ANAESTHETICS & INTENSIVE CARE MEDICINE · UK EDITION
Anaesthetics & ICU Evidence Rundown
May 2026 | Issue #4 | Monthly Edition
Jake Turner
Curated with the assistance of AI (Perplexity). All content editorially reviewed.
May 2026 is a landmark month for airway practice: a comprehensive review reframes sugammadex as a strategic enabler, not just a reversal agent. The SOHO trial settles the HFNO vs standard oxygen debate in hypoxaemic respiratory failure with a nuanced answer. The OPIOID-Discharge survey reveals uncomfortable compliance gaps with MHRA guidance in UK day surgery. And a UK safety alert demands immediate action on two device field safety notices affecting theatres and critical care.
WHAT'S INSIDE THIS MONTH (25 ITEMS)
UK Guidelines & Safety Alerts (6):
MHRA: Armstrong Medical APL valve FSN · MHRA: Philips Trilogy Evo ventilator FSN · MHRA: ICU Medical infusion set FSN · NICE HTG774/775: LV microaxial flow pump · High-risk surgery mortality — 80% from 20% of patients · Medical Training (Prioritisation) Act: RCoA response
Key Trials & Articles (12):
SOHO Trial: HFNO vs standard oxygen in hypoxaemic respiratory failure · R2D2-ICU: Restrictive restraint in ICU · SHOSREB: Remimazolam vs propofol ICU sedation · Sepsis: Lancet Seminar 2026 · SSC 2026 Guidelines synopsis · Perioperative CV medication JAMA synopsis · Vasopressors for caesarean spinal hypotension NMA · GA vs RA and persistent opioid use (558,944 patients) · OPIOID-Discharge: UK compliance gaps · Sugammadex paradigm shift review · Sex-based tidal volume disparities in ICU · ARDS resolution: first Delphi consensus definition
International Guidelines (3):
SCCM/ESICM Refractory Septic Shock consensus · ESRA/PROSPECT post-caesarean pain recommendations · SCCM Paediatric/Neonatal ICU end-of-life guideline
FOAMed & Appraisal (4):
The Bottom Line: ACTiVE closed-loop ventilation · PulmCrit: STRATIFY trial — peripheral alteplase = catheter-directed · ATOTW 567: LVAD and non-cardiac surgery · PulmCrit / EMCrit: SSC 2026 deep-dive
EVIDENCE TAG LEGEND
THIS MONTH'S CONTENTS
UK Guidelines & Safety Alerts
1. MHRA FSN: Armstrong Medical APL Valve (Mapleson resuscitation sets) 2. MHRA FSN: Philips Trilogy Evo/EV300 Ventilators 3. MHRA FSN: ICU Medical CADD High Volume Administration Sets 4. NICE HTG774/775: LV Microaxial Flow Pump for Cardiogenic Shock 5. Lancet Public Health: 80% of surgical deaths from 20% of patients 6. Medical Training (Prioritisation) Act: RCoA response on anaesthetic training
Key Trials & Journal Articles
7. SOHO Trial: HFNO vs Standard Oxygen in Hypoxaemic Respiratory Failure (NEJM) 8. R2D2-ICU: Restrictive vs Liberal Restraint in Mechanically Ventilated Patients (JAMA) 9. SHOSREB Trial: Remimazolam Non-Inferior to Propofol for ICU Sedation (ICM) 10. Sepsis 2026: Lancet Seminar — Endotypes, Immunomodulation, Precision Medicine 11. SSC 2026 Adult Sepsis Guidelines: JAMA Synopsis 12. Perioperative Cardiovascular Medication Management: JAMA Guidelines Synopsis 13. Vasopressors for Caesarean Spinal Hypotension: Network Meta-Analysis (Anaesthesia) 14. GA vs RA and Persistent Opioid Use: 558,944-Patient Nationwide Cohort (Anaesthesia) 15. OPIOID-Discharge Survey: UK Day Surgery Compliance Gaps (Anaesthesia) 16. Era of Sugammadex: A Paradigm Shift in Airway Management (Anesthesiology) 17. Sex-Based Tidal Volume Disparities in ICU: Registry Cohort (Crit Care Med) 18. ARDS Resolution: First Delphi Consensus Definition (Crit Care Med)
International Guidelines
19. SCCM/ESICM: Refractory Septic Shock — Delphi Consensus Criteria 20. ESRA/PROSPECT: Post-Caesarean Pain Management Recommendations 21. SCCM: Paediatric and Neonatal ICU End-of-Life Care Guideline
FOAMed & Critical Appraisal
22. The Bottom Line: ACTiVE — Closed-Loop Ventilation vs Protocolled Conventional Ventilation 23. PulmCrit: STRATIFY Trial — Peripheral Alteplase Equals Catheter-Directed for PE 24. ATOTW 567: LVAD and Non-Cardiac Surgery 25. EMCrit 422: SSC 2026 Sepsis Guidelines — Deep-Dive Discussion
Quick Hits | Action Points
UK GUIDELINES & SAFETY ALERTS
MHRA · FIELD SAFETY NOTICE · 5 MARCH 2026
1. MHRA FSN: Armstrong Medical APL Valve — Immediate Pre-Use Checks Required in All Theatre and Resuscitation Settings
A manufacturing defect in Armstrong Medical Resuscitation Sets has been confirmed: the APL valve may stick during opening or closing, preventing adequate pressure relief during manual ventilation. The result is sustained elevated airway pressures, excessive PEEP, haemodynamic compromise, and barotrauma risk. One case of transient patient harm has been confirmed.
