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Anaesthetics & ICU Evidence Rundown

Anaesthetics & ICU Evidence Rundown ·

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MONTHLY | ISSUE 3

Anaesthetics & ICU Evidence Rundown

April 2026 | Curated for UK Anaesthetics ST6–7 trainees

Issue 3 arrives with a life-saving safety alert you cannot afford to miss: patients with Venezuelan maternal ancestry may be at catastrophic risk from volatile anaesthetics — add this to your pre-assessment screen today. Alongside that, the largest-ever sepsis guideline update redraws vasopressor targets for older patients, the breastfeeding “sleep and keep” message changes your consent conversation, and biomarker-guided AKI prevention after major surgery finally has an RCT to back it up.

Key to badges

RCT SR/MA GUIDELINE CONSENSUS OBSERVATIONAL EXPERT OPINION

SAFETY ALERT REVIEW CHANGE PRACTICE Final FRCA

Contents

  1. UK Guidelines & Official Updates — 6 items
  2. Key Trials & Journal Articles — 7 items
  3. International Guidelines — 8 items
  4. FOAMed & Critical Appraisal — 3 items
  5. Quick Hits / Also Notable
  6. Action Points This Month

1. UK Guidelines & Official Updates

1.1 Association of Anaesthetists: Anaesthesia & Breastfeeding — “Sleep and Keep” GUIDELINE

CHANGE PRACTICE Final FRCA

Association of Anaesthetists / Anaesthesia | January 2026 | Endorsed: RCoA, BADS, OAA

The “pump and dump” era is over. The Association of Anaesthetists has published a formal guideline — endorsed by the RCoA and BADS — replacing the advice to discard breastmilk post-anaesthesia with “sleep and keep.” The guideline is based on the low lipid-solubility and short half-lives of most anaesthetic agents (propofol, sevoflurane, fentanyl), which transfer in very small quantities into breastmilk. Key recommendations: (1) Ask all patients with a child under 2 years about breastfeeding status at pre-assessment. (2) Encourage breastfeeding or expressing before surgery and resume as soon as the mother is alert enough to feed safely after recovery. (3) Use opioid-sparing multimodal analgesia — codeine is NOT recommended in breastfeeding mothers due to CYP2D6 ultra-metaboliser risk (potential neonatal respiratory depression). (4) No need to discard breastmilk after routine general anaesthesia.

Safety note: Codeine remains contraindicated in breastfeeding — ultra-rapid metabolisers convert codeine to morphine at dangerous concentrations in milk. Tramadol: use with caution. NSAIDs (ibuprofen, diclofenac): considered compatible for short-term use.

Why it matters: This is a direct, immediately actionable change to pre-assessment practice and patient consent. Any trainee giving a general anaesthetic to a breastfeeding woman must be aware of this guidance. FRCA candidates should expect questions on drug transfer in breastmilk.

Tell your department: Update your pre-assessment proforma to include breastfeeding status for all women with children under 2. Remove any legacy “pump and dump” advice from patient information leaflets. Avoid codeine in post-operative analgesia for breastfeeding mothers.

Source: Association of Anaesthetists / Anaesthesia 2026 — anaesthesia-journal.co.uk

1.2 National Patient Safety Alert: Epidural Infusion Bag & Diamorphine Shortage SAFETY ALERT

CHANGE PRACTICE Final FRCA

NHS England / MHRA | Ongoing — Dec 2025 through Q1 2026

A national supply disruption is affecting pre-mixed bupivacaine epidural infusion bags (including standard bupivacaine 0.1% + fentanyl 2 mcg/mL combinations). Trusts have been required to form working groups and activate contingency protocols. Key consequences: alternative concentrations or locally prepared solutions may increase motor block rates, affecting ambulatory epidural programmes and increasing instrumental delivery rates in obstetric patients. Concurrent with this, a national diamorphine shortage is affecting spinal anaesthesia for caesarean section — intrathecal fentanyl/morphine combinations are being used as alternatives. PIEB (programmed intermittent epidural bolus) regimes may need adjustment to match locally available concentrations.

