Anaesthetics & ICU Evidence Rundown — September 2026

ANAESTHETICS & INTENSIVE CARE MEDICINE

Anaesthetics & ICU Evidence Rundown

Issue 8 · September 2026 · UK Edition

Jake Turner — Senior Registrar in Emergency Medicine, ST6 — Curated with the assistance of AI (Perplexity). All content editorially reviewed.

Full archive and PDF downloads at emevidence.org

Lead: ATS Clinical Practice Guideline 2026 (American) — Noninvasive Respiratory Support: strong recommendation for HFNC first-line in acute hypoxaemic failure (intubation RR 0.76); strong recommendation for HFNC or NIV for pre-intubation preoxygenation (NIV RR 0.51, HFNC RR 0.69 vs standard O2). CHANGE TONIGHT: Dräger Atlan ventilators — piston failure risk, supervise all affected machines (MHRA DSI/2026/005). NGPod pH device withdrawn after UK death from falsely reassuring result — quarantine all devices immediately (MHRA DSI/2026/009). PN filters mandatory for all parenteral nutrition (MHRA DSI/2026/011). CHANGE THIS MONTH: DOLVI RCT — videolaryngoscopy for double-lumen tube intubation improves first-pass success and reduces malposition; SGLT-2 inhibitors: stop 3–4 days before elective surgery (euDKA risk). ICECAP (JAMA): longer therapeutic hypothermia post-arrest does not improve outcomes — 24h TTM is sufficient.

BOTTOM LINE UP FRONT — SEPTEMBER 2026

ACT ON THIS NOW

CHANGE TONIGHT Dräger Atlan (MHRA DSI/2026/005): Risk of piston ventilator failure. Permanent supervision required for all affected machines until piston motor replaced. Contact your medical device lead today.

CHANGE TONIGHT NGPod withdrawal (MHRA DSI/2026/009): One UK death from falsely reassuring NG pH reading (tube in lung). Quarantine and dispose of all NGPod devices and sensors immediately. Transition to aspiration/pH strip confirmation.

CHANGE TONIGHT PN filters mandatory (MHRA DSI/2026/011): ≤1.2 µm filter required for all parenteral nutrition in all settings. Check your ICU PN protocols now.

CHANGE THIS MONTH DOLVI RCT (BJA): VL for double-lumen tube intubation increases first-pass success and reduces malposition vs direct laryngoscopy. Move VL to first-line for all DLT intubation.

CHANGE THIS MONTH SGLT-2 inhibitors: Stop 3–4 days before elective surgery. Risk of euglycaemic DKA — check blood ketones (not just glucose) in any perioperative patient on gliflozins with metabolic acidosis.

CHANGE THIS MONTH ICECAP (JAMA, n=1,900): 48h TTM does not improve neurological outcomes vs 24h in cardiac arrest survivors. Maintain 24h targeted temperature management as standard.

KNOW FOR NEXT TIME

INFORMING ATS NIRS Guideline 2026 (American): HFNC first-line for hypoxaemic failure; NIV or HFNC for preoxygenation; NIV preferred post-extubation in high-risk patients. Aligned with UK practice but note helmet NIV US bias.

INFORMING SODa-BIC (NEJM): IV sodium bicarbonate does not reduce AKI in acidotic ICU patients. Do not use for renoprotection in metabolic acidosis.

INFORMING LOGICAL (NEJM): Conservative O2 post-ROSC (SpO2 90–95%) no better than liberal. Target SpO2 94–98% — pragmatic and safe.

INFORMING PUMA extubation & foundation guidelines (Anaesthesia): New airway management guidelines covering extubation planning, risk stratification, and structured airway assessment. Read before your next difficult airway.

INFORMING GPICS V3 (ICS/CICM): New edition of the Guidelines for the Provision of Intensive Care Services now in effect. Audit your ICU against GPICS V3 standards.

INFORMING Core revision: Neuromuscular monitoring and reversal — TOF, depth of block, neostigmine vs sugammadex in 2026.

September's issue has an unusually high safety alert load: three MHRA device alerts demand immediate departmental action, including the withdrawal of the NGPod pH device following a UK patient death from a falsely reassuring reading when a nasogastric tube had been placed in the bronchus. Alongside the safety alerts, two large NEJM trials close questions that have been running in ICU practice for years: SODa-BIC confirms that sodium bicarbonate does not protect against AKI in acidotic patients, and ICECAP confirms that 48 hours of TTM post-arrest is no better than 24. The airway section is particularly strong this month, with the DOLVI RCT supporting videolaryngoscopy as first-line for double-lumen tube intubation, two new PUMA guidelines (extubation and airway foundation), and a classification systematic review of videolaryngoscope designs. The lead item — the American Thoracic Society Clinical Practice Guideline on Noninvasive Respiratory Support — is comprehensive and directly applicable to ICU and anaesthetic practice in the UK, though readers should note that helmet NIV recommendations are drawn heavily from US and Italian single-centre experience, and facemask NIV remains the UK standard for most indications.

