrit: Four Fatal Flaws in the AHA/ACC PE System EXPERT OPINION

EMCrit/PulmCrit, 7 Mar 2026 | emcrit.org/pulmcrit/peguidelines

Josh Farkas identifies four fundamental errors: (1) failure to delineate low-risk PE — Bova score's "low-risk" group has 18% deterioration rate; (2) treating troponin and BNP as equivalent; (3) equating transient hypotension with incipient cardiopulmonary failure; (4) nonsensical "normotensive shock" defined as MAP <60 mmHg. Recommends continuing with ESC 2019 PE algorithms.

Bottom line for anaesthetists: Read both. The new A–E system simplifies risk communication but has significant methodological issues. For ICU PE management and PERT discussions, the ESC 2019 framework may remain more robust. The endorsement of pre-collapse escalation in Category D/E is relevant to anaesthetists managing haemodynamically unstable PE.

St Emlyn's TBS 2026: Key Prehospital & ICU Papers REVIEW

St Emlyn's, Feb 2026 | PHEM papers | ICU papers

Curated reviews from TBS 2026 conference. PHEM highlights: Post-intubation hypotension in severe TBI (19% incidence, AOR 13.55 for mortality in isolated TBI); TRAUMOX2 (restrictive vs liberal O₂ in trauma — no difference). ICM highlights: CLIP-II (cryopreserved platelets in cardiac surgery — more bleeding, advise caution); NfL as superior post-arrest prognostication biomarker (AUROC 0.93); early BP augmentation in spinal cord injury — more harm, no benefit.

Why it matters: The post-intubation hypotension data are immediately actionable — meticulous BP management during RSI in TBI is not optional. The CLIP-II data caution against adopting cryopreserved platelets in cardiac surgery. Both paper sets are highly relevant for PHEM- and ICU-track trainees.

QUICK HITS / ALSO NOTABLE

ACTION POINTS / THIS WEEK

  1. Update your airway trolley posters — DAS 2025 guidelines are published. Print the new algorithms from das.uk.com and brief your ODPs.
  2. Check your stock — Verify Cook Blue Rhino PCT kits and Armstrong Medical circuits in all anaesthetic rooms, ICUs, and airway trolleys against recalled lot numbers. Quarantine any affected stock.
  3. Review your MH protocol — The new EMHG MHG diagnostic category means more patients will be flagged. Ensure your trigger-free anaesthesia pathway is current and your dantrolene supply adequate.
  4. Advocate for "Sip Til Send" — Raise the 2026 fasting consensus at your next clinical governance meeting. Draft an updated patient fasting leaflet for your trust.
  5. Rethink ketamine in the critically ill — After the NEJM RSI Trial, ensure vasopressors are drawn up before ANY RSI in shocked patients, regardless of induction agent.
  6. Don't chase high PEEP — DESIGNATION confirms that driving pressure-guided high PEEP does not reduce PPCs but causes more hypotension. Standard protective ventilation with lower PEEP remains appropriate.
  7. Use CRT in septic shock — ANDROMEDA-SHOCK-2 supports CRT-guided resuscitation. Start using CRT as a bedside assessment tool and familiarise yourself with the CRT-PHR protocol.
  8. Read GPICS V3 — Download the full PDF and know the minimum standards. You'll need this for governance meetings, business cases, and your ARCP.

Sources Checked UK Guidelines & Safety: DAS, FICM, ICS, RCoA, AAGBI, CPOC, OAA, NICE, MHRA, SALG, RA-UK, NAP, NIAA International Guidelines: ESAIC, ESPA, SCCM, SSC, ELSO, ERC, ILCOR, ASA, ERAS Society, WFSA Journals: BJA, Anaesthesia, NEJM, JAMA, Lancet, Lancet Resp Med, CCM, Anesthesiology, EJA, RAPM, JCVA, Resuscitation, A&A, IJOA FOAMed: The Bottom Line, EMCrit/PulmCrit, St Emlyn's, LITFL, DFTB, BJA Education, ICU OnePager, DAS Blog, ESRA Academy No new items in target window: DAS OAA 2015, DAS ATI 2019, DAS Critical Care 2017, RA-UK, NAP, NIAA (website under reconstruction), NICE NG180/NG51/NG89/CG103, ICU OnePager (last update Oct 2025), JournalFeed (EM-focused; minimal anaesthesia coverage)

Next briefing: Tuesday, 17 March 2026

This newsletter is for educational purposes and does not constitute clinical advice. Trainees should verify guideline currency and applicability before clinical application. All URLs verified at time of compilation (12 March 2026).

Jake Turner

Curated with the assistance of AI (Perplexity). All content editorially reviewed.

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