Safety note: If switching from standard bag concentrations, formally re-prescribe and re-check rate calculations. Do not assume equivalent volumes are equivalent doses when concentrations change.

Tell your department: Know your trust’s current contingency protocol. For spinal CSs, know your preferred intrathecal morphine/fentanyl substitute doses. Document concentration used on drug charts explicitly.

Source: NHS England National Patient Safety Alert / NHS Supply Chain — ongoing

1.3 MHRA: GLP-1 Agonists & Acute Pancreatitis — Strengthened Perioperative Warning SAFETY ALERT

Final FRCA

MHRA | February 2026 | Relevant to perioperative GLP-1 management

The MHRA has strengthened warnings for severe, necrotising, and fatal pancreatitis associated with GLP-1 receptor agonists (semaglutide, liraglutide, dulaglutide, exenatide, tirzepatide). From an anaesthetic perspective, this reinforces the CPOC guidance on GLP-1 management: gastroparesis and delayed gastric emptying remain the primary airway risk. GLP-1 agonists slow gastric motility even after a single dose; this effect persists for days after last dose. The pancreatitis signal means that unexplained abdominal pain in a GLP-1 user presenting for surgery should prompt consideration of acute pancreatitis before proceeding.

Counterpoint: While CPOC recommends omitting GLP-1 agonists before elective surgery, evidence for the specific RSI/aspiration risk is largely observational. Decisions should be individualised. A rapid-sequence induction should be considered for patients who have not omitted their GLP-1 dose or who have symptoms of gastroparesis.

Source: MHRA Safety Roundup — March 2026

1.4 CPOC Recommendations for the NHS 10-Year Health Plan [carry-over]

CONSENSUS

Centre for Perioperative Care (CPOC) / RCoA | 11 March 2026

CPOC has submitted formal recommendations to the NHS England 10-Year Health Plan, focusing on perioperative pathways as a lever for elective recovery. Key asks: universal shared decision-making before elective surgery; expansion of prehabilitation services (exercise, nutrition, smoking cessation) across all pathways; integration of perioperative medicine into surgical hubs; and NHS-wide adoption of a Patient Charter to improve surgical journeys. The CPOC Patient Charter was simultaneously published, setting minimum standards for surgical preparation and recovery communication. For trainees: CPOC visibility in this space directly influences how perioperative medicine will be funded and structured within the NHS.

Why it matters: Higher trainees increasingly take consultant roles in perioperative medicine clinics. Understanding CPOC’s advocacy framework places your clinical practice within the NHS strategic agenda.

Source: cpoc.org.uk — 11 March 2026

1.5 OAA/PRSB Obstetric Anaesthetic Data Standard [carry-over]

CONSENSUS Final FRCA

OAA / Professional Record Standards Body (PRSB) / RCoA | Early 2026

The Obstetric Anaesthetists’ Association (OAA) in partnership with the Professional Record Standards Body (PRSB) has published a national obstetric anaesthetic information standard — defining the minimum data set that must be recorded when providing anaesthetic care in an obstetric setting. This will drive standardisation of documentation across NHS maternity units and forms the basis of future clinical audit. For trainees, this means a clearer expectation of what must be documented (including pre-assessment findings, consent discussion, block level assessment, and post-delivery handover) when providing obstetric anaesthetic care.

Source: OAA / PRSB — theprsb.org

1.6 REPACC: Enhanced Care Services in the UK — Bridging Anaesthetic Practice to L2 Care [carry-over] REVIEW

REPACC Collaborative / Anaesthesia | April 2026

A REPACC (Responsiveness in Enhanced Perioperative Anaesthetic and Critical Care) collaborative paper published in Anaesthesia (April 2026 issue) maps the current provision of Enhanced Care (EC) services across the UK — the intermediate “level 2” care between standard recovery and ICU admission. The paper identifies significant heterogeneity in EC provision, staffing ratios, and monitoring standards across NHS trusts. As anaesthetists increasingly take responsibility for EC beds (post-cardiac surgery stepdown, high-dependency post-operative patients), this paper defines the minimum expected competencies and the evidence base for EC over direct ICU admission.