WHAT'S INSIDE — ISSUE 8

• Safety: Dräger Atlan ventilator failure (MHRA)
• Safety: NGPod withdrawal after UK death (MHRA)
• Safety: PN filters mandatory (MHRA)
• Lead: ATS NIRS Guideline 2026 (American)
• ICECAP: 48h vs 24h TTM post-arrest (JAMA)
• SODa-BIC: NaHCO3 does not prevent ICU AKI (NEJM)
• LOGICAL: O2 targets post-ROSC (NEJM)
• DOLVI RCT: VL for double-lumen tube intubation
• PUMA: Extubation guidelines (Anaesthesia)
• PUMA: Airway assessment foundation guidelines
• VL classification: systematic review (Anaesthesia)
• RA alone for shoulder arthroscopy: less hypotension
• Real-time US for thoracic epidural (Anaesthesia RCT)
• PENG block anatomical basis (Reg Anesth Pain Med)
• SGLT-2 inhibitors: perioperative discontinuation
• Preoperative clear-fluid fasting: evidence review
• Postoperative hypotension: mechanism and vulnerability
• Cardiac surgery ventilation: BJA systematic review
• Frailty and ICU outcomes: BJA cohort
• ECMO long-term outcomes: critical care medicine
• ICU delirium coping: mixed-methods SR
• GPICS V3: ICS/CICM guideline update
• NAP8 case registry now open (RCoA)
• Ockenden: RCoA/OAA joint statement
• Quick Hits: dexmedetomidine survival, esketamine, i-gel size, negative pressure induction
• Core Revision: Neuromuscular Monitoring and Reversal

CHANGE TONIGHT Act immediately CHANGE THIS MONTH Adjust practice GUIDELINE Formal guidance INFORMING PRACTICE

Background evidence SAFETY ALERT

FINAL FRCA

AIRWAY

REGIONAL

ICU

PERIOPERATIVE

UK

Contents: 1. Safety Alerts — 2. Key ICU & Anaesthetics Trials — 3. Guidelines & UK Updates — 4. Airway & Regional — 5. Perioperative & Patient Safety — 6. Quick Hits — 7. Core Revision: Neuromuscular Monitoring & Reversal — 8. Action Points

1 — SAFETY ALERTS

CHANGE TONIGHT SAFETY ALERT UK

MHRA DSI/2026/005: Dräger Atlan Anaesthesia Workstations — Risk of Piston Ventilator Failure

MHRA / NHS England — Published: 4 August 2026 — gov.uk/drug-device-alerts The Dräger Atlan A300, A350, and A380 anaesthesia workstations have a reported risk of unexpected piston ventilator failure during use. The failure results from wear of the piston motor and may occur without warning. This is a device safety notice requiring immediate action in all UK operating theatres using Atlan machines.

Action required: Permanent visual supervision of all affected Atlan machines during use until the piston motor has been replaced by Dräger. Contact your theatre medical device lead and biomedical engineering team today. Do not use Atlan machines unsupervised. Arrange urgent servicing contact with Dräger. Have a backup ventilation plan available for every case on affected machines.

CHANGE TONIGHT SAFETY ALERT UK

MHRA DSI/2026/009: NGPod pH Device — Quarantine All Devices After UK Death from Falsely Reassuring Reading

MHRA — Published: 24 August 2026 — gov.uk/drug-device-alerts The NGPod pH testing device — used to confirm nasogastric tube position — has been withdrawn from the UK market following the manufacturer ceasing to trade. Critically, two UK patient safety incidents have been reported, including one death, where the device gave a falsely reassuring pH result when the tube was positioned in the bronchus rather than the stomach. All NGPod devices and sensor cartridges must be quarantined and disposed of immediately.

Action required: Remove all NGPod devices from clinical areas and kits immediately. Do not use any remaining stock. The underlying mechanism of false-positive readings must be understood: the device can read pH from bronchial secretions and report values interpreted as gastric, leading to failure to identify pulmonary malposition. Transition to aspiration and pH indicator paper (pH strip) as primary confirmation method. Report any prior incidents involving NGPod to your governance team and the MHRA via Yellow Card. Notify all staff who have used NGPod.

MHRA NatPSA/2026/004: ResMed Astral 100/150 Transport Ventilators — Supercapacitor Fault May Permanently Disable Device

MHRA / NHS England — Published: 17 August 2026 — gov.uk/drug-device-alerts A supercapacitor defect in affected ResMed Astral 100 and 150 ventilators can permanently disable the device without warning. These are used for home ventilator-dependent patients, inter-hospital transport, and critical care step-down. All affected patients must have a backup ventilation strategy in place within one month.

Action required: Identify all patients currently managed on ResMed Astral 100/150 ventilators. Ensure a viable backup ventilation strategy is documented for each patient within one month. Report affected devices and coordinate with the device manufacturer for replacement or inspection. Relevant to critical care retrieval, respiratory support, and ICU step-down teams.

