Anaesthetics & ICU Evidence Rundown — May 2026

ANAESTHETICS & INTENSIVE CARE MEDICINE · UK EDITION

Anaesthetics & ICU Evidence Rundown

May 2026 | Monthly Issue

Jake Turner

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

Standout: Pfizer/MHRA DHPC warns of fatal intrathecal tranexamic acid → local anaesthetic mix-ups. Immediate theatre and storage changes required. Change items: REMAP-CAP corticosteroids in severe CAP signal possible harm — ICUs must re-evaluate steroid protocols • GLP-1RA perioperative cohort (n∼3M): increased PONV risk, tailored antiemetic protocols needed • NMJ monitoring with sugammadex now mandatory per ASA/ESAIC guidelines UK updates: OAA sterile gown guidance for spinal anaesthesia (20 April 2026) • Local anaesthetic infusion supply shortage patient safety alert • NAP8 and DAS eFONA registry actively recruiting

BOTTOM LINE UP FRONT — MAY 2026

ACT ON THIS NOW

SAFETY TXA/LA mix-up MHRA alert: Store tranexamic acid injectables separately from all LA solutions. Label all TXA syringes “IV USE ONLY.” Brief theatre teams today. Fatal cases reported across EU/UK.

THIS MONTH PONV protocol for GLP-1RA patients: Implement triple antiemetic prophylaxis for semaglutide/liraglutide users. Female and Hispanic patients at disproportionate risk. Update pre-assessment paperwork.

TONIGHT NMJ monitoring with sugammadex: Confirm TOF ratio ≥0.9 before extubation on all elective lists using rocuronium/vecuronium. Sugammadex must be on every anaesthetic machine.

SAFETY LA infusion supply shortage: Convene multidisciplinary working group; prioritise obstetric epidural services; prepare pharmacy substitution protocols now.

THIS MONTH OAA sterile gown guidance: Review your labour ward spinal anaesthesia SOP against the new OAA guidance (20 April 2026). Update and circulate to obstetric anaesthetic team.

THIS MONTH ABCDEF bundle delirium reduction: Implement all six bundle components in your ICU. Umbrella meta-analysis confirms 50% delirium reduction (OR 0.50; I²=0%).

KNOW FOR NEXT TIME

GUIDELINE WATCH REMAP-CAP CAP steroids ICU harm signal: Hydrocortisone in severe CAP shows OR 1.56 for 90-day mortality. Directly conflicts CAPE COD/SCCM 2024. Review ICU steroid protocols at governance.

INFORMING Neuraxial vs GA in former preterm infants: Neuraxial anaesthesia reduces apnoea risk PMA cutoff from ~53w to ~38w (10% risk threshold). Key for day-case inguinal hernia planning.

INFORMING Cell salvage thresholds in cardiac surgery: 0.66–0.88 L threshold identifies when proactive factor replacement should be considered. Dose-dependent association (n=883).

INFORMING NAP8 regional anaesthesia recruitment open: First national audit of regional anaesthesia complications. Enrol your department and designate a NAP8 lead.

INFORMING DAS eFONA registry recruiting: All emergency front-of-neck airway events should be reported. Critical for post-DAS 2025 guideline real-world data.

INFORMING Propofol vs inhalational TIVA debate: No adequately powered RCT for mortality outcomes. 2026 editorial challenges latest 1,200-patient RCT. Final FRCA topic — know both sides.

FRCA REVISION Core revision: NMJ monitoring and sugammadex: TOF ratio ≥0.9 = full recovery. Deep block (TOF count 0–1): sugammadex 16 mg/kg. High-dose rocuronium RSI = credible suxamethonium alternative.

May 2026 brings two collisions of evidence and practice. An MHRA-backed manufacturer communication warns of fatal tranexamic acid intrathecal injections following mix-ups with local anaesthetics — a “never event” that has killed patients across Europe. REMAP-CAP’s corticosteroid domain directly contradicts CAPE COD and current SCCM guidelines, placing ICU teams in an uncomfortable position mid-admission. A landmark 3-million-patient GLP-1RA cohort reshapes perioperative risk conversations, paediatric anaesthetic teams gain clearer PMA thresholds for neuraxial vs GA in former preterm infants, and the ARTIST study confirms regional anaesthesia is feasible in minimally invasive thoracic surgery. This issue also covers the OAA’s first sterile gown guidance for spinal anaesthesia and a Core Revision section on neuromuscular monitoring and sugammadex — the paradigm shift quietly rewriting airway strategy.