Why it matters: With GPICS V3 (covered in Issue 1) now setting minimum ICU provision standards, EC services are the next focus. Trainees should understand level 1/2/3 distinctions for FRCA purposes and for post-operative care discussions.

Source: REPACC Collaborative — Anaesthesia (April 2026 issue)

2. Key Trials & Journal Articles

2.1 BigPAK-2 Trial: Biomarker-Guided KDIGO Care Reduces Post-Surgical AKI RCT

CHANGE PRACTICE Final FRCA

Zarbock et al. | The Lancet 2025 | Critically appraised: The Bottom Line (28 March 2026)

In a multicentre RCT, patients undergoing major surgery who were found to have elevated urinary biomarkers (TIMP-2 × IGFBP7 >0.3 [ngmL]²/1000) were randomised to a KDIGO-based preventive care bundle or standard care. The intervention arm received: avoidance of nephrotoxic drugs, haemodynamic optimisation protocol, fluid management, and withholding of contrast agents. Result: moderate/severe AKI occurred in 14.4% of the intervention group vs 22.3% of controls (OR 0.57; 95% CI 0.42–0.78; p=0.0002). No significant difference in 90-day mortality or the composite MAKE-90 endpoint. This is the best evidence yet that biomarker-guided, structured perioperative care can reduce AKI incidence after major surgery.

Why it matters: AKI after major surgery is common (up to 20–30% for high-risk patients) and associated with prolonged ICU stay and long-term CKD. Anaesthetists control most of the intraoperative intervention bundle components: fluid therapy, vasopressor choice, nephrotoxin avoidance. A point-of-care biomarker test to stratify risk is clinically feasible.

Caution: No mortality benefit at 90 days — the hard endpoint remains neutral. The KDIGO bundle is already standard good practice; how much of the benefit is specifically biomarker-guided versus simply applying best care is unclear. TIMP-2 × IGFBP7 testing (NephroCheck) is not universally available in UK hospitals.

Tell your department: For major surgery (cardiac, aortic, hepatic, major abdominal), identify patients at AKI risk preoperatively. Apply KDIGO preventive care principles intraoperatively: avoid NSAIDs/contrast, maintain MAP ≥65, targeted fluid therapy. Ask your trust pharmacy whether TIMP-2/IGFBP7 testing is available.

Source: The Bottom Line — BigPAK-2 summary

2.2 Personalised PEEP Optimisation in Obesity: Physiology-Based Framework REVIEW

Final FRCA

BJA | March 2026

A BJA narrative review proposes a physiology-based framework for individualising PEEP in obese surgical patients — moving beyond the one-size-fits-all approach. Key points: standard PEEP of 5–8 cmH2O is insufficient in most obese patients due to elevated chest wall compliance and increased intra-abdominal pressure. The framework advocates: PEEP >12 cmH2O as a starting point in patients with BMI >35; EIT (electrical impedance tomography)-guided PEEP titration where available (average optimal PEEP 18.5 cmH2O in EIT-guided studies); recruitment manoeuvres followed by decremental PEEP trials to identify the closing pressure; and driving pressure monitoring to avoid ventilator-induced lung injury at higher PEEP levels.

Why it matters: With the UK’s rising obesity prevalence, high-BMI patients are increasingly common on elective and emergency lists. Atelectasis, V/Q mismatch, and post-operative pulmonary complications are substantially increased. Personalised PEEP is a modifiable intraoperative variable with direct outcome implications — and it is examinable at Final FRCA.

Caution: High PEEP increases right heart afterload. In patients with known or suspected right ventricular dysfunction, standard recruitment manoeuvres may be harmful. Always assess haemodynamic response to any PEEP change.

Source: British Journal of Anaesthesia — March 2026 issue

2.3 Video Stylet vs Videolaryngoscopy in High Arne Score Patients — RCT RCT

Final FRCA

Leo et al. | BMC Anaesthesiology | March 2026

An RCT by Leo et al. compared the Provu video stylet (used under direct laryngoscopy) against standard videolaryngoscopy for tracheal intubation in patients with a high Arne risk score (predicted difficult airway). First-pass success rate, intubation time, and ease of use were assessed. The video stylet approach — combining the optical advantages of video with the tactile feedback of a malleable stylet — offers a complementary technique to videolaryngoscopy, particularly where direct laryngoscopy affords a grade 1–2 view but tube delivery remains difficult. This study provides level 1 evidence for a technique that is increasingly available in UK departments.