2 — KEY ICU & ANAESTHETICS TRIALS

LEAD INFORMING PRACTICE ICU FINAL FRCA

Noninvasive Respiratory Support in Acute Respiratory Failure — Official ATS Clinical Practice Guideline 2026

Goel NN, Ferreyro BL, Pitre T et al. American Journal of Respiratory and Critical Care Medicine. 2026;212(9):2135–2158. doi:10.1093/ajrccm/aamag302 — American Thoracic Society (ATS) guideline — not a UK guideline body What this is: This is an official clinical practice guideline from the American Thoracic Society, based on four network meta-analyses covering 39 RCTs (acute hypoxaemic failure), 42 RCTs (hypercapnic failure), 15 RCTs (preoxygenation), and 52 RCTs (post-extubation). It is the most comprehensive noninvasive respiratory support (NIRS) evidence synthesis to date. The framing is American/international — apply with UK FICM/ICS/NICE context as noted below.

PICO 1: ACUTE HYPOXAEMIC RESPIRATORY FAILURE (39 RCTS, N=7,640)

Strong recommendation: HFNC over standard oxygen therapy as first-line noninvasive oxygenation strategy for adults with de novo acute hypoxaemic respiratory failure of any aetiology.

• RR 0.76 HFNC VS STANDARD O2 — INTUBATION (95%CI 0.64–0.89; MODERATE CERTAINTY)
• RR 0.81 HFNC VS STANDARD O2 — MORTALITY (95%CI 0.67–0.97; LOW CERTAINTY)
• RR 0.22 HELMET NIV VS STANDARD O2 — INTUBATION (95%CI 0.11–0.43; MODERATE CERTAINTY)
• n=7,640 39 RCTS; INCLUDES COVID-19 POPULATIONS; NETWORK META-ANALYSIS

PICO 2: ACUTE HYPERCAPNIC RESPIRATORY FAILURE (42 RCTS, N=4,763)

Strong recommendation: NIV via facemask for adults with acute hypercapnic respiratory failure. Conditional: HFNC as alternative to NIV in mild acidaemia (pH >7.25) only, with close monitoring and ready NIV escalation.

• RR 0.47 NIV VS STANDARD O2 — INTUBATION (95%CI 0.43–0.56; MOD CERTAINTY)
• RR 0.47 NIV VS STANDARD O2 — MORTALITY (95%CI 0.34–0.65; MOD CERTAINTY)
• HFNC only pH>7.25 CONDITIONAL RECOMMENDATION; MUST HAVE READY NIV ESCALATION

PICO 3: PREOXYGENATION BEFORE INTUBATION (15 RCTS, N=3,420)

Strong recommendation: HFNC or NIV via facemask for preoxygenation in adults with acute respiratory failure undergoing intubation. No recommendation for or against HFNC vs NIV for this indication.

• RR 0.51 NIV VS STANDARD O2 — PERI-INTUBATION HYPOXAEMIA (95%CI 0.39–0.65; HIGH CERTAINTY)
• RR 0.69 HFNC VS STANDARD O2 — PERI-INTUBATION HYPOXAEMIA (95%CI 0.54–0.88; HIGH CERTAINTY)
• NIV vs HFNC NIV PROBABLY REDUCES HYPOXAEMIA VS HFNC (RR 0.73; 95%CI 0.55–0.98; MOD CERTAINTY)

PICO 4: POST-EXTUBATION SUPPORT (52 RCTS, N=9,840)

Conditional: HFNC or NIV via facemask over standard O2 for all ICU patients post-extubation. Conditional: NIV preferred over HFNC or standard O2 in high-risk post-extubation patients (age >65, obesity, hypercapnia, prolonged ventilation, severe illness).

Critical appraisal — UK context: This is an American guideline. Key points for UK practice: (1) Helmet NIV evidence is largely from US and Italian single-centre expertise — facemask NIV remains the UK standard for hypoxaemic and hypercapnic failure and is the relevant recommendation for most UK ICUs. (2) Recommendations broadly align with FICM/ICS practice for NIV in COPD exacerbations and hypercapnic failure. (3) The HFNC strong recommendation for preoxygenation is directly applicable and supported by the EM/ICU evidence base (including PreVent, PREOXI). (4) Post-extubation NIV for high-risk patients aligns with existing FICM recommendations. Implementation should be guided by local expertise, infrastructure, and patient tolerance.