Affected devices are used in theatre emergency resuscitation kits, recovery areas, and critical care backup circuits. Mandatory pre-use check per IFU: inflate the reservoir bag and confirm the APL valve opens and closes correctly at each PEEP setting before every use. Do not skip this check if the kit appears unused.
Immediate Action Required
Check all Armstrong Medical Mapleson C resuscitation sets across your entire department — theatres, recovery, ICU backup, resus trolleys. Perform the valve function check before the next clinical use. Return the FSN response form to Armstrong Medical.
Tell your department: "All Armstrong Medical Mapleson C circuits need a pre-use valve check before the next case. The APL valve can stick and build pressure silently. This is a patient safety issue, not a scheduled recall."
Source: MHRA Field Safety Notices 9-13 March 2026 — Armstrong Medical CAPA-100
MHRA · FIELD SAFETY NOTICE · UPDATED MARCH 2026
2. MHRA FSN: Philips Trilogy Evo/EV300 Ventilators — Non-Pneumatic Nebulisers Prohibited, Silent Tidal Volume Under-Delivery
Philips Respironics FSN 2026-CC-SRC-002: non-pneumatic (vibrating mesh) nebulisers used with Trilogy Evo, Trilogy Evo O2, Trilogy Evo Universal, and Trilogy EV300 ventilators cause incorrect leak estimation, resulting in tidal volume under-delivery with no user alarm. This is an entirely silent failure mode: the display shows normal values while the patient receives inadequate ventilation. The FSN also addresses flow sensor aerosol deposition and alarm timing delays. Required actions: immediately stop use of non-pneumatic nebulisers with all affected devices; update device software to version 1.06.15.00; inform all users including clinical engineers and nursing staff.
Immediate Action Required
If your ICU, anaesthetic department, or ward uses Trilogy Evo platform ventilators: stop using vibrating mesh nebulisers with these devices immediately. Contact clinical engineering for the software update. The failure mode is silent — no alarm fires during under-ventilation.
Source: MHRA Field Safety Notices 9-13 March 2026 — Philips FSN 2026-CC-SRC-002
MHRA · FIELD SAFETY NOTICE · 9-13 MARCH 2026
3. MHRA FSN: ICU Medical CADD High Volume Administration Sets
ICU Medical Ltd issued a Field Safety Notice for CADD High Volume Administration Sets used with their infusion pumps in perioperative and ICU settings. These sets are used for epidural and PCA infusions across UK hospitals. Contact the manufacturer directly for full FSN details and required action steps. Departments using CADD infusion pumps should verify affected set lot numbers against the FSN and check for any ongoing replacement supply via pharmacy and clinical engineering.
Source: MHRA Field Safety Notices 9-13 March 2026
NICE · HTG774 & HTG775 · LAST REVIEWED 25 MARCH 2026
4. NICE HTG774/775: LV Microaxial Flow Pump (Impella) Approved for Cardiogenic Shock
NICE has issued health technology guidance for both surgical (HTG774) and percutaneous (HTG775) insertion of catheter-based left ventricular microaxial flow pumps (including Impella) for cardiogenic shock, with a conditional recommendation for use with enhanced consent and mandatory outcome data collection. The guidance applies to specialist cardiac centres with appropriate infrastructure. For cardiac anaesthetists and intensivists: Impella management is complex, requiring specific perioperative expertise including anticoagulation management (unfractionated heparin to ACT 160–180 seconds), avoidance of hypovolaemia, RV afterload awareness, suction event recognition, and pump weaning protocols.
Why it matters: NICE approval accelerates Impella uptake across UK cardiac centres. Anaesthetists and intensivists in cardiac units should expect increasing Impella cases. Essential to know device-specific haemodynamic principles (preload dependence, augmented diastolic flow, interaction with IABP if combined) and perioperative complications (haemolysis, malpositioning, suction events). See also ATOTW 568 (Item 24) for IABP context.
Source: NICE HTG774 | NICE HTG775
LANCET PUBLIC HEALTH · MARCH 2026
5. High-Risk Surgery: 80% of Surgical Deaths Occur in 20% of Patients (12.9 Million Patient Study)
A large-scale Lancet Public Health cohort study of 12.9 million surgical cases confirms that the distribution of post-surgical mortality is highly skewed: approximately 80% of postoperative deaths occur in the highest-risk 20% of patients. High-risk determinants include age, ASA status, emergency surgery, intraperitoneal and thoracic procedures, and pre-existing cardiorespiratory comorbidity. The RCoA and CPOC have highlighted this as the strongest quantitative evidence base yet for concentrating perioperative medicine resources on high-risk patient identification and optimisation.
Why it matters: This is the most robust quantitative framing of the high-risk surgery problem. It directly supports investment in perioperative medicine clinics, prehabilitation, and high-risk surgical pathways — all priorities in the NHS 10-Year Health Plan submission by CPOC. Useful for trainees to understand the strategic case for perioperative medicine as a specialty.