Why it matters: Since the DAS 2025 difficult airway guideline update (Issue 1), the focus has shifted toward technique selection and first-pass success optimisation.

Understanding the full range of available videolaryngoscopy and video stylet devices is directly assessed in Final FRCA SOE (structured oral examination).

Source: BMC Anaesthesiology — March 2026

2.4 Liposomal Bupivacaine: Why Are Results So Inconsistent? REVIEW

Final FRCA

Orebaugh et al. | Regional Anesthesia & Pain Medicine (RAPM) | 2026;51(3):349–356

Liposomal bupivacaine (EXPAREL) was marketed as offering extended analgesia for up to 72 hours through slow lipid-vesicle drug release. Orebaugh et al. systematically examine why clinical RCT results are strikingly inconsistent. Key factors identified: compounding with plain bupivacaine neutralises the liposomal encapsulation mechanism (accelerates release); surgical approach (fascial plane infiltration vs joint injection) dramatically changes pharmacokinetics; use alongside US-guided nerve blocks may dilute the advantage as standard LRLA already provides long-duration analgesia; and patient selection (BMI, CYP enzyme activity). The paper is a rigorous critical appraisal of a product with significant commercial interest behind it.

Counterpoint: Liposomal bupivacaine is not routinely available in most NHS trusts and is considerably more expensive than standard long-acting LAs. The evidence for meaningful clinical advantage in the context of high-quality nerve block practice is weak. This paper supports a cautious NHS formulary position.

Source: RAPM 2026;51(3):349–356 — rapm.bmj.com

2.5 Epinephrine in Prehospital Traumatic Cardiac Arrest — Not Beneficial

OBSERVATIONAL Final FRCA

Witt et al. | Prehospital Emergency Care 2026;30:153–161 | PubMed 39889233

Witt et al. report from a large prehospital trauma database that epinephrine administration in traumatic cardiac arrest (TCA) was not associated with improved survival and may worsen outcomes. This challenges the extrapolation of medical cardiac arrest epinephrine protocols to TCA. The pathophysiology differs fundamentally: TCA is predominantly caused by haemorrhage, tension pneumothorax, and cardiac tamponade — conditions where epinephrine-mediated vasoconstriction without addressing the underlying cause may be counterproductive. For anaesthetists providing emergency anaesthesia for trauma: prioritise surgical haemorrhage control, bilateral needle/finger thoracostomies, and pericardiocentesis — not epinephrine as a first-line intervention in TCA.

Why it matters: Anaesthetic trainees at major trauma centres or with FICM/FPHC interests should understand the divergence between medical and traumatic arrest management. ERC 2025 already recommends prioritising reversible causes over drug therapy in TCA.

Source: Prehospital Emergency Care 2026;30:153–161 — PubMed 39889233

2.6 JCVA Year in Review: CT Anaesthesia 2025 [carry-over] REVIEW Final

FRCA

Journal of Cardiothoracic and Vascular Anesthesia | 2026;40(2) (Published February 2026)

The JCVA annual review of cardiothoracic anaesthesia for 2025 provides a structured summary of the year’s most influential trials and guidelines affecting cardiac anaesthesia practice. Key themes: advances in monitoring-guided anaesthetic depth in cardiac surgery; expanding role of regional anaesthesia (including pectoral nerve blocks, PECS II, and ESP blocks) in cardiac enhanced recovery; perioperative atrial fibrillation management; and post-TAVI anaesthetic considerations. For Final FRCA candidates with a cardiac anaesthesia interest, this is a single-source update for the year’s literature.