CONTENTS

Key Anaesthetics & ICU Articles

1. MHRA / Pfizer DHPC: Fatal TXA → Local Anaesthetic Mix-ups 2. REMAP-CAP Corticosteroids: Hydrocortisone Signal of Harm in Severe CAP 3. GLP-1RA Perioperative Outcomes — n∼3 Million Cohort 4. Postanaesthesia Apnea: Neuraxial vs GA in Former Preterm Infants 5. Cell Salvage Volume & Coagulation in Cardiac Surgery 6. ABCDEF Bundle: Umbrella Meta-analysis Confirms 50% Delirium Reduction

Guidelines & UK Updates

7. National Patient Safety Alert: Local Anaesthetic Infusion Bag Supply Shortage 8. OAA: Sterile Gown Guidance During Spinal Anaesthesia (April 2026) 9. RCoA Scottish Manifesto & Training Bottleneck Response 10. FICM Education 2026: Critical Care Rehabilitation

Airway & Regional

11. Era of Sugammadex: Paradigm Shift in Airway Strategy 12. ARTIST Study: Regional Anaesthesia in VATS/RATS 13. ESPB vs Intercostal Blocks in Uniportal VATS (RCT) 14. DAS eFONA Registry & Difficult Airway Registry

Perioperative & Patient Safety, FOAMed, Core Revision, Action Points, Trials to Watch

1 — KEY ANAESTHETICS & ICU ARTICLES

PHARMACEUTICAL JOURNAL / PFIZER DHPC (MHRA-BACKED) · 30 APRIL 2026

1. Pfizer/MHRA DHPC: Fatal Intrathecal Tranexamic Acid — Local Anaesthetic Mix-Ups

CHANGE TONIGHT SAFETY ALERT REGIONAL Final FRCA

Inadvertent intrathecal administration of tranexamic acid (due to mix-up with bupivacaine/levobupivacaine vials) has caused deaths and severe harm in EU/UK cases. Pfizer/MHRA issuing Direct Healthcare Professional Communication. Serious adverse reactions include severe back, gluteal and lower limb pain; myoclonus; generalised seizures; cardiac arrhythmias; and death. EMA reviewed October 2025; MHRA letter now circulating to UK HCPs. RCoA President Claire Shannon: “Prefilled syringes should be made available for TXA.”

Safety Alert: Cases involve mix-ups of identical-looking vials/ampoules. Both drugs are clear, colourless solutions in similar packaging — the key systems hazard. Risk is dose-dependent and related to the pharmacology of intrathecal TXA (GABA antagonism, Na-channel blockade). SALG advocates for TXA in prefilled syringes — support local procurement bids.

What You Must Do: (1) Store TXA injectables in a separate location from all LA solutions in anaesthetic rooms, drug fridges, and theatre trolleys. (2) Label all TXA syringes drawn up for IV use with “IV USE ONLY — NOT FOR NEURAXIAL USE.” (3) Brief anaesthetic technicians, scrub teams, and recovery staff. (4) Raise at next departmental M&M/governance meeting. (5) SALG advocates for TXA in prefilled syringes — support local procurement bids.

Critical Appraisal: DHPC/manufacturer communication is not an RCT — it is a patient safety alert driven by case series and EU regulatory review. This is a systems failure, not a pharmacological surprise. GRADE: Not applicable. Implementation friction: LOW (labelling and storage changes only).