CHANGE THIS MONTH ICU FINAL FRCA

ICECAP Trial: 48h vs 24h Targeted Temperature Management Post-Cardiac Arrest — No Improvement in Neurological Outcomes

ICECAP Investigators. JAMA. 2026 Aug 5. PMID: 42554995

• No difference FAVOURABLE NEUROLOGICAL OUTCOME AT 6 MONTHS: 48H VS 24H TTM
• No difference 90-DAY MORTALITY; ICU LOS
• More AEs ADVERSE EVENTS (ARRHYTHMIA, HYPOKALAEMIA) HIGHER WITH 48H TTM
• n=1,900 MULTICENTRE RCT; OHCA WITH ROSC; TARGET 33°C BOTH ARMS

Action: 24 hours of TTM at 33°C remains the standard for post-cardiac arrest temperature management. There is no benefit from extending to 48 hours, and the adverse event profile is worse. Update your ICU post-ROSC protocol if it currently prescribes 48h TTM. Note: the benefit of TTM vs permissive normothermia (TTM-2 trial, 2021) remains debated — active fever prevention (<37.7°C) for 72h is the minimum standard.

INFORMING PRACTICE ICU FINAL FRCA

SODa-BIC Trial: IV Sodium Bicarbonate Does Not Reduce AKI in Acidotic ICU Patients

SODa-BIC Investigators. New England Journal of Medicine. 2026. PMID: 42283370

• No difference AKI INCIDENCE OR SEVERITY: NAHCO3 VS PLACEBO IN ICU METABOLIC ACIDOSIS
• No difference MORTALITY; RRT REQUIREMENT; HOSPITAL LOS
• NEJM 2026 MULTICENTRE RCT; METABOLIC ACIDOSIS PH <7.35 IN ICU PATIENTS

UK practice: Do not use IV sodium bicarbonate for renoprotection in ICU metabolic acidosis. The physiological rationale — correcting acidaemia to preserve renal function — is not supported by outcome data. Bicarbonate remains indicated for specific situations (severe hyperkalaemia, tricyclic antidepressant toxicity, certain poisonings). For ICU acidaemia: identify and treat the cause; optimise perfusion; avoid acidaemia-aggravating factors (eg hyperchloraemia from normal saline — use balanced crystalloid).

INFORMING PRACTICE ICU FINAL FRCA

LOGICAL Trial (NEJM): Conservative vs Liberal O2 Post-ROSC — No Difference in 180-Day Neurological Outcome

LOGICAL Investigators. New England Journal of Medicine. 2026. PMID: 42267831

• 38.2% FAVOURABLE NEURO OUTCOME 180D: CONSERVATIVE O2 (SPO2 90–95%)
• 39.7% FAVOURABLE NEURO OUTCOME 180D: LIBERAL O2 (SPO2 ≥96%)
• No diff MORTALITY; ALL SECONDARY OUTCOMES
• n=1,840 ICU POST-ROSC; LARGEST OXYGEN RCT IN THIS SETTING

Post-ROSC O2 management: Target SpO2 94–98% — avoid hyperoxia and hypoxia without being excessively restrictive. Tight conservative targets (90–95%) are safe but offer no survival advantage. A pragmatic approach: titrate supplemental O2 continuously with pulse oximetry; avoid 100% O2 on high-flow; avoid SpO2 <94% for more than brief periods. This is consistent with RCUK post-resuscitation care guidance.

3 — GUIDELINES & UK UPDATES

GUIDELINE ICU UK FINAL FRCA

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

Intensive Care Society and College of Intensive Care Medicine (formerly FICM). Published January 2026; featured at ICS SOA26, July 2026. ics.ac.uk GPICS V3 replaces GPICS V2 (2019) and updates minimum standards for UK intensive care units across infrastructure, workforce, and clinical processes. The new edition strengthens expectations on consultant-delivered care, multi-professional ward rounds, patient and family centred care, and ICU-to-rehabilitation pathways. It was the centrepiece of the ICS State of the Art Congress 2026 (SOA26, Birmingham).

UK action: UK ICUs should audit their practice against GPICS V3 standards. Key areas of strengthened expectation: daily consultant-led ward rounds, minimum staffing ratios, structured family communication, delirium assessment and management protocols, and rehabilitation planning from day 1. Available free via ics.ac.uk. GPICS V3 is the definitive UK standard for ICU provision and should be cited in local policy and governance.

INFORMING PRACTICE ICU UK

ICS: 10 New Research Priorities for UK Intensive Care — Published July 2026

Intensive Care Society. Published 1 July 2026. ics.ac.uk Developed via a James Lind Alliance-style priority-setting exercise, the ICS top 10 priorities now guiding UK intensive care research are: preventing and treating delirium; improving psychological recovery after critical illness; preventing Post-Intensive Care Syndrome (PICS); improving communication for critically ill patients; improving ICU-to-rehabilitation transitions; improving the ICU environment for patients and families; supporting family involvement in care; improving infection diagnosis and treatment in ICU; and two further priorities confirmed through the exercise.

For trainees and consultants: These priorities should guide QI projects, audit programmes, and research fellowships. If you are choosing an ICU research project, align it with these priorities to maximise relevance and funding potential.