Source: Journal of Cardiothoracic and Vascular Anesthesia 2026;40(2) — jcvaonline.com

2.7 CPOC GLP-1 Receptor Agonist Perioperative Implementation

Guidance [carry-over] CONSENSUS

CHANGE PRACTICE

Final FRCA

CPOC | 2026

CPOC has published implementation guidance to help trusts operationalise GLP-1 agonist perioperative management into pre-assessment workflows. The key clinical question — how to manage these drugs before elective surgery — is addressed with a tiered approach based on indication and drug frequency: Daily GLP-1 agonists (liraglutide): omit on the day of surgery. Weekly GLP-1 agonists (semaglutide, dulaglutide, tirzepatide): consider omitting 1 week before surgery for elective procedures. If omission not possible or in emergency: treat as potentially full stomach — implement RSI or video-laryngoscopy-assisted intubation with appropriate aspiration precautions. Point-of-care gastric ultrasound (antral volume assessment) can be helpful in determining gastric content when history is uncertain.

Tell your department: Ensure GLP-1 status is captured in pre-assessment (many patients do not volunteer this). Update pre-operative fasting and pre-medication instructions. Consider making RSI default for patients who have not omitted their GLP-1 agonist.

Source: CPOC — cpoc.org.uk

3. International Guidelines (Practice-Changing for UK)

⚠ URGENT SAFETY ALERT

3.1 ESAIC/ESPA/ERN Joint Statement: Venezuelan Maternal Ancestry & Volatile Anaesthetic Risk SAFETY ALERT

CHANGE PRACTICE

Final FRCA

ESAIC / ESPA / ERN EURO-NMD / European Mitochondrial Society (E-MIT) | 26 March 2026 | esaic.org

Emerging case reports describe severe neurological complications — including basal ganglia infarction and death — following routine general anaesthesia with volatile agents (primarily sevoflurane) in otherwise healthy individuals with Venezuelan maternal ancestry. The implicated variant is a mitochondrial DNA mutation: mtND4 m.11232T>C, which impairs mitochondrial respiratory complex I, causing catastrophic cellular energy failure particularly in metabolically active neural tissue. Crucially, affected individuals appear clinically normal pre-operatively.

Immediate recommendations:

Tell your department: Add a Venezuelan maternal ancestry question to your pre-assessment template now. This costs nothing and could prevent a death. Brief your entire anaesthetic department — this is not restricted to specialist practice.

3.2 ESAIC/ESRA: Regional Anaesthesia in Patients on Antithrombotic Drugs — Updated Guideline GUIDELINE

CHANGE PRACTICE Final FRCA

ESAIC / ESRA | 9 March 2026 | 40 statements; Delphi consensus | esaic.org

This comprehensive joint guideline provides the definitive European framework for performing neuraxial and peripheral nerve blocks in anticoagulated patients. Key updates for UK practice:

Why it matters: This is the most common risk-assessment challenge faced by UK anaesthetics trainees performing regional anaesthesia. Plasma-level testing offers an alternative for patients with renal impairment where standard time intervals may underestimate drug levels. Knowing that ultrasound does not change the drug-free requirement avoids potentially harmful premature block placement.

Tell your department: Print and laminate the ESAIC/ESRA DOAC time-interval table for your regional anaesthesia trolley. For obstetric emergencies where the DOAC history is uncertain, consider anti-Xa or DOAC plasma level testing before proceeding with neuraxial block.

Source: ESAIC/ESRA Guideline — esaic.org | GRADE C; 40 statements; strong consensus >90% in 57.5% of statements

3.3 ASA 2026 Practice Guideline: Fascial Plane Blocks — Now Standard

of Care [carry-over] GUIDELINE

CHANGE PRACTICE

Final FRCA

ASA Task Force on Perioperative Pain Management | Anesthesiology 2026;144(1):19–43 | Jan 2026 | 628 RCTs reviewed | DOI: 10.1097/ALN.0000000000005790

The largest single-source systematic review of regional anaesthesia evidence to date formally elevates fascial plane blocks from “adjuncts to consider” to a strong recommendation for specific surgical procedures. UK trainees should know the hierarchy of evidence:

Why it matters: This transitions fascial plane blocks from optional to expected in NHS practice. Alongside ERAS Colorectal 2025 (item 3.8), this creates a convergent evidence base that will drive departmental protocol updates. ST6–7 trainees should be able to independently perform ESP, TAP, QL, and serratus blocks.

