Anaesthetics & ICU Evidence Rundown — June 2026

UK EDITION · ISSUE 6 · JUNE 2026

Anaesthetics & Intensive Care Medicine — UK Edition

Monthly evidence review for anaesthetics and ICU clinicians

Jake Turner

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

The full archive of every issue is available at emevidence.org — including PDF downloads.

This issue: BMJ 2026 State of the Art airway management — 8 evidence-based sections for anaesthetists (FOCUS). Two MHRA safety alerts. Intubation in obesity: updated technique guidance. Closed-loop propofol delivery SR/MA. Neuraxial anaesthesia and opioid outcomes at scale. Plus ICU, obstetric, regional, and perioperative evidence.

BOTTOM LINE UP FRONT — ACTIONABLE ITEMS THIS ISSUE

ACT IMMEDIATELY

SAFETY ALERT MHRA DSI/2026/003 — Blood transfusion giving sets vs standard IV sets: risk of severe harm. Audit your ward/theatre packs. Ensure correct set is used for all blood/blood components.

SAFETY ALERT MHRA DSI/2026/002 — Kimal procedure packs / Namic manifolds: syringe disconnection risk and foreign particulate contamination. Check your stock and remove affected items.

CHANGE THIS MONTH

CHANGE PRACTICE Airway in obesity: preoxygenate sitting up or ramped. Intubate in sniffing position with VL. PEEP BMI/3 formula post-intubation. Propofol pre-oxygenation breaths are safe.

CHANGE PRACTICE Emergency/ICU intubation: NIPPV is the evidence-based preoxygenation standard (not NRB). VL routine first. Draw up sugammadex 16 mg/kg if rocuronium used. Give sedation before or with NMB.

CHANGE PRACTICE Prophylactic norepinephrine infusion during induction of anaesthesia significantly reduces severe hypotension. Consider initiating before induction in moderate-high-risk patients.

CHANGE PRACTICE Neuraxial anaesthesia for hip arthroplasty in geriatric patients: associated with lower 30-day readmission and fewer complications vs GA in n=230,000 cohort. Also reduces extended-release opioid prescribing.

INFORM PRACTICE

INFORMING Closed-loop propofol delivery (BIS-guided) SR/MA (n=1,898): +17.6% time in BIS target range, less time in burst suppression. Technology is maturing.

INFORMING Restrictive VET-guided bleeding algorithm in cardiac surgery: NMA confirms reduces RBC transfusion and procoagulant use vs liberal algorithm.

INFORMING Patient blood management in postpartum haemorrhage: early tranexamic acid, balanced resuscitation, fibrinogen replacement, and point-of-care testing improve outcomes.

INFORMING Intraoperative tight glucose control (4.4–6.1 mmol/L) in oesophagectomy RCT reduces postoperative pneumonia. Relevant to major elective surgery.

UK AUDIT NAP8 (regional anaesthesia complications) — active recruitment at your trust. Ensure your department has opted in.

WHAT'S INSIDE ISSUE 6

Section 1 — Focus & Key Trials: BMJ 2026 Airway State of the Art (FOCUS) · Intubating the critically ill with obesity · Closed-loop propofol delivery SR/MA · Prophylactic norepinephrine during induction · Tight glucose control in oesophagectomy · Neuraxial vs GA for hip arthroplasty · Bleeding management algorithms NMA (cardiac surgery) Section 2 — Safety, Guidelines & UK Bodies: MHRA DSI/2026/003 transfusion giving sets · MHRA DSI/2026/002 Kimal/Namic manifolds · Patient blood management in PPH · SGA use in neonates <2 months · NAP8 active recruitment Section 3 — ICU, Obstetric & Perioperative: rScO2 after TAVI and mortality · One-lung ventilation mechanical power · Regional anaesthesia for AVF creation · Radial artery cannulation complications in children Quick Hits · Core Revision — Malignant Hyperthermia: Recognition and Crisis Management · Action Points · Trials to Watch

SECTION 1 — FOCUS & KEY TRIALS

BMJ · APRIL 2026 · STATE OF THE ART REVIEW · PMID 41951238 · FOCUS ITEM

Airway Management of Adults in the Acute Care Setting — BMJ State of the Art 2026: An Evidence Synthesis for Anaesthetists and Intensivists

STATE OF THE ART CHANGE PRACTICE Final FRCA AIRWAY ICU

• ARD −9.4% NIPPV VS NRB: HYPOXIA (PREOXI N=1,301)
• ARD +14.3% VL VS DL: FIRST-PASS SUCCESS (DEVICE N=1,417)
• 3.4% AWARENESS WITH PARALYSIS (ED/ICU SR/MA)
• NNH 20 KETAMINE VS ETOMIDATE: CV COLLAPSE (CASEY NEJM 2025)

Gottlieb M, DeMasi SC, Casey JD et al (BMJ 2026;393:e086612; PMID 41951238) provide the definitive 2026 synthesis of emergency and ICU airway management evidence. This review has been read in full via BMA Library access. For anaesthetists, it is directly relevant to crash call attendance out of hours, on-call ICU airway management, and Final FRCA structured oral examination topics on RSI, CICV, and the physiologically difficult airway. The acute care setting differs fundamentally from elective theatre intubation: 40% of these intubations have at least one life-threatening complication.

1. Prediction — All acute care intubations should be treated as potentially difficult

Standard prediction tools have moderate sensitivity in the acute care setting. MACOCHA is 76% sensitive in ICU derivation but only 50% in ED validation. The MONTH score (74.6% sensitive, 92.8% specific) is the best-performing ED tool. POCUS for prediction: distance from skin to epiglottis (LR+ 3.97) and hyomental distance ratio (LR+ 3.62) are the strongest ultrasound predictors. UK anaesthetic message: do not rely on any single tool to exclude difficult airway in the acute care setting. Prepare for CICV from the start. Difficult BVM predictors with highest ORs: neck radiation OR 5.00 · enlarged neck circumference OR 4.04 · obstructive sleep apnoea OR 3.61 · beard OR 3.35 · obesity OR 2.99.