UK INFORMING PRACTICE FINAL FRCA

RCoA/OAA Joint Statement on the Ockenden Maternity Review — Obstetric Anaesthesia Implications

RCoA and OAA. Published 17 July 2026. rcoa.ac.uk The RCoA and Obstetric Anaesthetists' Association welcomed the publication of the Ockenden Review into maternity services at Nottingham University Hospitals NHS Trust (published 24 June 2026) and issued a joint statement on implications for obstetric anaesthesia and maternity safety. The review identified systemic failures in team communication, escalation, consultant presence, and documentation.

UK practice: All obstetric anaesthetists should read the RCoA/OAA statement. Key implications: consultant presence at high-risk deliveries must be robust; consent for neuraxial analgesia and anaesthesia must be thorough and documented; structured communication (SBAR) between obstetric, midwifery, and anaesthetic teams should be embedded; epidural review protocols and response times must be audited. Link the Ockenden learning to your local maternity safety governance.

UK INFORMING PRACTICE REGIONAL FINAL FRCA

NAP8: RCoA Case Registry for Complications of Regional Anaesthesia — Now Open

RCoA / NAP8 Steering Group. Registry opened July 2026. rcoa.ac.uk The 8th National Audit Project (NAP8) focuses on complications of regional anaesthesia, including peripheral nerve blocks, central neuraxial blockade, local anaesthetic infiltration, and perioperative nerve injury. The case registry is now open, and departments performing regional anaesthesia are encouraged to report eligible cases. NAP8 will generate the largest UK dataset on regional anaesthesia complications to date.

Action: Register your department for NAP8 case submission. Case reporting is straightforward and takes approximately 10 minutes per eligible patient. NAP audits have historically generated landmark practice guidance — NAP4 (airway), NAP5 (awareness), NAP6 (anaphylaxis) are all now embedded in UK training and practice. NAP8 will define the regional complication safety landscape for the next decade.

4 — AIRWAY & REGIONAL ANAESTHESIA

CHANGE THIS MONTH AIRWAY FINAL FRCA

DOLVI RCT: Videolaryngoscopy for Double-Lumen Endobronchial Tube Intubation — Superior to Direct Laryngoscopy

DOLVI Trial. British Journal of Anaesthesia. Volume 136, 2026. BJA editorial: Rowland et al. argues for VL as first-line for DLT.

• Higher FPS FIRST-PASS SUCCESS: VL > DL FOR DOUBLE-LUMEN TUBE INTUBATION
• Less malposition REDUCED DLT MALPOSITION AND FIBREOPTIC REPOSITIONING REQUIRED
• BJA 2026 RCT; BJA EDITORIAL RECOMMENDS VL AS FIRST-LINE FOR ALL DLT

Change in practice: Move videolaryngoscopy to first-line for double-lumen tube intubation in all patients, not just those with predicted difficult airway. DLT malposition causes intraoperative desaturation and surgical complications — reducing this with VL is a patient safety improvement. Ensure your thoracic theatre VL devices are maintained and staff are trained. Fibreoptic bronchoscope confirmation of DLT position post-intubation remains standard regardless of intubation technique.

GUIDELINE AIRWAY FINAL FRCA

PUMA: Guidelines for Tracheal Extubation (Project for Universal Management of Airways)

PUMA Collaborators. Anaesthesia. 2026. The PUMA extubation guidelines provide a structured, evidence-based framework for tracheal extubation. Key elements: pre-extubation risk stratification (low vs high risk for failed extubation); preparation for extubation failure; choice of extubation technique (awake vs deep); post-extubation oxygenation strategy (HFNC/NIV for high-risk patients); and management of failed extubation. Special situations include obesity, OSA, difficult/failed intubation, ICU patients, and paediatric patients. PUMA guidelines are the extubation complement to the DAS intubation guidelines.

UK practice: Read the PUMA extubation guidelines before your next high-risk extubation. Extubation failure (requiring reintubation) is associated with significantly worse outcomes than primary intubation failure. The framework: (1) Stratify risk; (2) Plan for failure; (3) Optimise reversible factors; (4) Post-extubation oxygenation strategy; (5) HFNC or NIV for high-risk patients immediately post-extubation (consistent with ATS PICO 4 above). Share with your department.

GUIDELINE AIRWAY FINAL FRCA

PUMA: Guidelines for Providing a Foundation for Airway Assessment and Planning

PUMA Collaborators. Anaesthesia. 2026. The PUMA foundation guidelines standardise airway assessment, documentation, and communication across all patients requiring airway management. Core elements: a four-step model (Assess, Plan, Prepare, Perform); structured risk stratification; standardised documentation; and communication expectations between anaesthetists, recovery staff, and ICU teams. Intended to complement DAS guidelines and provide a universal framework regardless of the specific airway technique used.

Tell your department: PUMA provides the first truly comprehensive structured approach to airway management as a process, not just a technique. Review your departmental airway documentation practices — does every high-risk patient have a documented airway plan? PUMA gives you the framework to standardise this. Both PUMA guidelines (extubation + foundation) should be read as a pair.