Tell your department: Use this guideline to drive protocol updates in your thoracic, laparoscopic, and breast surgical lists. Consider whether your department has a competency-sign-off framework for the blocks specifically recommended — if not, raise this with your Training Programme Director.

Source: ASA Practice Guideline — asahq.org | PubMed: 41363869

3.4 SSC 2026 Adult Sepsis Guidelines — ICU & Anaesthetic Perspective

GUIDELINE CHANGE PRACTICE Final FRCA

Prescott H, Antonelli M, Alhazzani W, et al. | Crit Care Med. 2026 Mar | 129 statements, 46 new | DOI: 10.1097/CCM.0000000000007075

Note: Covered in the EM newsletter for the Emergency Department angle. Here we focus on ICU admission and intraoperative/critical care management implications.

ICU-specific practice-changing statements for anaesthetic trainees:

Why it matters: The MAP 60–65 recommendation for elderly patients is the single most immediately applicable change — lower targets mean less vasopressor, potentially fewer vasopressor-associated arrhythmias and digital ischaemia. The HFNC-over-NIV recommendation aligns with existing UK practice and is now evidence-graded.

Tell your department: Review your ICU’s default MAP target for patients over 65. Discuss the NMBA bolus vs infusion preference with your intensivist colleagues. Ensure your HFNC availability and training is adequate for the post-cardiac-surgery stepdown setting.

Source: SSC 2026 Guidelines — sccm.org | PubMed: 41869847

3.5 SCCM: First Guideline on Caring for Older Adults in the ICU

GUIDELINE CHANGE PRACTICE Final FRCA

Ferrante LE, Chaudhuri D, et al. | Crit Care Med. 2026 Mar | 22-member panel | DOI: 10.1097/CCM.0000000000007085

The first dedicated SCCM guideline for older ICU patients (≥65 years) yields two conditional recommendations and three notable “no recommendation” conclusions:

Why it matters: Prophylactic quetiapine for ICU delirium is common practice in many UK units. This recommendation actively challenges that approach. The SCCM panel is not saying it never works — it is saying the evidence does not justify routine prophylactic use. Review your unit’s current practice against this guidance.

Tell your department: Stop routine prophylactic haloperidol or quetiapine in ICU patients ≥65 unless in context of a study. Implement structured frailty assessment (Clinical Frailty Scale) on ICU admission for all patients ≥65.

Source: SCCM Older Adults ICU Guideline — sccm.org | PubMed: 41860322

3.6 SSC 2026 Paediatric Sepsis Guidelines — New Definition & POCUS Recommendation GUIDELINE

Final FRCA

Weiss S, Peters MJ, Oczkowski SJ, et al. | Pediatr Crit Care Med. 2026 Mar 23 | 61 statements | DOI: 10.1097/PCC.0000000000003927

The 2026 paediatric SSC guideline updates the 2020 framework with 20 new topics and a new data-driven sepsis definition. Key elements for anaesthetic trainees providing paediatric cover:

Source: SSC Paediatric Guideline 2026 — sccm.org

3.7 ELSO 2025 Guideline: ECMO Training, Competency & Certification Framework GUIDELINE

ELSO | ASAIO Journal 72(4):274–283 | Published 1 April 2026 (epub 30 March) | DOI: 10.1097/MAT.0000000000002686 | PubMed: 41910607

ELSO has published its narrative guideline establishing international standards for ECMO training, simulation, and competency-based certification. The framework defines: curriculum structure for initial ECMO training; simulation requirements (both task-trainer and in-situ); competency-based assessment milestones for different ECMO roles (specialist, coordinator, physician); and the E-AEC (ELSO Advanced ECMO Certification) pathway for programme-level accreditation. As NHS England expands commissioned ECMO centres and regional programmes, UK trainees in intensive care-linked anaesthetic posts will face increasing expectations around ECMO competency.

Why it matters: If you are in a dual CCT (anaesthetics/ICM) or a post with ECMO exposure, ask your programme whether your training aligns with the ELSO competency framework. E-AEC certification may become the international benchmark.