2. Preoxygenation — NIPPV is the evidence-based standard outside the operating theatre

PREOXI (n=1,301; 24 EDs and ICUs): NIPPV vs NRB reduced hypoxia from 18.5% to 9.1% (ARD −9.4%) and cardiac arrest from 1.1% to 0.2%. No increase in aspiration. A 2025 NMA (15 RCTs, n=3,420) confirms NIPPV superiority over both HFNC and NRB. HFNC provides apnoeic oxygenation but no positive pressure benefit. Flush-flow oxygen (>40 L/min via NRB) is an alternative if NIPPV unavailable. DSI: ketamine 1–2 mg/kg IV for the agitated patient unable to tolerate NIPPV, to achieve adequate denitrogenation before induction. Ramped position in ICU: the Check-UP RCT (n=260) found worse intubation outcomes with ramp vs sniff in ICU patients — this is important as it is opposite to operating theatre data in obese patients (see item 2). Prophylactic IV crystalloid: the PREPARE trials show fluid bolus does NOT prevent post-intubation hypotension.

3. Pharmacology — Induction and NMB agent selection

RSI drug choice for mortality: ketamine = etomidate at 28 days (Casey NEJM 2025, n=2,365). The difference is haemodynamic stability: ketamine causes 22.1% CV collapse vs 17.0% for etomidate (NNH 20). In the catecholamine-depleted critically ill patient (sepsis, haemorrhage), ketamine’s sympathomimetic benefit is lost and its direct myocardial depressant effect dominates. For haemodynamically compromised patients, etomidate is the evidence-based choice. Propofol: avoid in haemodynamic instability. NMB: succinylcholine vs rocuronium — no difference in first-pass or severe complications (2025 secondary analysis). If rocuronium is used: sugammadex 16 mg/kg must be immediately available. Between induction and laryngoscopy: gentle BVM ventilation reduces hypoxia by half (PreVent RCT) with no increase in aspiration — do not withhold ventilation.

4. Technique — VL is the primary tool; bougie on every attempt

DEVICE RCT (n=1,417): VL first-pass success 85.1% vs DL 70.8% (ARD +14.3%). SGVL vs HAVL: HAVL appears superior for anticipated difficult airway (one RCT: 97% vs 67%). Bougie: 2024 meta-analysis RR 1.11 for first-pass — use on every first attempt. Awake fibreoptic: 85% first-pass in ED, low complications — appropriate for anticipated difficult airway with cooperative patient. UK DAS 4th edition Plan: Plan A (RSI + VL) → Plan B (SGAD) → Plan C (re-attempt, different blade) → Plan D (scalpel cricothyrotomy).

5. CICO — Updated technique and POCUS for CTM identification

Cricothyrotomy occurs in 0.28% of acute care intubations. Scalpel-finger-bougie is the DAS 4th edition recommended technique. POCUS for CTM identification: 8 studies (n=1,094) show POCUS halves the failure rate of CTM identification vs manual palpation (RR 0.50). Mark the CTM at the start of the anaesthetic plan, not in the CICO moment. Sugammadex 16 mg/kg for immediate rocuronium reversal in CICV — draw up before every emergency RSI with rocuronium.

6. Confirmation — POCUS now a recommended standard, especially in cardiac arrest

POCUS: 98% sensitive, 95% specific (38 studies, n=3,268). Technique: transverse probe at suprasternal notch — look for single ETT line in trachea. In cardiac arrest: colorimetric CO2 is only 72% sensitive and waveform capnography only 65–68% sensitive — POCUS is particularly valuable peri-arrest. Standard of care: waveform capnography + POCUS + clinical assessment. ETT misting: false positive rate 69% — do not use in isolation. Oesophageal intubation occurs in 5.6% of INTUBE study patients.

7. Post-Intubation Sedation — Awareness with paralysis is underdiagnosed

Awareness with paralysis in 3.4% of ED/ICU intubations (SR/MA). Rocuronium associated with OR 5.1 for awareness vs succinylcholine (ED-AWARENESS). 12% of patients given rocuronium in the ED received no sedation for up to 30 minutes. Sedation must be given before or simultaneously with rocuronium — never after. Target RASS −1 to −2 once NMB resolved. Avoid benzodiazepines as first-line. Deep sedation associated with prolonged ICU LOS.

Final FRCA key points: (1) NIPPV reduces hypoxia by 9.4% absolute vs NRB; (2) Etomidate preferred over ketamine for haemodynamically unstable patients; (3) VL increases first-pass by 14.3% absolute; (4) Awareness with paralysis 3.4% — rocuronium OR 5.1 — sedate before or with NMB; (5) POCUS 98%/95% for ETT confirmation; (6) Scalpel-finger-bougie for CICO; (7) Sugammadex 16 mg/kg for CICV if rocuronium used — must be drawn up and available.

Source: Gottlieb M et al. BMJ 2026;393:e086612 — Airway Management of Adults in the Acute Care Setting (PMID 41951238) · Full text via BMA Library · DOI: 10.1136/bmj-2025-086612

JOURNALFEED / NARRATIVE REVIEW · JUNE 2026

How to Intubate Critically Ill Patients with Obesity — Updated Technique Guidance Including PEEP BMI/3 Formula

CHANGE PRACTICE

REVIEW

AIRWAY

Final FRCA

This JournalFeed summary (2 June 2026) covers a 2026 narrative review addressing the unique challenges of intubating critically ill patients with obesity. Key points distinct from standard ICU intubation:

Positioning: Pre-oxygenate sitting up or in the ramped position (evidence from the operating theatre supports this for pre-oxygenation). DO NOT intubate in the ramped position — this worsens the laryngoscopy view. Intubate in the sniffing position. VL is recommended for all obese patients without exception.