Source: Pharmaceutical Journal / Pfizer DHPC — April 2026

REMAP-CAP PLATFORM TRIAL · INTENSIVE CARE MEDICINE / THE BOTTOM LINE · APRIL 2026

2. REMAP-CAP Corticosteroids: Hydrocortisone Signal of Possible Harm in Severe CAP

CHANGE THIS MONTH ICU Final FRCA

In severe CAP requiring ICU admission, a 7-day course of hydrocortisone 200 mg/day did NOT reduce 90-day mortality and showed a signal of harm (OR 1.56, 95% CrI 0.80–3.31). This directly conflicts with CAPE COD (2023) and SCCM 2024 guidelines. ICUs must not automatically continue or initiate steroids for CAP post-admission without team discussion.

Key Statistics

• OR 1.56 HARM SIGNAL — 90D MORTALITY
• 10% PROBABILITY OF BENEFIT
• 95% CrI 0.80 – 3.31
• n=643 SEVERE CAP, ICU

ICU/Anaesthetic Angle: Post-ICU admission management — patients admitted for severe CAP often continue steroids started in ED. These data suggest this practice should be re-examined. The CAPE COD vs REMAP-CAP conflict: CAPE COD was blinded, REMAP-CAP open-label. The 23% cross-over in the control arm weakens REMAP-CAP’s signal. SCCM 2024 guidelines still recommend corticosteroids. Reasonable approach: shared decision-making; do not initiate hydrocortisone routinely; consider tapering decisions post-48h based on clinical trajectory. Document rationale for every course now.

Why It Matters: Hydrocortisone use in CAP is common in UK ICUs. If this harm signal is confirmed, it will represent one of the most significant reversals in critical care practice since corticosteroids became standard for CAP.

Source: The Bottom Line — REMAP-CAP Corticosteroids Summary

ANESTHESIOLOGY · APRIL 2026 · PMID 41895163

3. GLP-1 Receptor Agonist Users and Perioperative Outcomes — Retrospective Cohort n∼3 Million

CHANGE THIS MONTH PERIOP Final FRCA

In the largest perioperative GLP-1RA cohort to date (~3 million patients), GLP-1RA use was associated with reduced 30-day mortality but significantly increased PONV. Female and Hispanic patients had disproportionately higher PONV and complication rates. Tailored perioperative management — including extended antiemetic protocols and gastric ultrasound use — is now supported by large-scale data.

• ▼ Mortality REDUCED 30D MORTALITY
• ▲ PONV INCREASED PONV RISK
• Female / Hispanic HIGHER RISK SUBGROUPS
• n∼3M RETROSPECTIVE COHORT

Why It Matters: GLP-1RAs are now among the most prescribed drugs in the UK. This cohort confirms the gastroparesis/delayed gastric emptying concern is clinically real, but also shows a net mortality benefit. The key actionable point is risk stratification by sex and ethnicity, and proactive antiemetic protocol adjustment for GLP-1RA patients in consent and pre-assessment paperwork.

Critical Appraisal: Retrospective design with unmeasured confounders. GLP-1RA users may be healthier in some dimensions. The mortality benefit may partly reflect indication bias. The PONV finding is consistent with mechanism and multiple smaller studies. GRADE: Very low for mortality; low for PONV. CPOC already published GLP-1RA perioperative guidance — this cohort reinforces it.

Source: Anesthesiology, April 2026 — PMID 41895163

ANESTHESIOLOGY · MARCH 2026 · PMID 41894258

4. Postanaesthesia Apnea in Former Preterm Infants: Neuraxial vs GA — IPD Meta-analysis

CHANGE THIS MONTH PAEDS REGIONAL Final FRCA

The largest individual patient data meta-analysis on this topic shows neuraxial anaesthesia substantially reduces the postmenstrual age (PMA) cutoff at which apnoea risk falls below 10%: from ~53 weeks PMA (GA) to ~38 weeks PMA (neuraxial). This has direct implications for safe day-case or short-stay inguinal hernia repair planning in former preterm infants.

• 38w PMA 10% RISK — NEURAXIAL
• 53w PMA 10% RISK — GA
• OR 6.0 GA VS NEURAXIAL APNOEA ODDS
• IPD MA INDIVIDUAL PATIENT DATA

PMA cutoffs at which apnoea risk <1%: 65w PMA (GA) vs 45w PMA (neuraxial). Anaemia is a risk factor only for infants >48w PMA. GA with caudal block (OR 2.94) also has higher risk than neuraxial alone.