Source: Lancet Public Health — March 2026 (highlighted by RCoA/CPOC; search "high-risk surgical cohort Lancet Public Health 2026" for full access)
RCOA / PARLIAMENT · 6 MARCH 2026
6. Medical Training (Prioritisation) Act Receives Royal Assent: RCoA Flags Anaesthetics Training Bottleneck
The Medical Training (Prioritisation) Act achieved Royal Assent, providing a legislative basis for NHS workforce planning linked to training commissions. The RCoA responded by highlighting that increasing medical school places without expanding anaesthetic training posts will not solve theatre access bottlenecks — anaesthetics is already one of the most training-constrained specialties in the NHS, with insufficient post numbers relative to the service need. The RCoA has called for post expansion proportional to the legislation's ambitions.
Context for trainees: This legislative development may translate to more training opportunities in the medium term — but the RCoA is right to flag that infrastructure (supervised training capacity, SPA time, trainers) must expand alongside any post increases. Follow the RCoA news feed for further responses.
Source: rcoa.ac.uk/news — RCoA response to Medical Training (Prioritisation) Act, 6 March 2026
KEY TRIALS & JOURNAL ARTICLES
NEW ENGLAND JOURNAL OF MEDICINE · 17 MARCH 2026
7. SOHO Trial: High-Flow Nasal Oxygen Does Not Reduce 28-Day Mortality in Acute Hypoxaemic Respiratory Failure
In 1,110 patients with acute hypoxaemic respiratory failure (PaO₂/FiO₂ ≤200), high-flow nasal oxygen (HFNO) versus standard oxygen therapy produced identical 28-day mortality (14.6% vs 14.6%; P=0.98). HFNO did reduce the intubation rate by approximately 6 percentage points (42.4% vs 48.4%; P=0.03). However, serious adverse events during spontaneous breathing trials — cardiac arrest and pneumothorax — were numerically higher in the HFNO group. The HFNO benefit may be in comfort and intubation avoidance, not survival.
Why it matters: HFNO is widely used post-operatively and in ICU for hypoxaemic respiratory failure. This well-powered RCT confirms it avoids intubation but does not save lives. For anaesthetic and ICU practice: HFNO remains a valid intervention for intubation deferral and patient comfort, but should not be persisted with beyond a reasonable trial if oxygenation is failing — early intubation before physiological deterioration is still the safer escalation path.
Caution: The numerically higher serious adverse event rate (cardiac arrest, pneumothorax) in the HFNO group warrants attention. Patients on HFNO can maintain near-normal ventilation even with rapidly developing respiratory fatigue — don't be falsely reassured by comfortable-appearing patients with high respiratory rates. Reconsider this trial before the post-cardiac surgery HFNO routine (different population, different physiology).
Tell your department: "SOHO confirms HFNO avoids intubation but does not reduce mortality. Use it as a bridge, not a destination. Set a clear failure threshold and escalate early — don't let HFNO delay a needed intubation."
Source: NEJM 2026 — PMID 41841715 — doi:10.1056/NEJMoa2516087
JAMA · 17 MARCH 2026
8. R2D2-ICU Trial: Restrictive Restraint Strategy Does Not Increase Delirium-Free Days — Safe Without Benefit
405 mechanically ventilated ICU patients; restrictive (low-use) vs liberal (systematic) wrist-strap restraint strategy. Restrictive restraints did not increase delirium- or coma-free days at 14 days (mean 6.67 vs 6.30 days; adjusted difference 0.37, 95% CI −0.71 to 1.46; P=0.51). Self-extubation rates were similar (9.2% vs 8.5%). 90-day mortality did not differ. The key finding: avoiding routine restraints is safe — no increase in self-extubation, unplanned device removal, or harm.
Why it matters: Physical restraint in ICU is distressing for patients and families, and is associated with psychological harm including PTSD. This RCT provides level-1 evidence that a restraint-minimisation approach does not increase adverse events. Supports movement towards restraint-free or restraint-minimisation ICU cultures, consistent with NICE delirium prevention guidance and ABCDEF bundle principles.
Tell your department: "Routine wrist restraints don't protect against self-extubation or improve delirium outcomes. Start with restraint minimisation as default — individualise based on specific patient risk."
Source: JAMA 2026 — PMID 41841304 — doi:10.1001/jama.2026.2897
INTENSIVE CARE MEDICINE · 31 MARCH 2026
9. SHOSREB Trial: Remimazolam Non-Inferior to Propofol for Light ICU Sedation
Multicentre non-inferiority RCT, 164 mechanically ventilated ICU patients. Remimazolam besylate was non-inferior to propofol for achieving target light sedation (RASS −2 to +1): successful sedation rate 97.5% vs 97.5% (difference 0%, 95% CI −6.5% to +6.4%). Time at target RASS, infusion duration, adverse events, and time to extubation were comparable. No evidence of propofol infusion syndrome in either arm.
Why it matters: Remimazolam has theoretical advantages over propofol in ICU: no lipid vehicle (no hypertriglyceridaemia, no PRIS risk), organ-independent metabolism by tissue esterases (no accumulation in renal failure), and flumazenil reversibility. This RCT provides the strongest evidence yet for equivalence at light sedation targets. Relevant as remimazolam adoption in UK theatres and ICUs expands following its licensing.