Source: ELSO ECMO Training Guideline — PubMed 41910607 | elso.org

3.8 ERAS Society Colorectal Surgery 2025 — Fascial Plane Blocks

Formalised [carry-over] GUIDELINE

CHANGE PRACTICE

Final FRCA

ERAS Society | Surgery 2025 (5th edition) | erassociety.org

The fifth edition of the ERAS Society colorectal surgery guidelines formally recommends TAP and quadratus lumborum (QL) blocks as components of standard multimodal analgesia for both open and laparoscopic colorectal procedures. This represents a convergent alignment with ASA 2026 (item 3.3), establishing fascial plane blocks as expected rather than exceptional practice across the highest-volume elective surgical list in the NHS. The guideline also reinforces: carbohydrate loading up to 2h pre-operatively, opioid-sparing analgesia throughout, early enteral feeding, and goal-directed fluid therapy.

Tell your department: If your trust’s colorectal ERAS protocol does not yet include TAP or QL blocks as standard, use this guideline — alongside ASA 2026 — as the evidence base to drive a protocol update.

Source: ERAS Society — Colorectal Guidelines 2025

4. FOAMed & Critical Appraisal

4.1 The Bottom Line: BigPAK-2 — Structured Critical Appraisal REVIEW

The Bottom Line | 28 March 2026 | thebottomline.org.uk

The Bottom Line provides one of the best free structured appraisals of BigPAK-2 (see item 2.1 above), methodically working through bias risk, effect size interpretation, and clinical applicability. Key appraisal points: low risk of bias (concealed allocation, blinded outcome assessment); the OR of 0.57 is clinically significant; however, the lack of MAKE-90 difference raises questions about whether AKI reduction translates to meaningful patient-centred outcomes. The appraisal usefully distinguishes between the biomarker-testing component (identifying high-risk patients) and the KDIGO care bundle component (the actual intervention) — both necessary for the trial to work as a paired strategy.

Source: The Bottom Line — BigPAK-2

4.2 PulmCrit: Six Reasons to Stop Relying on the Neurological Pupil Index (NPi) EXPERT OPINION

PulmCrit (Josh Farkas) / EMCrit | 14 March 2026 | emcrit.org/pulmcrit/npi/

NPi (Neurological Pupil Index, generated by automated pupillometry) has been increasingly adopted in UK neurocritical care units and ICUs as an objective pupil assessment tool. PulmCrit’s Farkas presents a detailed critique: (1) NPi is an algorithmic output, not a direct physiological measurement; (2) correlation with intracranial pressure is weak and not consistent across studies; (3) no high-quality RCT shows NPi-guided management improves outcomes; (4) normal NPi does not exclude early herniation; (5) NPi adds cost and complexity without replacing a skilled clinical examination; (6) the clinical pupil light reflex (PLR) performed with a bright standardised light remains the evidence-anchored assessment. This is particularly relevant for anaesthetic trainees in neuro-ICU or post-neurosurgical settings where NPi devices are marketed heavily.

Counterpoint: NPi proponents argue it provides reproducibility and removes inter-observer variability. Some centres use NPi in concert with clinical assessment — the debate is not whether to examine pupils, but whether the NPi adds incremental value over standardised PLR. Engage with your neurocritical care team before de-implementing.

Source: PulmCrit — emcrit.org/pulmcrit/npi/ (14 March 2026)

4.3 St Emlyn’s: TBS 2026 — Post-Intubation Hypotension in TBI REVIEW

Final FRCA

St Emlyn’s Blog / The Best Science 2026 Series | stemlynsblog.org

St Emlyn’s TBS (The Best Science) 2026 review of prehospital papers includes a critical evaluation of post-intubation hypotension (PIH) in traumatic brain injury — a complication directly relevant to anaesthetic technique selection. PIH (MAP <65 mmHg within 15 minutes of intubation) is common in TBI patients and independently associated with worsened neurological outcome: each episode of MAP <70 mmHg in TBI doubles the risk of secondary brain injury. Relevant for anaesthetists: induction agent choice (ketamine safe — does not cause ICP spikes at standard doses; etomidate suitable; thiopentone can cause haemodynamic instability), pre-intubation vasopressor use to pre-empt PIH, and the value of point-of-care POCUS to guide fluid decisions before induction.