Why It Matters: This IPD meta-analysis provides the most precise PMA thresholds to date, and strongly supports offering spinal or caudal anaesthesia to eligible former preterm infants, enabling earlier same-day discharge planning. The benefit is large (OR ~6) and consistent across strata. GRADE: Moderate.

Source: Anesthesiology, March 2026 — PMID 41894258

JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA · MARCH 2026 · PMID 41875678

5. Cell Salvage Volume & Coagulation/Transfusion Requirements in Cardiac Surgery

INFORMING PRACTICE Final FRCA PERIOP

In cardiac surgery, cell salvage volume shows a dose-dependent association with post-CPB coagulation requirements. The 0.66–0.88 L threshold identifies when haematology/transfusion team involvement and proactive factor replacement should be considered.

• 0.66–0.88 L DOSE-DEP. COAGULOPATHY THRESHOLD
• Dose-dep. ASSOCIATION WITH COAG. TRANSFUSION
• n=883 CARDIAC SURGERY PTS

Critical Appraisal: Retrospective single/multi-centre design — unmeasured confounders (greater cell salvage needed in more bleeding patients, which are also more coagulopathic). Cannot determine if cell salvage volume causes coagulopathy or if both are markers of severity. However, the dose-response relationship is biologically plausible (washed RBCs deplete coagulation factors). Use as an early trigger for proactive haemostatic management, not a contraindication to cell salvage. GRADE: Very low.

Source: J Cardiothorac Vasc Anesth, March 2026 — PMID 41875678

CRITICAL CARE / PUBMED · PMID 41185378 · UMBRELLA META-ANALYSIS

6. ABCDEF Bundle: Umbrella Meta-analysis Confirms 50% Reduction in ICU Delirium

CHANGE WHEN GUIDELINE UPDATES

ICU

Final FRCA

Moderate-to-high certainty evidence across multiple meta-analyses shows ABCDEF bundle compliance reduces ICU delirium incidence by 50% (OR 0.50; 95% CI 0.39–0.65; p<0.001; I²=0%). ICU LOS and mechanical ventilation duration also reduced. This is the strongest summary evidence to date for the bundle as a whole.

• OR 0.50 DELIRIUM RISK REDUCTION
• 50% ARD DELIRIUM INCIDENCE
• I²=0% LOW HETEROGENEITY
• Mod–High GRADE CERTAINTY

Why It Matters: ICU delirium is associated with longer ventilation, increased mortality, and post-ICU cognitive impairment. The six bundle components (Assess pain, Both SAT/SBT, Choose sedation, Delirium assessment, Early mobilisation, Family engagement) are all feasible in most UK ICUs. This umbrella MA provides the highest-level summary — share with your ICU governance committee.

Source: Critical Care — PMID 41185378

2 — GUIDELINES & UK UPDATES

NHS ENGLAND / RCOA · APRIL 2026

7. National Patient Safety Alert: Local Anaesthetic Infusion Bag Supply Shortage

CHANGE TONIGHT SAFETY ALERT UK DATA

A national patient safety alert has been issued to all UK healthcare providers regarding supply issues affecting commercially prepared local anaesthetic infusions. All Trusts must convene a working group and implement mitigation plans for the duration of the shortage.

Immediate Action Required: (1) Assemble a multidisciplinary working group including pharmacy, anaesthetics, pain team, and theatres. (2) Identify which commercially prepared LA infusions are affected (e.g., bupivacaine epidural bags, levobupivacaine infusions). (3) Prepare substitution protocols — consider local preparation under pharmacy supervision. (4) Prioritise obstetric anaesthesia (labour epidurals) and post-operative pain services. (5) Document all substitutions and report adverse events via yellow card. (6) DO NOT substitute with higher-concentration preparations without appropriate dilution protocols.

Tell Your Department: This shortage may affect labour ward epidural services, post-surgical pain infusions, and nerve block top-ups. Inform theatre coordinators and ward staff of any changes to standard LA preparation protocols.