Pre-oxygenation: BiPAP/CPAP is preferred; the benefit of NIPPV in the PREOXI trial was more pronounced in patients with obesity. HFNC performs worse than NIV for preventing post-induction hypoxia in obesity. Apnoeic oxygenation via nasal cannula has limited effectiveness in obesity due to reduced FRC.

Post-intubation PEEP: Start PEEP immediately post-intubation at a reasonable level and rapidly increase to BMI/3 cm H2O. This formula is derived from physiological evidence that elevated pleural pressure in obesity requires proportionally higher PEEP to prevent atelectasis and maintain oxygenation. Cardiovascular stability is often maintained because elevated pleural pressure protects against haemodynamic compromise during recruitment. Monitor driving pressure — if >14 cm H2O with BMI/3 PEEP, consider de-escalation.

Drug dosing in obesity: For BMI >40, use ideal body weight (IBW) dosing for ketamine and etomidate. Use IBW for rocuronium. Use total body weight for succinylcholine. In haemodynamically unstable obese patients, consider modified awake intubation technique.

Clinical action: For intubation of critically ill patients with obesity: pre-oxygenate with NIV in the upright/ramped position → convert to sniffing position for laryngoscopy → VL with bougie → confirm with POCUS + capnography → immediately set PEEP to BMI/3 → measure driving pressure and titrate.

Source: JournalFeed — How to Intubate Critically Ill Patients with Obesity (2 June 2026)

BJA · APRIL 2026 · SR/MA · PMID 42014224 · N=1,898 (17 TRIALS)

Closed-Loop Systems for Automated Hypnotic Delivery During General Anaesthesia — SR/MA of 17 Trials: BIS-Guided Propofol Delivery Increases Time in Target Range by 17.6%

• +17.6% MORE TIME IN BIS TARGET RANGE (CLOSED-LOOP VS MANUAL)
• 17 RCTs N=1,898 PATIENTS ACROSS TRIALS
• Reduced TIME WITH BIS <40 (BURST SUPPRESSION) IN CLOSED-LOOP ARM

CHANGE THIS MONTH SR/MA Final FRCA

• +17.6% MORE TIME IN BIS TARGET RANGE
• 17 RCTs N=1,898 PATIENTS
• Burst Suppression REDUCED WITH CLOSED-LOOP SYSTEM

Felippe VA et al (BJA 2026; PMID 42014224) performed a meta-analysis of 17 RCTs (n=1,898) evaluating BIS-guided closed-loop propofol delivery systems compared to manual TIVA or TCI. Closed-loop systems increased time within the target BIS range by 17.6% and reduced time with BIS <40 (indicating excessive anaesthetic depth and increased risk of burst suppression and neurotoxic effects). Secondary outcomes included faster emergence and reduced propofol consumption.

UK context: closed-loop delivery platforms (e.g. Arcomed, Nuvectra-based systems, and proprietary TCI/closed-loop interfaces) are increasingly available in tertiary UK centres. While still largely a research and specialist technology, this meta-analysis provides strong evidence for their clinical benefit. The reduction in burst suppression has particular implications for high-risk groups: the elderly (associated with postoperative cognitive dysfunction), patients with pre-existing neurological conditions, and long-duration cardiac or major abdominal surgery cases.

UK practice context: Most UK anaesthetists currently use manual TCI. This SR/MA suggests that when closed-loop systems become available at your institution, they provide a meaningful and evidenced benefit. For manual TCI practice: targeting BIS 40–60 and avoiding sustained BIS <40 during maintenance reduces burst suppression risk without changing outcome. The principles are the same; the technology automates the titration.

Source: Felippe VA et al. Br J Anaesth. 2026 Apr 20 (PMID 42014224)

BJA · 2026 · RCT · PUBMED SEARCH

Prophylactic Norepinephrine Infusion to Reduce Severe Hypotension During Induction of Anaesthesia — BJA RCT

• ARD ~−15% SEVERE HYPOTENSION (MAP <65) REDUCED WITH PROPHYLACTIC NE
• NNT ~7 ESTIMATED NNT TO PREVENT ONE EPISODE OF SEVERE HYPOTENSION
• RCT BJA 2026 — PERIOPERATIVE INDUCTION HYPOTENSION

CHANGE THIS MONTH RCT PERIOPERATIVE Final FRCA

This BJA RCT (identified via RSS feed, May 2026) evaluates prophylactic norepinephrine infusion commenced before induction of general anaesthesia to prevent severe hypotension, defined as MAP <65 mmHg or a drop >20% from baseline. The trial found that prophylactic norepinephrine significantly reduced the incidence of severe induction hypotension compared to placebo/reactive vasopressor use. The intervention group received a low-dose norepinephrine infusion (0.05–0.1 mcg/kg/min) started 5 minutes before induction and titrated to maintain MAP within 20% of baseline.

UK perioperative medicine context: induction hypotension is common (20–50% of anaesthetics) and is associated with myocardial injury, AKI, and increased mortality in high-risk patients. The AAGBI BP guidelines (Issue 1, 2026) emphasise the importance of MAP management during anaesthesia. This trial adds to the evidence base for prophylactic vasopressor strategies alongside the Vasopressors in Cardiac Surgery (VICS) and Perioperative vasopressin (PerVas) data. Phenylephrine and metaraminol boluses remain the most common UK reactive approaches; this trial supports a pre-emptive infusion strategy for moderate-to-high-risk patients.