Caution: This trial is relatively small (n=164) and from a single Asian centre context. UK ICU formulary decisions will require cost-effectiveness data alongside efficacy. Remimazolam is considerably more expensive than propofol. Flumazenil reversibility is a theoretical advantage, but tolerance develops rapidly with benzodiazepine use and reversal may precipitate withdrawal in prolonged sedation.
Source: Intensive Care Med 2026 — PMID 41915173 — doi:10.1007/s00134-026-08381-x
THE LANCET · 28 MARCH 2026
10. Sepsis 2026: Lancet Seminar — Endotypes, Immunomodulation, and Why Trials Keep Failing
The 2026 Lancet Seminar on sepsis by Singer, Angus, Annane and colleagues provides a comprehensive state-of-the-art review. Key themes: (1) biological endotyping — the hyperinflammatory vs immunosuppressed phenotype dichotomy explains why one-size-fits-all interventions fail; (2) precision medicine as the future framework, with endotype-matched trials showing early promise; (3) the ongoing failure of immunomodulatory therapies in unselected populations; (4) antimicrobial stewardship integrated into resuscitation; and (5) the argument for sepsis screening tools that identify phenotype, not just diagnosis.
Why it matters: Essential reading for the Final FRCA and for ICU-linked anaesthetic trainees. This seminar contextualises why recent large RCTs in sepsis (steroids, vitamins, immunotherapy) have been negative — and what precision medicine approaches may deliver. Read alongside the SSC 2026 guidelines synopsis (Item 11) for the clinical translation.
Source: Lancet 2026 — PMID 41765030 — doi:10.1016/S0140-6736(25)02422-5
JAMA · 26 MARCH 2026
11. SSC 2026 Adult Sepsis Guidelines: JAMA Clinical Guidelines Synopsis
The JAMA Clinical Guidelines Synopsis presents the 2026 Surviving Sepsis Campaign adult guidelines (covered in depth in a previous issue) in a condensed, clinician-facing format ideal for practice integration. Key updates recap: MAP target 60–65 mmHg in patients ≥65 years; norepinephrine first-line vasopressor; peripheral vasopressor administration in monitored settings endorsed; antibiotic timing guidance updated to allow brief delay in possible-but-uncertain sepsis; early de-resuscitation addressed; extended-infusion beta-lactams recommended. This synopsis is the most accessible entry point into the full guideline.
Tell your department: "Print the JAMA SSC 2026 synopsis for the ICU notice board. The MAP 60-65 target for patients over 65 and peripheral vasopressor administration are the two most immediately actionable changes for UK ICUs."
Source: JAMA 2026 — PMID 41886281 — doi:10.1001/jama.2026.3793
JAMA · 31 MARCH 2026
12. Perioperative Cardiovascular Medication Management: AHA/ACC JAMA Guidelines Synopsis
JAMA synopsis of the AHA/ACC 2024 perioperative cardiovascular medication management guidelines for noncardiac surgery. Directly applicable to UK pre-assessment practice. Key recommendations: continue beta-blockers perioperatively in patients already taking them; continue statins perioperatively; hold ACE inhibitors/ARBs on the day of surgery in most elective cases; antiplatelet management requires individualised cardiology input; anticoagulant bridging recommendations updated (bridging generally not indicated for most patients with AF on warfarin). These are the recommendations to know for pre-assessment clinic and the Final FRCA SAQ.
UK context: UK pre-assessment practice already follows these principles in most respects; however, practices around antiplatelet management before intermediate-risk procedures and RAAS agent timing vary between trusts. Use this synopsis to standardise your department's pre-assessment proforma.
Source: JAMA 2026 — PMID 41915402 — doi:10.1001/jama.2026.0067
ANAESTHESIA · 19 MARCH 2026
13. Vasopressors for Spinal Hypotension at Caesarean: Network Meta-Analysis of 55 RCTs
Network meta-analysis of 55 RCTs, 5,487 patients. Compared vasopressor infusions for spinal hypotension at caesarean section. All four agents (metaraminol, noradrenaline, phenylephrine, adrenaline/epinephrine) were significantly superior to control for hypotension prevention. For foetal acid-base balance (the critical outcome): noradrenaline and metaraminol were superior to ephedrine, while phenylephrine showed comparable performance to noradrenaline and metaraminol. Ephedrine's beta-agonism causes placental passage and foetal metabolic acidosis — well-established and confirmed again here. Maternal heart rate was better maintained with noradrenaline and metaraminol vs phenylephrine.
Why it matters: This NMA provides the clearest current evidence hierarchy for obstetric vasopressor choice. Noradrenaline and metaraminol are the preferred first-line agents for preventing spinal hypotension at caesarean, particularly given the foetal acid-base advantage over ephedrine. Phenylephrine remains acceptable. Ephedrine should not be used as first-line. Relevant to OAA guidelines and UK obstetric anaesthesia training.
Tell your department: "Noradrenaline or metaraminol infusion for spinal hypotension at caesarean. Ephedrine should not be first-line — the foetal acid-base evidence is now stronger than ever."