Source: RCoA News — April 2026

OBSTETRIC ANAESTHETISTS’ ASSOCIATION · 20 APRIL 2026

8. OAA: New Guidance on Sterile Gown Use During Spinal Anaesthesia

CHANGE WHEN GUIDELINE UPDATES OBSTETRIC REGIONAL Final FRCA

The OAA has published new guidance specifying when sterile gown use is required during spinal anaesthesia, in response to evidence on infection risk and inconsistent practice across UK units. This is especially relevant for obstetric spinal practice in labour wards.

Why It Matters: Spinal abscess and meningitis following neuraxial procedures are rare but catastrophic. The OAA guidance will standardise aseptic technique requirements for spinal anaesthesia across UK obstetric units. Review your current labour ward protocol against the new guidance. NICE NG51 (caesarean section) requires strict aseptic technique — this OAA guidance provides more specific details on gown use for spinal procedures.

Tell Your Department: Share with lead obstetric anaesthetist and theatre/labour ward managers. Update local SOPs to reflect the OAA guidance. Confirm with your infection control team.

Source: OAA News — 20 April 2026

ROYAL COLLEGE OF ANAESTHETISTS · APRIL 2026

9. RCoA: Scottish Manifesto & Medical Training (Prioritisation) Bill Response

INFORMING PRACTICE UK DATA

Ahead of the May 2026 Scottish Parliament election, the RCoA published its manifesto on tackling Scottish NHS waiting lists through anaesthesia. The RCoA also formally responded to the Medical Training (Prioritisation) Bill, flagging that bottlenecks in anaesthetic training are central to NHS waiting list recovery.

The RCoA and CPOC also announced appointments of new Deputy Directors — Dr Jo Simpson and Professor Javed Sultan — to strengthen the perioperative care agenda. The RCoA has stopped posting on X (formerly Twitter) due to rise in harmful content.

Tell Your Department: The RCoA’s response to the Medical Training Bill is relevant to trainees and consultants in regions where anaesthetic training numbers are below safe staffing thresholds. Consider making a local representation via your Regional Advisor or College Tutor.

Source: RCoA News — April 2026

FACULTY OF INTENSIVE CARE MEDICINE · 28 APRIL 2026

10. FICM Education 2026: Critical Care Rehabilitation

INFORMING PRACTICE ICU UK DATA

FICM’s 2026 education event focused on critical care rehabilitation, aligning with GPICS V3 standards on post-ICU rehabilitation and long-term functional outcomes. Covers early mobility, physiotherapy integration, and post-ICU follow-up standards.

Why It Matters: GPICS V3 (January 2026) mandates that ICU services provide validated functional outcome metrics after ICU discharge. ICU-acquired weakness affects 25–33% of ventilated patients — early physiotherapy remains one of the few effective interventions.

Source: FICM Events — 28 April 2026

3 — AIRWAY & REGIONAL

ANESTHESIOLOGY 2026;144(4):978–997 · PMID 41805213 · MARCH 2026

11. Era of Sugammadex: A Paradigm Shift in Airway Management Strategy

CHANGE WHEN GUIDELINE UPDATES

AIRWAY

Final FRCA

Comprehensive review formally documents how sugammadex has fundamentally changed airway strategy. The complete, reliable reversal of steroidal NMBAs (rocuronium/vecuronium) enables high-dose rapid-sequence rocuronium as a credible alternative to succinylcholine, with no ceiling effect and no risk of residual NMB. This is a Final FRCA core topic.

Key Points from the Review (1) High-dose rocuronium (1.2 mg/kg) provides intubating conditions equivalent to succinylcholine with full reversal guaranteed by sugammadex. (2) No cholinergic side effects unlike neostigmine. (3) Safe use in penetrating eye injury, hyperkalaemia risk, malignant hyperthermia susceptibility. (4) Cost barrier reducing with generic availability.

Critical Appraisal: This is a narrative review, not primary RCT evidence. However, the underlying evidence base for sugammadex over neostigmine is now well-established across multiple RCTs and the ESAIC/ASA quantitative NMB monitoring guidelines. Key limitation: sugammadex does not reverse benzylisoquinolinium agents (atracurium, cisatracurium). Quantitative TOF monitoring remains essential to confirm full reversal.