INFORMING PRACTICE AIRWAY FINAL FRCA

Classification of Videolaryngoscopy — Systematic Review (Anaesthesia 2026)

Anaesthesia. 2026. Systematic review. This systematic review classifies videolaryngoscope designs and their clinical implications. Two main categories: channelled (device-integrated blade that guides tube delivery) and non-channelled (conventional blade with standard tube-plus-stylet insertion). Blade geometry also varies: hyperangulated blades improve glottic view but may hinder tube advancement; standard-geometry VL blades improve view compared to DL while retaining conventional insertion technique. Selection of VL device significantly affects technique and outcome in both normal and difficult airways.

Critical appraisal: VL devices are not interchangeable. A channelled device (e.g. Airtraq) provides a guide for tube delivery but limits positioning. A non-channelled hyperangulated device (e.g. C-MAC D-Blade, GlideScope) gives excellent view but requires a preformed stylet and different insertion angle. Know your device. Device selection should be part of your pre-intubation planning — particularly relevant for difficult airway lists.

INFORMING PRACTICE REGIONAL FINAL FRCA

Real-Time vs Pre-Procedural Ultrasound for Thoracic Epidural Insertion — RCT (Anaesthesia 2026)

Anaesthesia. 2026. RCT — lower thoracic epidural puncture. This RCT compared real-time ultrasound guidance vs pre-procedural scanning alone for lower thoracic epidural insertion. Real-time guidance improved first-attempt success rate and reduced the number of needle passes, skin punctures, and procedure time. Patient comfort was also improved.

UK practice: Real-time US-guided thoracic epidural is a skill that requires dedicated training — it is not simply pre-procedural scanning with a needle insertion immediately afterwards. Consider structured training in your department. This technique is particularly relevant for patients with obesity, scoliosis, or previous spinal surgery where anatomical landmarks are unreliable.

INFORMING PRACTICE REGIONAL FINAL FRCA

Regional Anaesthesia Alone Reduces Intraoperative Hypotension vs Combined GA+RA in Shoulder Arthroscopy (Beach-Chair Position)

Cohen-Balaloum V, et al. Regional Anesthesia and Pain Medicine. 2026. PMID: 40484653 In patients undergoing elective shoulder arthroscopy in the beach-chair position, regional anaesthesia alone (interscalene nerve block) was associated with significantly reduced intraoperative hypotension, shorter recovery times, and higher same-day discharge rates compared with combined general and regional anaesthesia. The beach-chair position carries significant risk of cerebral hypoperfusion from haemodynamic instability — avoiding GA reduces this risk.

UK practice: For shoulder arthroscopy in the beach-chair position, discuss RA-only technique (interscalene block + sedation) as a preferred approach where patient factors allow. Ensure your surgeons and teams are comfortable with RA-only cases. For combined GA cases: invasive arterial BP monitoring from the wrist at the level of the auditory meatus is appropriate; target MAP at ear level, not transducer level.

5 — PERIOPERATIVE MEDICINE & PATIENT SAFETY

Liberal Preoperative Clear-Fluid Fasting Does Not Increase Pulmonary Aspiration Risk — BJA Review

British Journal of Anaesthesia. 2026. Evidence review. This review synthesises evidence for liberal preoperative clear-fluid fasting regimens (clear fluids allowed up to 2 hours before elective surgery). There is no evidence that permitting clear fluids up to 2 hours preoperatively increases pulmonary aspiration risk in non-urgent adult patients. Liberal fasting reduces patient thirst, dehydration, pre-operative anxiety, and adverse insulin responses to surgery.

UK practice: ERAS and RCoA guidance already endorses 2-hour clear-fluid fasting. If your department still applies a "nil by mouth from midnight" policy for elective cases, this is out of line with current evidence and guidance. Work with your day surgery, anaesthetic, and nursing teams to implement 2-hour clear-fluid fasting as standard. Carbohydrate loading drinks 2 hours preoperatively are additionally supported by evidence for major surgery.

INFORMING PRACTICE

PERIOPERATIVE

FINAL FRCA

Postoperative Hypotension After Non-Cardiac Surgery — Mechanisms, Vulnerability, and Management (BJA)

British Journal of Anaesthesia. 2026. Review. Postoperative hypotension (POH; MAP <65 mmHg) occurs in up to 30% of patients recovering from major non-cardiac surgery and is independently associated with AKI, myocardial injury (MINS), and 30-day mortality. Key mechanisms: residual vasodilation from anaesthesia and neuraxial blockade; hypovolaemia; cardiac dysfunction; inflammatory vasodilation. High-risk populations: older patients, those with comorbidities, and patients undergoing major intra-abdominal or orthopaedic surgery.