Source: Anaesthesia 2026 — PMID 41854017 — doi:10.1111/anae.70204
ANAESTHESIA · 19 MARCH 2026
14. GA Doubles Risk of Persistent Postoperative Opioid Use vs Regional Anaesthesia: 558,944-Patient Cohort
Propensity-matched South Korean nationwide cohort of 558,944 surgical patients. General anaesthesia was associated with significantly higher odds of persistent postoperative opioid utilisation (defined as >120 days of supply dispensed between POD 91–365) compared with regional anaesthesia (OR 2.13, 95% CI 1.50–3.01; P<0.001). The difference was most pronounced for thoracotomy, where the absolute risk difference was largest. This represents the largest study to date addressing this question.
Why it matters: Provides large-scale real-world evidence for a key opioid stewardship argument: regional anaesthesia reduces the risk of chronic postoperative opioid dependency. This is not just about acute pain — it has implications for surgical pathway design, consent discussions, and the case for regional anaesthesia services in the NHS. Directly relevant to the opioid stewardship agenda (see also Item 15).
Source: Anaesthesia 2026 — PMID 41852109 — doi:10.1111/anae.70184
ANAESTHESIA · 29 MARCH 2026
15. OPIOID-Discharge Survey: 14% of UK Day Surgery Units Still Prescribe Modified-Release Opioids at Discharge
UK NHS cross-sectional survey of 83 Day Surgery Units and 70 Drugs and Therapeutics Committees, 6 months after the March 2025 MHRA drug safety update prohibiting routine modified-release (MR) opioids at discharge from day surgery. Findings: 75% of previously non-compliant Trusts had stopped MR opioid prescribing at discharge; 14% still prescribed them. Only 32% of units provided discharge letters to GPs advising against repeat prescriptions. Only 28% gave patients information about opioid risks. These gaps are significant patient safety failures.
Safety point: If your day surgery unit prescribes modified-release opioids (morphine SR, oxycodone CR, tramadol SR) routinely at discharge, this is contrary to MHRA guidance from March 2025. Check your formulary and discharge prescription templates today.
Tell your department: "Check your day surgery discharge prescription template. Modified-release opioids should not be on it. If they are, raise this with your Drugs and Therapeutics Committee today. Also ensure GP discharge letters include opioid non-repeat advice."
Source: Anaesthesia 2026 — PMID 41906196 — doi:10.1111/anae.70206
ANESTHESIOLOGY · 1 APRIL 2026
16. Era of Sugammadex: A Paradigm Shift in Airway Management Strategy
Comprehensive narrative review in Anesthesiology examining how universal sugammadex availability fundamentally changes airway strategy. Key strategic implications: (1) high-dose rocuronium RSI (1.2 mg/kg) with sugammadex rescue is now a viable succinylcholine alternative — providing deep NMB with a guaranteed reversal pathway; (2) the "can't intubate, can't oxygenate" scenario algorithm changes when high-dose rocuronium rescue sugammadex is available; (3) residual NMB should be considered eliminated as a clinical concern when sugammadex is used; (4) sugammadex does not replace the airway plan — it is one element within a structured airway strategy. The paper directly engages with DAS 2025 guidelines and NAP4/NAP7-era evidence.
Why it matters: This is the most important single review of sugammadex strategy published this year. Every UK anaesthetic trainee should read it before their Final FRCA SAQs on RSI and NMB management. It reframes sugammadex from "reversal agent" to "strategic enabler" and has immediate implications for how departments should approach RSI, failed intubation protocols, and NMB monitoring.
Source: Anesthesiology 2026 — PMID 41805213 — doi:10.1097/ALN.0000000000005828
CRITICAL CARE MEDICINE · 31 MARCH 2026
17. Female ICU Patients Persistently Over-Ventilated: Sex-Based Tidal Volume Disparities and Mortality Implications
Registry-based cohort, 20,351 mechanically ventilated ICU patients from 9 Toronto hospitals. Female patients received consistently higher tidal volumes per predicted body weight than males throughout ventilation, not only in the first 24 hours. Bayesian joint modelling estimated that a meaningful proportion of the excess mortality observed in females was mediated through this tidal volume difference. The finding persisted even when weight-based PBW calculation was used — because females have a smaller lung volume for a given height than males, PBW-based 6 mL/kg delivers proportionately more volume to female lungs.
Why it matters: A critical equity and safety issue for ICU mechanical ventilation. The standard 6 mL/kg PBW target may systematically over-ventilate female patients. Consider using driving pressure and lung compliance as additional targets in female patients to detect relative over-ventilation. This is directly relevant to ICU ventilation audit and quality improvement.
Tell your department: "Check our ventilation audit data by sex. Are we over-ventilating female patients? Driving pressure monitoring should supplement the PBW calculation in all ARDS patients."
Source: Crit Care Med 2026 — PMID 41914820 — doi:10.1097/CCM.0000000000007103
CRITICAL CARE MEDICINE · 2 APRIL 2026
18. ARDS Resolution: First Delphi Consensus Definition — Two-Criterion Standard
19-expert Delphi consensus; the first agreed operational definition of ARDS resolution. ARDS is resolved when both of the following are met for >24 hours: (1) Hypoxaemia resolved: PaO₂/FiO₂ >300 or SpO₂/FiO₂ >315; AND (2) Respiratory support normalised: if intubated, PEEP ≤5 cmH₂O with no adjunctive interventions primarily for respiratory reasons; if HFNC/NIV/CPAP was the maximum support, the patient no longer requires it. This definition is designed for clinical trial use but has immediate clinical relevance for extubation and discharge decision-making.