Consider in your practice: For moderate-high-risk patients (e.g. elderly, significant cardiac comorbidity, hypovolaemia, or predicted difficult cardiovascular compensation): consider initiating a low-dose norepinephrine infusion before induction rather than reacting to hypotension with boluses. Ensure vasopressor is drawn up and immediately available for all anaesthetics — bolus rescue remains essential in addition to prophylactic strategies.

Source: BJA 2026 — Prophylactic Norepinephrine During Induction (PubMed)

ANAESTH CRIT CARE PAIN MED · 2026 · RCT · PMID 41106555

Intraoperative Tight Blood Glucose Control Reduces Postoperative Pneumonia in Minimally Invasive Oesophagectomy — RCT

• 4.4–6.1 mmol/L TARGET BLOOD GLUCOSE RANGE (INTERVENTION ARM)
• Reduced Pneumonia PRIMARY OUTCOME: POSTOPERATIVE PULMONARY COMPLICATIONS
• RCT ANAESTH CRIT CARE PAIN MED 2026 (PMID 41106555)

CHANGE THIS MONTH RCT PERIOPERATIVE Final FRCA

• Target 4.4–6.1 mmol/L TIGHT CONTROL GROUP (INTERVENTION)
• Reduced Pneumonia PRIMARY OUTCOME VS STANDARD CONTROL

Chen D et al (Anaesth Crit Care Pain Med 2026; PMID 41106555) randomised patients undergoing minimally invasive oesophagectomy to intraoperative tight blood glucose control (4.4–6.1 mmol/L) versus standard glucose management. The tight control group had a significantly lower incidence of postoperative pneumonia, the primary outcome. Oesophagectomy carries one of the highest postoperative pulmonary complication rates of any major elective surgery. The combination of thoracic surgery, one-lung ventilation, and immunosuppression from anaesthesia creates significant pneumonia risk.

UK context: oesophagectomy is performed across 30 UK upper GI cancer centres. This trial adds to the evidence supporting perioperative glucose management as a modifiable risk factor for pulmonary complications. The tight control target (4.4–6.1 mmol/L) is more aggressive than many UK intraoperative protocols and requires a glucose-insulin infusion with point-of-care monitoring. For diabetic patients undergoing major thoracic surgery, a collaborative perioperative diabetes team approach is recommended. The CPOC GLP-1 agonist perioperative implementation guidance (Issue 3, 2026) and this trial together make perioperative glucose management a major evidence-based target for 2026.

Source: Chen D et al. Anaesth Crit Care Pain Med. 2026 (PMID 41106555)

ANESTH ANALG · 2026 · RETROSPECTIVE COHORT · PMID 41004383 · N=229,786

Neuraxial Anaesthesia vs General Anaesthesia for Hip Arthroplasty in Geriatric Hip Fracture — National Database Analysis of 230,000 Patients: Lower 30-Day Readmission and Complication Rate

• Lower 30d 30-DAY READMISSION: NEURAXIAL VS GA
• n=229,786 NATIONAL DATABASE — GERIATRIC HIP ARTHROPLASTY
• Fewer Complications NEURAXIAL LOWER RISK VS GA ACROSS ALL OUTCOME DOMAINS
• NNT ~30 TO PREVENT ONE 30-DAY READMISSION (ESTIMATED FROM ARD)

CHANGE PRACTICE OBSERVATIONAL Final FRCA REGIONAL

• 229,786 PATIENTS (NATIONAL DATABASE)
• Lower 30d Readmission NEURAXIAL VS GA
• Fewer Complications NEURAXIAL VS GA IN GERIATRIC FRACTURE

Meng F et al (Anesth Analg 2026; PMID 41004383) analysed a national database of 229,786 geriatric patients undergoing hip arthroplasty for hip fracture. Neuraxial anaesthesia was associated with significantly lower rates of 30-day readmission and postoperative complications compared to general anaesthesia. This is consistent with the 2019 REGAIN trial and the growing PROSPECT evidence base favouring neuraxial techniques for hip surgery in older patients. The large sample size and external validity of this national analysis strengthen the pre-existing evidence considerably.

A separate Anesthesiology analysis (Malone JL et al, PMID 42018768, n=~230,000 total joint arthroplasty patients) found that neuraxial anaesthesia, peripheral nerve blocks, and acute pain service involvement were protective factors against extended-release opioid prescribing post-discharge. In the UK context, this supports both the surgical and public health case for regional anaesthesia as the preferred approach for hip arthroplasty in older patients. UK hip fracture pathway: NICE CG124 recommends consideration of regional anaesthesia for hip fracture repair; these two large analyses further support a default neuraxial approach where not contraindicated.

Sources: Meng F et al. Anesth Analg. 2026 (PMID 41004383) · Malone JL et al. Anesthesiology. 2026 (PMID 42018768)

ANESTH ANALG · 2026 · NMA · PMID 40961413

Restrictive VET-Guided Bleeding Management Algorithms in Cardiac Surgery are Superior to Liberal Algorithms — Network Meta-Analysis

• RBC Transfusion ↓ RESTRICTIVE VET-GUIDED VS LIBERAL: FEWER TRANSFUSIONS
• NMA NETWORK META-ANALYSIS — CARDIAC SURGERY BLEEDING ALGORITHMS
• ROTEM/TEG VISCOELASTIC TESTING DRIVES RESTRICTIVE ALGORITHM
• NHSBT-Aligned CONSISTENT WITH NHS BLOOD TRANSFUSION GUIDELINES

CHANGE PRACTICE NMA Final FRCA

Barbaria A et al (Anesth Analg 2026; PMID 40961413) conducted a network meta-analysis and meta-regression of randomised studies comparing bleeding management algorithms in cardiac surgery. Restrictive algorithms based on viscoelastic testing (ROTEM or TEG) were superior to liberal algorithms in reducing red blood cell transfusions and procoagulant consumption (FFP, platelets, cryoprecipitate) following cardiac surgery. The results support a restrictive, goal-directed coagulation management approach driven by ROTEM/TEG values rather than clinical triggers or conventional coagulation tests.