Why it matters: For Final FRCA: ketamine’s safety profile in raised ICP is now well-evidenced (ICP neutrality at 1–2 mg/kg); this changes historical teaching. Pre-emptive vasopressor bolus (norepinephrine or metaraminol) before RSI in hypovolaemic TBI patients is supported by observational data.

Source: St Emlyn’s — TBS 2026 Prehospital Papers

5. Quick Hits / Also Notable

6. Action Points / This Month

  1. Add Venezuelan maternal ancestry to your pre-assessment template now. Speak to your pre-assessment lead this week — this is a zero-cost, potentially life-saving screening question. If at-risk patients are identified, plan TIVA or regional as default, and document accordingly.
  2. Update breastfeeding advice: “sleep and keep.” Check that your trust’s patient information leaflets, pre-operative instructions, and consent documentation no longer include “pump and dump” language. Ensure codeine is removed from post-operative analgesia options for breastfeeding women.
  3. Know your trust’s epidural bag contingency protocol. The supply shortage is ongoing. Be aware of current available concentrations and the implications for motor block and PIEB programmes. Document the concentration used explicitly on any epidural prescription.
  4. Review your ICU’s MAP target for patients ≥65 with septic shock. SSC 2026 now supports 60–65 mmHg in this cohort. Discuss with your intensivist team whether this should update your unit’s vasopressor titration protocol.
  5. Stop prophylactic antipsychotics for ICU delirium prevention. SCCM 2026 (Older Adults) recommends against routine prophylactic haloperidol or quetiapine. If your unit uses this routinely, raise the evidence at your next clinical governance meeting.
  6. Confirm competency in ESP, TAP, and QL blocks. With ASA 2026 and ERAS Colorectal 2025 converging, these blocks are expected practice for thoracic, abdominal, and colorectal surgical lists. Use this as a prompt to complete your regional anaesthesia logbook targets and sign off competencies before Final FRCA.
  7. Ensure GLP-1 agonist management is in your pre-assessment system. With growing prevalence of semaglutide and tirzepatide use, every pre-assessment must capture this. Apply CPOC guidance on omission timing and default to RSI if omission has not occurred.
  8. Check ESAIC/ESRA DOAC thresholds for your regional anaesthesia practice. The plasma-level threshold approach (<30 ng/mL) is now formally endorsed as an alternative to fixed time intervals — particularly useful in renally impaired patients. Know your trust’s anticoagulation reversal and testing pathway.

Sources Checked This Issue

UK: Association of Anaesthetists (Anaesthesia) | NHS England Patient Safety Alerts | MHRA Safety Roundup | CPOC | OAA/PRSB | RCoA | NICE | AoMRC | REPACC/Anaesthesia International: ESAIC | ESPA | ERN EURO-NMD | E-MIT | ESRA | ASA | SCCM | SSC (ESICM/SCCM) | ELSO | ERAS Society | ILCOR | ERC Journals: Anaesthesia | BJA | Lancet | NEJM | JAMA | Crit Care Med | Pediatr Crit Care Med | RAPM | ASAIO Journal | Prehospital Emergency Care | BMC Anaesthesiology | JCVA | Resuscitation FOAMed: The Bottom Line (thebottomline.org.uk) | PulmCrit/EMCrit (emcrit.org) | St Emlyn’s (stemlynsblog.org)

Next briefing: First week of May 2026 | Covering: WCA 2026 outputs (Marrakech), any NICE NG253 Sepsis update, RCoA exam session updates

Disclaimer: This newsletter is an educational summary for qualified medical professionals in training. It does not constitute clinical advice. Always refer to primary sources, local guidelines, and senior colleagues before changing practice. Drug doses and recommendations should be verified against current BNF, MHRA guidance, and local pharmacy before prescribing. Items marked [carry-over] were identified in prior research cycles but reach this issue for first coverage. Items covered in Issues 1 or 2 are not repeated.

Jake Turner

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

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