Why it matters: Without a consensus ARDS resolution definition, weaning and extubation decisions have been inconsistent. This Delphi definition provides an objective two-criterion framework for ARDS resolution that can be applied clinically, audited, and used in trial design. Relevant to Final FRCA candidates for ARDS questions and to intensivists managing the weaning trajectory.
Source: Crit Care Med 2026 — PMID 41925519 — doi:10.1097/CCM.0000000000007107
INTERNATIONAL GUIDELINES (PRACTICE-CHANGING FOR UK)
SCCM / ESICM · 24 MARCH 2026
19. SCCM/ESICM: Refractory Septic Shock — First Delphi Consensus on Diagnostic Criteria
56 international experts, five Delphi rounds. Refractory septic shock diagnostic criteria reaching ≥90% consensus: norepinephrine equivalent >0.5 μg/kg/min after adequate fluid resuscitation; persistent hyperlactataemia (>2 mmol/L for >2 hours); prolonged capillary refill time (>3 seconds); mottling beyond the knee; and POCUS as the sole recommended haemodynamic monitoring modality (requiring ≥4 criteria including one of the above vasopressor threshold). This defines the threshold for ECMO/MCS escalation decisions.
Why it matters: "Refractory septic shock" has lacked a consensus definition, leading to inconsistent ECMO referral practices. This consensus provides the first objective criteria set. UK intensivists should use the norepinephrine >0.5 μg/kg/min threshold as the trigger for escalation discussion with
ECMO centres. Directly relevant to VA-ECMO referral pathways and Final FRCA critical care scenarios.
Source: PMID 41873857 — SCCM/ESICM Refractory Septic Shock Delphi Consensus 2026
ESRA / PROSPECT · PUBLISHED 23 MARCH 2026 (ESRA WEBSITE)
20. ESRA/PROSPECT: Post-Caesarean Analgesia — Intrathecal Morphine 50-100 mcg or Diamorphine 300 mcg First-Line
ESRA/PROSPECT systematic review and recommendations for post-caesarean analgesia. Key recommendations: intrathecal morphine 50–100 μg or diamorphine 300 μg as first-line neuraxial analgesia (diamorphine explicitly endorsed — highly relevant given UK supply context from previous issues); paracetamol + NSAIDs post-delivery as standard multimodal analgesia; dexamethasone recommended; Joel-Cohen incision preferred; peritoneum non-closure. TAP block or quadratus lumborum block where neuraxial opioids not given or contraindicated.
Why it matters: This is the most current evidence-based framework for post-caesarean pain management. The explicit endorsement of intrathecal diamorphine 300 μg is highly relevant for UK practice where diamorphine remains the preferred intrathecal opioid despite ongoing supply challenges. OAA and NICE should be expected to align with these recommendations. Directly applicable to obstetric anaesthetic practice and Final FRCA OSCE scenarios.
Source: PMID 41693258 — ESRA/PROSPECT Post-Caesarean Analgesia
SCCM · PEDIATRIC CRITICAL CARE MEDICINE · 20 MARCH 2026
21. SCCM: Paediatric and Neonatal ICU End-of-Life Care Guideline — Five Conditional Recommendations
SCCM's first dedicated paediatric and neonatal ICU end-of-life care guideline, using GRADE methodology with five conditional recommendations: (1) implement a structured advance care planning programme for PICU/NICU patients; (2) provide palliative care consultation for high-risk patients; (3) use systematic symptom assessment tools for pain, agitation, and dyspnoea; (4) deliver structured staff education on EOL communication; (5) implement structured bereavement care. All five carry "very low certainty" evidence ratings — reflecting the ethical and practical barriers to conducting RCTs in this area.
UK context: UK paediatric intensive care has robust frameworks including SPICT-A and NICE-aligned care, but formal PICU EOL guidelines from RCPCH/FICM are less systematised than this SCCM document. Useful reference for trainees in PICU rotations and for departments reviewing their
EOL care pathways. Very low certainty evidence reflects the nature of the field, not the importance of the recommendations.
Source: sccm.org — Paediatric EOL Guideline 2026
FOAMED & CRITICAL APPRAISAL HIGHLIGHTS
THE BOTTOM LINE · 14 MARCH 2026
22. The Bottom Line: ACTiVE Trial — Closed-Loop Ventilation No Better Than a Good Protocol
The Bottom Line critically appraises the ACTiVE RCT comparing INTELLiVENT-ASV closed-loop automated ventilation versus protocolled conventional mechanical ventilation. The trial found no difference in ventilator-free days at 28 days (primary outcome), 28-day mortality, or any clinical secondary outcomes. The Bottom Line's appraisal highlights that the control arm was an unusually high-quality protocolled ventilation strategy — the closed-loop system performed equivalently, not better. Conclusion: closed-loop ventilation is safe, but it adds no clinical benefit over a well-implemented conventional protocol in a competent ICU.
Take-home: Don't chase technology at the expense of protocol discipline. A rigorous conventional ventilation protocol delivers equivalent outcomes to automated closed-loop systems in experienced ICUs. Invest in the protocol before the machine.