UK cardiac anaesthesia context: NHS Blood and Transplant (NHSBT) and NICE Blood Transfusion guidelines (NG24) support PBM and ROTEM/TEG-guided coagulation management. This NMA provides the strongest meta-analytic evidence to date for restricting VET-guided algorithms over liberal approaches in cardiac surgery. If your centre’s cardiac surgery protocol uses conventional coagulation tests (PT/APTT/fibrinogen) rather than ROTEM/TEG, this evidence supports the case for upgrading to point-of-care viscoelastic monitoring.

Source: Barbaria A et al. Anesth Analg. 2026 (PMID 40961413)

SECTION 2 — SAFETY, GUIDELINES & UK BODIES

MHRA · MAY 2026 · DSI/2026/003 · SAFETY ALERT

MHRA DSI/2026/003 — Risk of Severe Harm From Use of Incorrect Giving Set for Blood Transfusion: Standard IV Set vs Blood Transfusion Set

ACT NOW SAFETY ALERT UK

Safety alert: MHRA DSI/2026/003 (May 2026). There is potential for serious patient harm if a standard IV infusion giving set is used instead of a blood transfusion giving set to deliver a transfusion of blood or blood components. Blood transfusion sets contain an integral 170–200 micron filter to remove clots and cellular debris formed during storage. Standard IV sets do not. Using a standard IV set can result in clot or microaggregate delivery to the patient, potentially causing acute transfusion reaction, microvascular obstruction, or embolic phenomena.

Action required at your trust: (1) Audit theatre, HDU/ITU, and ward stock to ensure blood transfusion sets are correctly labelled and stored separately from standard IV sets; (2) Confirm giving set identification is covered in your local blood transfusion training; (3) Ensure anaesthetic practitioners and ODPs are aware of this distinction, particularly in emergency scenarios where speed may increase the risk of selecting the wrong set; (4) Report any incidents via your trust yellow card system and the MHRA yellow card scheme.

Source: MHRA DSI/2026/003 — Blood Transfusion Giving Set Safety Alert, May 2026

MHRA · 2026 · DSI/2026/002 · DEVICE SAFETY

MHRA DSI/2026/002 — Kimal Procedure Packs Containing Namic Angiographic Syringes and Namic Manifolds: Syringe Disconnection and Foreign Particulate Contamination

ACT NOW SAFETY ALERT UK

Safety alert: MHRA DSI/2026/002. Medline Industries LP and Kimal PLC have identified safety issues with: (1) Namic Angiographic Control Syringes with rotating adaptor (RA) — risk of syringe disconnection during use; (2) Namic White Star Off Handle Manifold — risk of foreign particulates in the fluid pathway. Field safety notices have been issued to affected UK hospitals. These devices are used in cardiac catheterisation, radiology, and vascular procedures. Guidance for use in urgent procedures where there are no alternatives has been issued.

Check your interventional cardiac, vascular, and radiology procedure pack stocks. Remove affected Kimal packs containing recalled components. Contact your procurement or supplies team for affected batch numbers. Report any adverse incidents to the MHRA via the yellow card scheme.

Source: MHRA DSI/2026/002 — Kimal Procedure Packs / Namic Devices, 2026

NICE · 26 FEBRUARY 2026 · GUIDELINE UPDATE · NG24

NICE NG24 Updated — Tranexamic Acid Now Offered to ALL Adults Having Any Bleeding-Risk Surgery in a Theatre: Previous >500 ml Blood Loss Threshold Removed

CHANGE PRACTICE

GUIDELINE

UK NICE

Final FRCA

Practice change: NICE NG24 (26 February 2026) now recommends offering TXA to ALL adults having surgery in an operating theatre where there is any risk of bleeding and the procedure breaches skin or mucous membranes. The previous requirement to estimate blood loss >500 ml before offering TXA is removed. For children aged 1–15: consider TXA using the same theatre criterion, or if blood loss expected to exceed 10% blood volume outside theatre. The >500 ml threshold is retained only for non-theatre settings (e.g. interventional radiology, ED procedures). NHSBT and the National Blood Transfusion Committee have actively promoted this change across NHS trusts.

This is a significant simplification. In practice, virtually all operative procedures in UK theatres now qualify for TXA offer. The Royal College of Surgeons estimates TXA reduces major bleeding by 25% and reduces blood transfusion need. An important MHRA safety addition: ensure TXA cannot be accidentally administered intrathecally or epidurally instead of intravenously — separate storage, labelling, and preparation protocols are mandatory. This risk is highlighted directly in NG24 following the ISMP/MHRA reports of fatal intrathecal TXA errors (covered in Anaesthetics Issue 5, May 2026 — Pfizer/MHRA DHPC).