UK practice: Consider continuous non-invasive BP monitoring in higher-risk patients in recovery and post-anaesthesia care units. Treat MAP <65 mmHg with early vasopressor initiation (noradrenaline 0.05–0.1 mcg/kg/min) rather than repeated fluid boluses in patients who are euvolaemic. Routine BP check intervals of 15 minutes are inadequate to detect transient postoperative hypotension — upgrade to continuous monitoring for major surgery patients.

INFORMING PRACTICE ICU FINAL FRCA

Perioperative Ventilation Strategies in Adult Cardiac Surgery — BJA Systematic Review

PMID: 42660723. British Journal of Anaesthesia. 2026. This systematic review found that ventilation strategies in cardiac surgery remain highly heterogeneous — no single optimal approach has been confirmed. Continued ventilation during cardiopulmonary bypass, rather than apnoea, is associated with lower rates of postoperative pulmonary complications. Low tidal volume ventilation (6–8 mL/kg IBW) with PEEP 5–8 cmH2O reduces atelectasis. Recruitment manoeuvres post-bypass have inconsistent evidence.

Tell your cardiac anaesthetic team: Standardise your cardiac theatre ventilation protocol around lung-protective principles: low Vt, PEEP 5–8 cmH2O, continued ventilation during bypass if feasible. Document your protocol and audit pulmonary complication rates. This is both an immediate patient safety intervention and an ERAS cardiac initiative.

INFORMING PRACTICE ICU

Pre-Admission Frailty and Functional Status Independently Predict ICU Mortality — BJA Cohort

British Journal of Anaesthesia. 2026. Cohort study. Pre-admission frailty (measured by Clinical Frailty Scale, CFS) and functional dependency were independently associated with higher ICU mortality in this large cohort. Frail patients who survived ICU admission had worse functional trajectories than non-frail patients. Overall post-ICU functional status was substantially reduced from pre-admission baseline in frail patients.

UK practice: Document CFS at ICU admission for all patients — it is a prognostic tool, an ICNARC-required field, and supports clinically appropriate goal-setting with patients and families. A CFS of 5+ at admission should prompt early goals-of-care discussion. Frailty does not contraindicate ICU admission but should inform treatment intensity, rehabilitation planning, and ceiling-of-care conversations.

INFORMING PRACTICE ICU FINAL FRCA

Long-Term Mortality and Functional Outcomes After ECMO — Large Cohort Study

Critical Care Medicine. 2026. Large cohort. Long-term mortality following ECMO varied substantially by modality: 37.2% of adults receiving VV-ECMO (for respiratory failure) died at long-term follow-up; VA-ECMO (for cardiac failure) had substantially higher long-term mortality. Survivors of both modalities had significant ongoing functional impairment at 6–12 months post-discharge.

Critical appraisal: Long-term outcomes after ECMO are worse than commonly communicated to patients and families during consent discussions. These data should inform ECMO patient selection conversations, MDT discussions, and family counselling. ECMO is life-sustaining — but the post-ECMO trajectory for many patients involves significant morbidity. Integrate long-term outcome data into your ECMO consent and withdrawal-of-treatment conversations.

INFORMING PRACTICE ICU

Psychosocial Coping with ICU Delirium in Patients and Families — Mixed-Methods Systematic Review

Critical Care (London). 2026. Mixed-methods SR. This systematic review examined coping strategies employed by patients and families in response to ICU delirium. Both patients and families actively used a range of strategies: seeking information and explanation, reframing the experience, maintaining hope, and drawing on social and professional support. Delirium causes lasting psychological distress in both patients (contributing to PICS) and families, yet family communication about delirium is often inadequate.

UK practice: ICU delirium management cannot focus solely on non-pharmacological prevention (lighting, orientation, early mobilisation) — family communication must be an explicit component. When a patient is delirious: (1) inform families early with an explanation; (2) involve families in reorientation; (3) normalise the experience while being honest about risks; (4) provide written information for families. Review your ICU delirium family communication protocol.

6 — QUICK HITS

INFORMING PRACTICE Dexmedetomidine: Intraoperative Use Not Associated with Improved Postoperative

Survival — Meta-Analysis FINAL FRCA

Frontiers in Pharmacology. 2026. Meta-analysis of real-world evidence.

Intraoperative dexmedetomidine is not independently associated with improved postoperative survival across real-world cohort data. This does not affect its well-established role in ICU sedation (reduced delirium vs benzodiazepines; MIDEX/PRODEX trials). For intraoperative use: prescribe for specific indications — opioid-sparing, attenuating haemodynamic response to intubation, sedation for awake fibreoptic intubation — not with expectation of survival benefit.

INFORMING PRACTICE Low-Dose IV Esketamine for Acute Postoperative Pain — RCT FINAL FRCA

Journal of Clinical Anaesthesia. 2026. RCT.

Low-dose intraoperative IV esketamine (sub-anaesthetic) reduced acute postoperative pain scores without significant increase in psychomimetic side effects. Supports the use of sub-anaesthetic ketamine/esketamine in multimodal opioid-sparing analgesia, particularly for opioid-tolerant patients, major abdominal surgery, or orthopaedic procedures. Consider as part of your ERAS protocol review.