Source: thebottomline.org.uk — ACTiVE appraisal, 14 March 2026
PULMCRIT / EMCRIT · 6 MARCH 2026
23. PulmCrit: STRATIFY Trial — Peripheral Alteplase Equals Catheter-Directed Thrombolysis for PE
PulmCrit's Farkas reviews the STRATIFY trial, which randomised intermediate-to-high risk PE patients to peripheral IV alteplase vs catheter-directed ultrasound-assisted thrombolysis (USAT). Peripheral alteplase was equivalent to USAT for all primary and secondary outcomes. Farkas's key insight: thrombolytic drug redistributes throughout the pulmonary vasculature regardless of delivery site — the catheter does not provide a pharmacological advantage. USAT therefore adds procedural risk, cost, and delay without clinical benefit. The implication: for the patient who needs thrombolysis for intermediate-high risk PE, peripheral infusion of a low-dose alteplase regimen (~18 mg) is the most rational approach.
Why it matters: PE management sits at the intersection of cardiology, anaesthetics, and critical care. The STRATIFY data finalises the case against USAT as a premium intervention. For anaesthetic and ICU practitioners: if thrombolysis is indicated in decompensating PE, a peripheral low-dose alteplase infusion is equivalent to catheter-directed therapy and simpler to deliver. Read alongside the HI-PEITHO data covered in the EM newsletter.
Source: emcrit.org — PulmCrit STRATIFY review, 6 March 2026
ATOTW (WFSA) · TUTORIAL 567 · 10 MARCH 2026
24. ATOTW 567: Perioperative Management of LVAD Patients Undergoing Non-Cardiac Surgery
Free educational tutorial covering the perioperative anaesthetic management of patients with a Left Ventricular Assist Device (LVAD) undergoing non-cardiac surgery — a scenario of increasing frequency as LVAD patients survive longer. Key principles: extreme preload dependence (avoid hypovolaemia); mandatory arterial line (cannot use NIBP alone — LVAD patients often have no palpable pulse); RV protection (avoid RV afterload increases: no hypoxia, hypercarbia, acidosis; cautious use of vasoconstriction); anticoagulation bridging (device-specific — usually UFH); suction event recognition; avoidance of CPR as first-line (ineffective with LVAD in situ); LVAD team communication mandatory pre- and intra-operatively.
Why it matters: As the LVAD population grows, UK DGH and university hospital anaesthetists will encounter these patients on emergency and elective lists. ATOTW 567 is a concise, practical, free resource. Essential reading for Final FRCA candidates on cardiac anaesthesia. Read alongside NICE HTG774/775 (Item 4) for context on the expanding mechanical circulatory support landscape.
Source: resources.wfsahq.org/atotw/ — ATOTW 567, 10 March 2026
EMCRIT · EPISODE 422 · 29 MARCH 2026
25. EMCrit 422: SSC 2026 Sepsis Guidelines — Nuanced Deep-Dive with Practical Implications
Scott Weingart and guests provide a comprehensive 90-minute deep-dive into the SSC 2026 adult sepsis guidelines, focusing on the practical and conceptually difficult elements. Key discussion points: nuanced antibiotic timing (the brief delay permitted in possible-but-uncertain sepsis is not a license for delay in sick patients); peripheral vasopressor administration — acceptable for early initiation without central line, requires monitoring for extravasation; prolonged beta-lactam infusions now formally recommended (continuous or extended infusion); balanced crystalloids preferred (Hartmann's/PlasmaLyte over 0.9% NaCl); no role for beta-blockers in septic shock; active de-resuscitation addressed after the initial 6-hour window.
Why it matters: The SSC 2026 guideline has 129 statements — the EMCrit episode is the best 90-minute synthesis of what actually changes for clinicians. Listen before updating your department's sepsis bundle. The peripheral vasopressor and extended-infusion beta-lactam points are immediately implementable.