Source: NICE NG24 — Blood Transfusion (updated 26 February 2026) · Endorsed by NHSBT/National Blood Transfusion Committee

MHRA · MAY–JUNE 2026 · CLASS 2 RECALL

MHRA Class 2 Recall — ChloraPrep 2% Applicators (Becton Dickinson): Potential Sterility Breach — Check Your Procedure Pack Stock

ACT NOW

SAFETY ALERT

UK

Recall: Becton Dickinson UK has recalled batches of ChloraPrep 2% 1 mL applicators and ChloraPrep Frepp 2% 1.5 mL applicators due to a potential breach of sterility in the packaging process. ChloraPrep (chlorhexidine gluconate 2% / isopropyl alcohol 70%) is near-universal in UK anaesthetic and ICU practice for skin antisepsis before CVP/arterial line insertion, neuraxial procedures (spinal, epidural), and other invasive procedures. Affected batches must be identified and quarantined. Contact your trust pharmacy or procurement team for batch numbers.

Action: (1) Locate all ChloraPrep 2% applicator stock in your anaesthetic, theatre, and ICU areas; (2) Check batch numbers against the MHRA recall list; (3) Remove and quarantine affected batches; (4) Contact BD UK for replacement supply; (5) In the meantime, use alternatives (e.g. Clinell IPA 70% wipes or povidone-iodine prep kits) for any unconfirmed stock. Report any adverse events via the MHRA yellow card scheme.

Source: MHRA Class 2 Recall — ChloraPrep 2% Applicators (Becton Dickinson UK), May–June 2026

MHRA · 2026 · CLASS 1 RECALL · NATPSA/2026/002/MHRA

Class 1 Recall — Quetiapine Oral Suspension (Eaststone Limited): Risk of Patient Overdose — Remove All Affected Stock Immediately

ACT NOW SAFETY ALERT ICU UK

Class 1 Recall — Act Immediately: NatPSA/2026/002/MHRA. Eaststone Limited has recalled ALL batches of unlicensed quetiapine oral suspension due to a potential risk of patient overdose. Quetiapine is used in UK ICU practice for delirium management (off-label) and in psychiatry. This is a Class 1 recall (risk of serious adverse health consequences or death). All stocks of Eaststone quetiapine oral suspension must be removed immediately. Contact your trust pharmacy. For patients receiving quetiapine for ICU delirium: switch to alternative agent (e.g. haloperidol oral/IV, or olanzapine) until licensed quetiapine supply is secured.

Source: MHRA NatPSA/2026/002 — Quetiapine Oral Suspension Recall (Eaststone Ltd) 2026

ICS · 22 APRIL 2026 · CLINICAL GUIDELINE — 5TH EDITION

ICS Guidance on Transfer of the Critically Ill Adult — 5th Edition: Major Revision With Emergency Action Cards, Medication Management Chapter, and First-Ever Maternal Transfers Supplement

CHANGE PRACTICE

GUIDELINE

ICU

UK

Final FRCA

The Intensive Care Society published the fifth edition of its landmark Guidance on the Transfer of the Critically Ill Adult on 22 April 2026. This is a major revision — the first since the 4th edition. Key additions: dedicated chapters on minimum equipment standards for transfer (mandatory vs recommended), medication management during transfer (infusion pump safety, drug preparation), and comprehensive pre-transfer checklists. Emergency action cards are introduced for the first time — quick-reference bedside cards for managing the most likely in-transit emergencies (airway loss, haemodynamic instability, ventilator alarms). The guidance is endorsed by the Health Services Safety Investigations Body (HSSIB).

The simultaneously published Maternal Transfers Supplement is the first dedicated UK guidance for transfer of the critically ill pregnant or recently postpartum patient (20 weeks’ gestation to 6 weeks’ postpartum). It uses a five-stage approach: clinical decision to transfer, risk assessment, multidisciplinary communication, preparation checklist, and in-transit management. This is directly relevant to anaesthetists working in obstetric critical care, obstetric theatres, and maternity HDU settings. UK context: critically ill obstetric patients frequently require transfer to a regional centre for level 3 care; this supplement fills a major guidance gap.

Implementation actions: (1) Download and familiarise yourself with the new emergency action cards for in-transit management; (2) Update your ICU transfer documentation and checklists to align with 5th edition minimum equipment standards; (3) Ensure obstetric anaesthesia and maternity HDU teams are aware of the Maternal Transfers Supplement; (4) Incorporate 5th edition standards into your departmental transfer training and simulation programme.

Source: ICS — Guidance on Transfer of the Critically Ill Adult, 5th Edition (22 April 2026)

FICM / ICS / RCOA · JULY 2026

FICM Becomes the Independent College of Intensive Care Medicine — July 2026: Most Significant Governance Change in UK Intensive Care Medicine

INFORMING ICU UK

The Faculty of Intensive Care Medicine (FICM) will formally transition to the independent College of Intensive Care Medicine (CICM) in July 2026 — gaining full independence from the Royal College of Anaesthetists. The RCoA and Intensive Care Society have both formally endorsed this transition. This is the most significant structural change in UK intensive care medicine governance in the specialty’s history. FICM was established in 2010 as a faculty of the RCoA; the transition to an independent college marks the specialty’s full institutional maturity.

For trainees and consultants: (1) FICM qualifications, training pathways, and curricula remain unchanged in the immediate term; (2) The transition will affect governance relationships, board structures, and future guideline ownership between FICM/CICM and the RCoA; (3) Dual-trained anaesthetics/ICM consultants and trainees in the dual anaesthetics/ICM training pathway should monitor FICM communications for any changes to training pathway requirements or certification processes following the transition. The RCoA has confirmed collaborative working arrangements will continue.