INFORMING PRACTICE PENG Block: Anatomical Basis Confirmed — Dissection and Ultrasound Correlation

Study REGIONAL

Regional Anesthesia and Pain Medicine. 2026.

Detailed anatomical dissection confirms that the PENG (pericapsular nerve group) block targets the femoral nerve and accessory obturator nerve at the hip capsule. Cryo-cross-sections and ultrasound correlation validate the technique. Supports PENG as the preferred opioid-sparing regional technique for hip fracture and arthroplasty — complementing fascia iliaca compartment block approaches.

INFORMING PRACTICE Negative Pressure Ventilation During GA Induction in Predicted Difficult Airway —

Prolongs Safe Apnoea Time AIRWAY

British Journal of Anaesthesia. 2026.

Application of negative pressure ventilation (cuirass/NPV) during induction of general anaesthesia in predicted difficult airway patients significantly prolongs safe apnoea time and maintains SpO2 compared with standard preoxygenation. An emerging technique complementing HFNC-during-laryngoscopy for high-risk airway patients. Not yet widely available in UK theatres but worth awareness for complex airway planning discussions.

INFORMING PRACTICE i-gel Size 1.0 Too Large for Most Neonates — CT Assessment FINAL FRCA

British Journal of Anaesthesia. 2026. CT airway study.

CT imaging shows that the i-gel size 1.0 (the smallest commercially available) is markedly too large for all neonates weighing up to 1750g and most of those up to 2500g. This is a significant limitation for neonatal and paediatric anaesthesia. Always have a surgical airway plan for neonatal GA where SGA rescue is not viable — and inform neonatal teams of this device limitation for unexpected airway emergencies.

INFORMING PRACTICE ChloraPrep Supply Disruption — Plan Alternative Antiseptic for Regional and Vascular

Access Procedures UK

MHRA / NHS England. August 2026.

UK supply disruption of ChloraPrep (chlorhexidine-alcohol applicators), commonly used for skin antisepsis prior to regional anaesthesia, central line insertion, and other sterile procedures. Departments should identify alternative antiseptic preparations (chlorhexidine 2% + alcohol 70% alternative brands; povidone-iodine where CHX is contraindicated). Update your regional kit and central line trolleys accordingly.

CORE REVISION — ISSUE 8 — FINAL FRCA

Neuromuscular Monitoring and Reversal: TOF, Depth of Block, and the Neostigmine vs Sugammadex Evidence in 2026

Anaesthetics & ICU Evidence Rundown — UK Edition — emevidence.org

Exam goal: Understand train-of-four (TOF) monitoring, definitions of depth of neuromuscular block, the pharmacology and limitations of neostigmine vs sugammadex, and the clinical evidence for reversal strategies in 2026 including the SNaPP trial. Be able to justify your choice of reversal agent and state the dose-response relationship for sugammadex.

1. TRAIN-OF-FOUR (TOF) MONITORING

2. DEPTH OF NEUROMUSCULAR BLOCK

3. NEOSTIGMINE VS SUGAMMADEX: PHARMACOLOGY AND EVIDENCE

4. SNAPP TRIAL CONTEXT (ISSUE 7 — LANCET RESPIR MED 2026)

The SNaPP trial (PMID 42263720, Lancet Respir Med, June 2026 — covered in full in Issue 7) randomised 6,000+ patients to neostigmine vs sugammadex for reversal of rocuronium/vecuronium. Sugammadex was associated with a modest but significant reduction in postoperative pulmonary complications at 30 days (ARD –3.8%, NNT≈26). Combined with consistently higher rates of complete reversal (TOFR ≥0.9 at extubation), sugammadex should be considered the preferred reversal agent when rocuronium or vecuronium have been used — particularly for patients at higher risk of pulmonary complications (obese, OSA, thoracic, upper abdominal surgery, respiratory comorbidity).

5. BEST PRACTICE SUMMARY FOR REVERSAL IN 2026

Final FRCA Exam Focus: (1) Define TOF ratio and explain why TOFR <0.9 is clinically significant. (2) State the four depths of NMB and appropriate reversal agents at each depth. (3) Compare neostigmine and sugammadex: mechanism, dose, limitations, and evidence. (4) Quote the SNaPP trial: ARD, NNT, and clinical conclusion. (5) Describe the emergency sugammadex dose and expected response time. (6) Explain why subjective TOF monitoring cannot reliably confirm adequate reversal.

Anaesthetics & ICU Evidence Rundown — emevidence.org

FINAL FRCA

8 — ACTION POINTS

Jake Turner

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

Anaesthetics & ICU Evidence Rundown — Issue 8 — September 2026 — UK Edition Published by EM Evidence. For clinical use only — verify against local guidelines before implementing changes in practice. Feedback form · emevidence.org · emevidence999@gmail.com