Source: Anesthesiology, March 2026 — PMID 41805213

ANESTHESIOLOGY · MARCH 2026 · PMID 41875998 · PROSPECTIVE MULTICENTRE OBSERVATIONAL, N=456

12. ARTIST Study: Regional Anaesthesia in VATS/RATS — French Multicentre Observational

CHANGE WHEN GUIDELINE UPDATES

REGIONAL

Final FRCA

Regional anaesthesia (paravertebral blocks, ESP blocks, intercostal blocks) is feasible and widely used in video-assisted (VATS) and robot-assisted (RATS) thoracic surgery across major French thoracic units. This multicentre observational study provides the first large-scale national description of regional anaesthesia practice in minimally invasive thoracic surgery.

• n=456 VATS/RATS PATIENTS
• 23 centres FRENCH THORACIC SURGERY UNITS
• Observational FEASIBILITY / PRACTICE MAPPING

Why It Matters: UK thoracic anaesthesia practice increasingly involves VATS/RATS. This study confirms that regional anaesthesia is not just possible but standard of care in French centres — paravertebral block (PVB) and erector spinae plane block (ESPB) predominate. With PROSPECT recommendations and ASA 2026 fascial plane block guidelines, this supports integrating regional techniques into UK VATS/RATS protocols.

Critical Appraisal: Observational design — cannot determine which regional technique is most effective (no comparator arm). French practice may not directly map to UK centres. RCT data (comparing PVB vs ESPB in VATS) would be the next level of evidence.

Source: Anesthesiology, March 2026 — PMID 41875998

ANESTHESIOLOGY 2026;143:1015 · MULTICENTRE DOUBLE-BLIND RCT

13. ESPB vs Intercostal Nerve Blocks in Uniportal VATS: RCT

INFORMING PRACTICE REGIONAL Final FRCA

In uniportal VATS, thoracoscopy-guided intercostal nerve blocks (ICNB) provided superior early analgesic effect (at 4 and 8 hours) compared to ESPB, though the difference disappeared at 24 hours. Both techniques gave high patient satisfaction and mild pain intensities in both groups.

• ICNB superior EARLY PAIN (4–8H)
• No difference 24H OPIOID CONSUMPTION
• n=100 DOUBLE-BLIND, PLACEBO-CONTROLLED

Critical Appraisal: Well-designed double-blind RCT with placebo controls. The ICNB advantage is early but not sustained. In practice, the choice between ICNB and ESPB may depend on surgeon willingness to perform ICNB at thoracoscopy insertion vs anaesthetist-placed ESPB pre-operatively. Both are appropriate for uniportal VATS.

Source: Anesthesiology 2026;143:1015 — PMC editorial

DIFFICULT AIRWAY SOCIETY · MARCH 2026

14. DAS: eFONA Registry & Difficult Airway Registry — Open for Submissions

INFORMING PRACTICE AIRWAY UK DATA

DAS is actively recruiting for both the eFONA Registry (emergency front-of-neck airway events) and the Difficult Airway Registry. Both registries are critical to building UK-specific evidence on airway emergency incidence, outcomes, and training needs post-DAS 2025 guidelines.

The DAS eFONA Registry specifically captures “Had a Plan D?” events. With the DAS 2025 guidelines now in place, real-world data on Plan D implementation, success rates, and complications are urgently needed. The DAS Professor 2026 and Adrian Pearce Award nominations are also open.

Tell Your Department: Ensure all eFONA events are reported to the DAS registry. This is equivalent in importance to NAP4 case reporting. Use your local M&M process to facilitate reporting. Every case provides critical data for future UK airway guidelines.