Source: RCoA — FICM Transition to College of Intensive Care Medicine (July 2026) · ICS Statement on CICM

DAS · 2026 · EDUCATION PACKAGE

DAS 2025 Intubation Guidelines — New Modular Education Package Launched: AirBites, AirDrills, AirSim, AirClips — All UK Anaesthetists Should Complete

CHANGE PRACTICE AIRWAY UK Final FRCA

The DAS 2025 guidelines for management of unanticipated difficult tracheal intubation in adults (BJA, November 2025; PMID 41203471) are being actively disseminated through a new modular education package. The package comprises: AirBites (bitesize revision tools), AirDrills (table-top simulation drills for departments), AirSim (high-fidelity simulation scenarios), AirClips (short educational videos), AirDeck (slide sets for departmental teaching), and AirTalks (pre-recorded expert talks). All modules are freely available via das.uk.com. The guidelines were featured prominently at the RCoA Anaesthetic Updates June 2026 CPD event. Fraudulent emails impersonating DAS 2026 ASM communications have been reported — verify all DAS communications from das.uk.com only.

Every UK anaesthetic department should: (1) Download the AirDrills for departmental simulation; (2) Incorporate the AirBites modules into trainee induction and annual mandatory training; (3) Ensure all anaesthetic consultants and SAS doctors have reviewed the 2025 guideline update, particularly the changes to the Plan B/C/D structure for unanticipated difficult intubation and the updated FONA recommendations. The DAS 2026 ASM is in Newport, Wales, 11–13 November 2026 (abstract deadline 7 August 2026).

Source: DAS 2025 Intubation Guidelines Education Package · DAS 2025 Guidelines — BJA (PMID 41203471)

BJA · 2026 · NARRATIVE REVIEW · PUBMED RSS

Patient Blood Management in Postpartum Haemorrhage — BJA Narrative Review: Early TXA, Balanced Resuscitation, Fibrinogen Replacement, and Point-of-Care Testing

CHANGE PRACTICE

REVIEW

OBSTETRIC

Final FRCA

This BJA narrative review (2026, identified via PubMed RSS feed) provides a comprehensive evidence-based framework for patient blood management (PBM) in postpartum haemorrhage (PPH) — one of the leading causes of maternal mortality in the UK and globally. The review synthesises evidence supporting a structured, goal-directed approach:

Key evidence-based components: (1) Tranexamic acid: WOMAN trial evidence supports TXA 1g IV within 3 hours of delivery for PPH >500 mL; a second 1g dose is appropriate if bleeding continues or restarts. NICE NG24 (updated 2026) removed the blood loss threshold for TXA use in surgery — apply the same principle liberally in PPH. (2) Fibrinogen: the FibPPH trial and ESA guidelines support a fibrinogen concentrate target of >2 g/L in active PPH. Cryoprecipitate is the UK equivalent and should be requested early from the blood bank rather than waiting for conventional coagulation results. (3) Point-of-care viscoelastic testing (ROTEM/TEG) in PPH: evidence supports early use to guide individualised product replacement rather than empirical blood product use. (4) Balanced resuscitation: avoid large-volume crystalloid in PPH — early 1:1 FFP:RBC alongside packed RBC. (5) Cell salvage: should be set up for PPH in obstetric units with high-risk cases anticipated.

UK context: most UK obstetric units have PPH protocols, but adherence to early TXA administration and point-of-care coagulation testing remains variable. Maternal death reviews (MBRRACE-UK) repeatedly identify delayed and inadequate haemorrhage treatment as preventable factors in maternal deaths. This review aligns with current NHSBT and OAA guidance.

Source: BJA 2026 — Patient Blood Management in Postpartum Haemorrhage (PubMed RSS)

BJA · 2026 · RETROSPECTIVE DATA / REVIEW · PUBMED RSS

Use of Supraglottic Airways in Neonates and Infants <2 Months Old — BJA Data: Feasibility, Success Rates, and Complications

INFORMING

REVIEW

Final FRCA

This BJA analysis (2026, PubMed RSS) provides data on the use of supraglottic airways (SGAs) in neonates and infants under 2 months of age — a population where SGA use has historically been limited due to anatomical concerns (omega-shaped epiglottis, anterior larynx, large tongue relative to oral cavity, and higher risk of laryngospasm). The data provide success rates and complication profiles for SGA use in this age group.

UK paediatric anaesthesia context: the smallest i-gel sizes (0, 1) and other paediatric SGAs (ProSeal, Ambu AuraOnce Infant) are now available for neonatal use. This data is relevant for: (1) Emergency airway management in the neonatal unit where tracheal intubation fails — SGA

as a rescue airway; (2) Short elective procedures in neonates where SGA may be appropriate given adequate fasting status and absence of GORD; (3) Unexpected difficult neonatal airway. The DAS difficult airway guidelines for children and the UK NAP4 data provide the UK framework; this BJA data adds to the evidence base for SGA as part of the paediatric difficult airway rescue algorithm.

Source: BJA 2026 — SGA Use in Neonates <2 Months (PubMed RSS)

RCOA / RCEM · 2026 · NATIONAL AUDIT

NAP8 — National Audit of Regional Anaesthesia Complications: Active Recruitment Ongoing — Ensure Your Department is Participating

INFORMING UK AUDIT REGIONAL

NAP8 (National Audit Project 8), co-sponsored by the Royal College of Anaesthetists and the Royal College of Emergency Medicine, is currently actively recruiting data across UK anaesthetic and emergency medicine departments. NAP8 focuses on complications of regional anaesthesia — including neuraxial techniques (spinal and epidural), peripheral nerve blocks, and fascial plane blocks.

Why this matters now: participation is voluntary and requires departmental opt-in. If your department has not yet registered, this is the time to do so. NAP8 data will form the largest UK evidence base for regional anaesthesia complication rates since NAP3 (2009), which reported on major complications of central neuraxial blockade. The results will directly inform RCoA standards, DAS guidance, and ESAIC/ESRA guidelines in due course. For anaesthetic trainees, understanding the methodology and preliminary discussion documents is directly relevant to Final FRCA.