Source: emcrit.org — EMCrit 422, SSC 2026 Guidelines, 29 March 2026
QUICK HITS / ALSO NOTABLE
Association of Anaesthetists: Updated PHEA Guidelines GUIDELINE CHANGE PRACTICE — Updated national guidelines for prehospital emergency anaesthesia published in Anaesthesia (24 March 2026). Relevant for anaesthetists with HEMS/PHEM roles and major trauma centre practice. Sets same standard as in-hospital RSI. Covered in depth in the PHEM Evidence Rundown (May 2026). (PMID 41873247)
Lidocaine + Low-Dose Esketamine for Post-Hepatectomy Pain RCT — In 304 patients undergoing hepatic resection with TAP block, combined IV lidocaine and low-dose esketamine infusion significantly reduced 24-72h movement-evoked pain and moderate-severe pain incidence vs placebo. Clinically modest effect sizes but supports opioid-sparing strategy in hepatobiliary surgery where regional techniques are limited. (Anaesthesia 2026 — PMID 41913698)
ARDS Complications: SR/MA of Incidence and Spectrum SR/MA — Systematic review and meta-analysis characterising pooled incidence of ARDS complications (ICU-acquired weakness, VAP, barotrauma, delirium, atelectasis, cardiovascular events). Provides reference epidemiological data for quality improvement and consent. (Critical Care 2026 — PMID 41906154)
BJA Education: Screening for Perioperative Neurocognitive Disorders (PND) REVIEW — April 2026 BJA Education review covering validated screening tools (CAM, 3D-CAM, MMSE, MoCA) and practical implementation for delirium and POCD in the perioperative pathway. Aligned with NICE and RCoA guidance on peri-operative brain health. Essential resource for pre-assessment practitioners. (BJA Education April 2026 — PMID 41924038)
BJA Education: ERAC Part 2 — Post-Operative Considerations and Quality Indicators
REVIEW — Second part of a ERAC (Enhanced Recovery After Caesarean) series from BJA
Education, covering postoperative pain management, early mobilisation, breastfeeding, thromboprophylaxis, and ERAC quality indicators. Practical implementation guide for UK obstetric anaesthetic departments. (BJA Education April 2026 — PMID 41924041)
Individualised PEEP in Lung Cancer Surgery: Negative RCT (Anaesthesia) RCT — EIT-guided individualised PEEP (median 11 cmH₂O) in 400 older patients undergoing lung cancer surgery improved intra-operative physiology but did not reduce postoperative pulmonary complications (28% vs 25%; P=0.60). Physiological improvement does not guarantee clinical benefit; caution before widespread EIT-guided PEEP adoption in thoracic anaesthesia. (Anaesthesia 2026 — PMID 41815001)
ATOTW 568: Intra-Aortic Balloon Pump REVIEW — Free WFSA tutorial covering IABP indications, contraindications, counterpulsation physiology, timing, and complications. Read alongside NICE HTG774/775 (Impella guidance) for a full mechanical circulatory support overview. (ATOTW 568, 24 March 2026 — wfsahq.org/atotw)
ACTION POINTS / THIS MONTH
| 1. | Check all Armstrong Medical Mapleson C resuscitation sets before the next use. Perform the APL valve function check per IFU. Report the FSN to Armstrong Medical. This is the highest-priority immediate action from this issue. |
| 2. | Stop using vibrating mesh nebulisers with Philips Trilogy Evo ventilators. Contact clinical engineering for the software update (version 1.06.15.00). The failure mode is silent — no alarm fires during under-ventilation. |
| 3. | Check your day surgery unit's discharge prescription template for modified-release opioids. The OPIOID-Discharge survey shows 14% of UK units are still non-compliant with the March 2025 MHRA guidance. Remove MR opioids if present. Add a GP letter advising against repeat prescriptions. |
| 4. | Read the Sugammadex Paradigm Shift review (PMID 41805213). This is the most important single anaesthetics review of the month. If you haven't updated your understanding of high-dose rocuronium RSI strategy and the DAS 2025 interaction with sugammadex, this is the paper to read before your next Final FRCA preparation session. |
| 5. | Update your obstetric vasopressor practice if you are still using ephedrine first-line. Noradrenaline or metaraminol infusion is now the evidence-supported first-line agent for spinal hypotension at caesarean. Align with the ESRA/PROSPECT post-caesarean analgesia recommendations for intrathecal opioids. |
| 6. | Implement restraint minimisation as default ICU policy. The R2D2-ICU RCT provides level-1 evidence that restrictive restraints are safe and do not increase self-extubation. Review your department's current restraint documentation and defaults. |
| 7. | Audit your ICU mechanical ventilation data by sex. The sex-based tidal volume disparity study identifies a systematic over-ventilation issue in female patients. Run a simple audit of tidal volume per PBW stratified by sex across your ventilated patients in the last 3 months. |
| 8. | Set a clear SOHO-informed HFNO failure threshold in your post-operative respiratory failure pathway. HFNO avoids intubation but does not improve survival. Agree with your team what SpO₂, respiratory rate, or clinical trajectory triggers intubation, and ensure this is documented in your ICU protocol. SOURCES CHECKED THIS ISSUE UK Bodies: RCoA · Association of Anaesthetists · DAS · OAA · FICM · ICS · CPOC · NICE · MHRA · SALG · NAP Series · NIAA · NPIS · AoMRC · NHSBT · NHS England International: ESAIC · ESPA · ASA · SCCM · SSC (ESICM/SCCM) · ELSO · ERC/ILCOR · ERAS Society · WFSA · ESRA Journals (PubMed date-ranged): Anaesthesia · BJA · Anesthesiology · Anesth Analg · EJA · RAPM · IJOA · JCVA · Intensive Care Med · Crit Care Med · Critical Care · Resuscitation · NEJM · Lancet · JAMA · BJA Education (direct browse) · Cochrane Library FOAMed: The Bottom Line · EMCrit/PulmCrit · ATOTW (WFSA) · St Emlyn's · ESRA Academy · First10EM · LITFL · DAS Blog Next briefing: First week of June 2026 | Watch for: WCA 2026 outputs (Marrakech, 15-19 April), any DAS updates, NICE perioperative care pathway developments This newsletter is an educational summary for qualified medical professionals. It does not constitute clinical advice or replace primary sources, local guidelines, or senior clinical guidance. Drug doses and recommendations should be verified against current BNF, MHRA guidance, and local pharmacy protocols before prescribing. All clinical decisions should be made in the context of individual patient assessment. Limitations of original studies apply. Jake Turner Curated with the assistance of AI (Perplexity). All content editorially reviewed. |