Source: DAS News — March 2026

4 — PERIOPERATIVE & PATIENT SAFETY

ROYAL COLLEGE OF ANAESTHETISTS / RCEM · 2026

15. NAP8: Regional Anaesthesia Complications Audit — Active Recruitment

INFORMING PRACTICE REGIONAL UK DATA SAFETY ALERT

NAP8 is the first national audit specifically exploring regional anaesthesia complications in Emergency Departments and the wider perioperative environment across UK and Ireland. Active recruitment is under way in 2026. All EDs and anaesthetic departments performing nerve blocks should ensure they are enrolled.

Why It Matters: Regional anaesthesia in the ED is expanding rapidly. NAP8 will provide the first national data on complication rates, near misses, and training requirements. This follows the model of NAP4 (airway) and NAP5 (accidental awareness) — both transformed UK practice. Your participation directly shapes the guidelines your juniors will train on.

Tell Your Department: Contact your Regional Advisor to confirm enrolment. Designate a NAP8 lead for your department. Ensure all nerve block complications (haematoma, nerve injury, LAST, failed block) are captured through the NAP8 reporting pathway.

Source: NAP8 Information — RCoA/RCEM 2026

CRITICAL CARE 2026 · PMC12990538

16. Propofol TIVA vs Inhalational Anaesthesia: The Evidence Debate Continues

INFORMING PRACTICE Final FRCA

Ongoing controversy surrounds observational data suggesting propofol TIVA may have outcomes advantages over inhalational agents (less delirium, lower mortality in some cohorts). A 2026 Critical Care editorial challenges the latest 1,200-patient RCT showing higher delirium with propofol, highlighting methodological limitations. This is a live debate with direct Final FRCA examination relevance.

Key Debate Points (1) Retrospective cancer cohorts showing 50% higher mortality with volatile agents. (2) Korean nationwide cohort (n>700,000 spine surgery) — increased in-hospital mortality with inhalational anaesthesia. (3) Current RCTs are underpowered for mortality. (4) Mechanistic plausibility for both: propofol has anti-inflammatory effects; volatiles have ischaemic preconditioning properties.

Critical Appraisal: No adequately powered RCT exists for TIVA vs VIMA mortality outcomes. All observational data suffer from indication bias. Current RCoA and AAGBI guidance does not mandate one over the other. For oncological surgery, some units have adopted TIVA by default pending better evidence. For delirium prevention, propofol may have a marginal advantage in older patients — but this is not established at high certainty.

Source: Critical Care 2026 — PMC12990538

5 — FOAMED & CRITICAL APPRAISAL

EMCRIT PODCAST · APRIL 2026

17. EMCrit Wee: DAS 2025 Guidelines Discussion — Protected Airway Collaborative

INFORMING PRACTICE AIRWAY

Scott Weingart discusses the DAS 2025 guidelines with Jonathan St George of the Protected Airway Collaborative. Key controversies: DAS recommends 3+1 intubation attempts; Weingart advocates “3 and done.” The podcast covers Plan A–D implementation, NIPPV pre-oxygenation evidence, and post-DAS practice changes in critical care airway management.

Practical pearls: MACOCHA score, predictors of difficult mask ventilation, importance of having push-dose vasopressors drawn up before any critical care intubation, and the physiological vs anatomical distinction in difficult airway assessment. Excellent listening before any difficult airway workshop or FRCA OSCE preparation.

Source: emcrit.org — April 2026

THE BOTTOM LINE / ICM · 2026

18. The Bottom Line: REMAP-CAP & Family Voice Recordings for Delirium

INFORMING PRACTICE ICU

Two standout summaries this month. (1) REMAP-CAP corticosteroids — full structured appraisal confirming harm signal and limitations. (2) Delirium reduction using scripted family voice recordings in mechanically ventilated patients (Am J Crit Care 2025) — structured family voice reorientation reduces delirium days; feasible, low-cost intervention that aligns with ABCDEF bundle F (Family engagement).

Source: thebottomline.org.uk — ICM summaries 2026

6 — QUICK HITS

OAA ASM 2026

OAA Annual Scientific Meeting Liverpool — 14–15 May 2026. Labour analgesia, post-caesarean pain, obstetric haemorrhage, maternal cardiac arrest on the programme. Registration open.

OBSTETRIC

AIRWAY

DAS 2026 WALES

DAS Annual Scientific Meeting 2026 — Wales. Programme includes DAS Residents Competition, FDAS nominations, and the Adrian Pearce Award. Details on DAS website.

NACCS 2026

Neuro Anaesthesia and Critical Care Society Annual Meeting — 6–8 May, Edinburgh. Neurological disease and anaesthesia, neuro ICU updates.

ICU

SOAP 2026

Society for Obstetric Anesthesia and Perinatology 58th Annual Meeting — April 29–May 3, Quebec. Key obstetric anaesthesia research will be presented — watch for spinal hypotension vasopressor updates and labour analgesia outcomes data.

OBSTETRIC

BJA EDUCATION

BJA Education 2026 Editorial Board applications open. Applications for membership of the BJA Education Editorial Board to commence 2026 — apply via RCoA.

UK DATA

EMCRIT PULMCRIT

PulmCrit: HI-PEITHO trial — low-dose alteplase in PE. ICU/anaesthetic relevance: thrombolysis decision-making in post-surgical/post-anaesthetic PE. STRATIFY trial (catheter-directed = peripheral lysis) also covered.

ICU

CORE REVISION — FINAL FRCA TOPIC

Neuromuscular Monitoring & Sugammadex: The Paradigm Shift

Relevant to: Final FRCA written (pharmacology + physiology), OSCE (NMB reversal), BJA written paper

NMB Monitoring — Quantitative vs Qualitative

Sugammadex vs Neostigmine

Residual NMB (RNMB) — Clinical Impact

RNMB (TOF ratio <0.9) is associated with: ▸ Upper airway obstruction ▸ Impaired hypoxic ventilatory response ▸ Pulmonary aspiration risk ▸ Prolonged PACU stay ▸ 2× risk of postoperative pulmonary complications. Incidence with neostigmine reversal: 20–40%. Incidence with sugammadex + quantitative monitoring: <5%.

Key Exam Mnemonics

7 — ACTION POINTS

• Store TXA and local anaesthetic solutions in separate locations in every anaesthetic room and drug fridge. Label all drawn-up TXA syringes “IV USE ONLY — NOT FOR NEURAXIAL USE.” Brief theatre and recovery teams today. (MHRA/Pfizer DHPC, April 2026)
• Convene a departmental working group on the commercial LA infusion shortage. Identify which products are affected, develop pharmacy substitution protocols, and prioritise obstetric epidural services. (NHS England Patient Safety Alert)
• Review your unit’s CAP steroid protocol in light of REMAP-CAP. Do not automatically initiate or continue hydrocortisone in severe CAP post-ICU admission without team discussion and documented rationale. Flag at next governance meeting. (REMAP-CAP, ICM 2026)
• Update GLP-1RA pre-assessment paperwork to capture drug name, dose, and formulation (weekly vs daily). Implement extended antiemetic prophylaxis (triple therapy: ondansetron + dexamethasone + droperidol or aprepitant) for GLP-1RA users. Flag high-risk subgroups (female, Hispanic). (PMID 41895163)
• Implement quantitative neuromuscular monitoring on all elective lists where rocuronium or vecuronium is used. Confirm TOF ratio ≥0.9 before extubation. Ensure sugammadex is available on every anaesthetic machine. (ASA/ESAIC NMB Guidelines 2023, PMID 41805213)
• For paediatric inguinal herniorrhaphy in former preterm infants: discuss spinal/caudal anaesthesia with the team. Neuraxial reduces apnoea risk cutoff from ~53w to ~38w PMA — consider this in day-case admission threshold decisions. (PMID 41894258)
• Enrol your department in NAP8 if not already done. Designate a NAP8 lead and ensure all regional anaesthesia complications are captured through the reporting pathway. (RCoA/RCEM NAP8)
• Review OAA sterile gown guidance for spinal anaesthesia against your current labour ward SOP. Update protocol if needed and circulate to obstetric anaesthetic team. (OAA, 20 April 2026)

TRIALS TO WATCH

Jake Turner

Curated with the assistance of AI (Perplexity). All content editorially reviewed. Anaesthetics & ICU Evidence Rundown — May 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