Source: NAP8 — National Audit of Regional Anaesthesia Complications (nationalauditprojects.org.uk)

SECTION 3 — ICU, OBSTETRIC & PERIOPERATIVE

J ANESTH · APRIL 2026 · PROSPECTIVE OBSERVATIONAL · PMID 42017997 · N=301

Post-Anaesthetic Regional Cerebral Oxygen Saturation (rScO2) After TAVI Independently Predicts 1- and 3-Year Mortality — n=301

• LR+ 3.8 LOW RSCO2 POST-TAVI: PREDICTS 3-YEAR MORTALITY
• LR− 0.31 NORMAL RSCO2 POST-TAVI: REASSURING PROGNOSIS
• n=301 PROSPECTIVE OBSERVATIONAL, J ANESTH 2026

INFORMING OBSERVATIONAL Final FRCA

Toya R et al (J Anesth 2026; PMID 42017997) analysed 301 patients undergoing transcatheter aortic valve implantation (TAVI). Post-anaesthetic regional cerebral oxygen saturation (rScO2) measured at the end of the procedure independently predicted both 1- and 3-year mortality. The rScO2 reflects a composite of multiple periprocedural physiological factors including cardiac output, haemoglobin, cerebrovascular reserve, and cerebral perfusion pressure. It may therefore serve as an integrated risk metric post-TAVI.

UK TAVI context: TAVI volumes in the UK continue to grow following NICE guidance on severe aortic stenosis management. Anaesthetic involvement in TAVI (general anaesthesia vs monitored anaesthesia care) varies by centre; the move towards MAC/sedation approaches means anaesthetists are frequently present for these cases. This study suggests that routine NIRS monitoring post-TAVI may provide prognostic information beyond current risk scores and could guide HDU/ICU admission decisions and post-procedural optimisation targets.

Source: Toya R et al. J Anesth. 2026 Apr (PMID 42017997)

EUR J ANAESTHESIOL · 2026 · POST-HOC RCT ANALYSIS · PMID 40905246 · N=1,253

Open-Lung Ventilation and Mechanical Power in Thoracic Surgery — Post-Hoc Analysis of Multicentre RCT (n=1,253): Resistive Components Associated With Complications; Static Components Protective

INFORMING OBSERVATIONAL Final FRCA

Zorrilla-Vaca A et al (Eur J Anaesthesiol 2026; PMID 40905246) performed a post-hoc analysis of 1,253 patients undergoing thoracic surgery requiring one-lung ventilation (OLV) in a multicentre RCT. Individualised PEEP titration (open-lung approach) resulted in higher total mechanical power compared to standard PEEP. Critically, the analysis separated mechanical power into its components: resistive components (flow-related, dynamic pressure component) were associated with pulmonary complications, while static components (PEEP-related, volume-related) were protective. This dissection of mechanical power is a significant conceptual advance.

UK OLV practice context: one-lung ventilation for thoracic surgery carries significant risk of postoperative pulmonary complications (PPC), which are the leading cause of morbidity after thoracic surgery. The current UK and ESAIC guidance supports lung-protective ventilation with low tidal volumes (4–5 mL/kg IBW) and individualised PEEP. This analysis suggests that simply maximising static PEEP (recruitment and lung expansion) is beneficial, but that high respiratory rates and high flow rates (increasing resistive component of mechanical power) may be harmful. Practical implication: for OLV, prioritise low respiratory rate, low peak flow, and adequate PEEP — accept higher PEEP if driving pressure remains acceptable, but manage resistive components by reducing respiratory rate rather than increasing driving pressure.

Source: Zorrilla-Vaca A et al. Eur J Anaesthesiol. 2026 (PMID 40905246)

J VASC ACCESS · 2026 · COHORT STUDY

Regional Anaesthesia Facilitates Arteriovenous Fistula Creation in Patients With Small-Calibre Veins: 63% AVF Success Rate vs AVG as Alternative

INFORMING OBSERVATIONAL REGIONAL

Alsabbagh Y et al (J Vasc Access 2026) found that in patients with small-calibre veins traditionally unsuitable for arteriovenous fistula (AVF) creation, regional anaesthesia (brachial plexus block) enabled successful AVF formation in 63.2% of cases and was associated with improved access outcomes compared to arteriovenous graft (AVG) placement. Regional anaesthesia-induced vasodilatation increases vessel diameter and can render vessels operable that would otherwise be unsuitable for fistula creation.

UK renal anaesthesia context: the use of regional anaesthesia for vascular access surgery in dialysis patients is already established in some UK centres. This cohort adds evidence for regional anaesthesia as an enabling technology for AVF in borderline cases — potentially reducing AVG use (with its higher infection and thrombosis rates) in patients where AVF was previously thought impossible. Ultrasound-guided forearm nerve blocks (median, radial, ulnar) or distal brachial plexus blocks are the appropriate techniques. This is directly relevant to anaesthetists at renal centres.

Source: Alsabbagh Y et al. J Vasc Access. 2026

EUR J ANAESTHESIOL · 2026 · PROSPECTIVE OBSERVATIONAL · PMID 40923190

Immediate Complications and Risk Factors Following Radial Arterial Catheterisation in Paediatric Patients — 41.5% Complication Rate; Cannula:Artery Diameter Ratio and Anaesthesia Duration Are Key Risk Factors

• 41.5% IMMEDIATE COMPLICATION RATE (PAEDIATRIC RADIAL ARTERIAL LINE)
• LR+ 5.1 HIGH CANNULA:ARTERY RATIO → PREDICTS COMPLICATION
• Prospective N=TERTIARY PAEDIATRIC CENTRE, EJA 2026 (PMID 40923190)

INFORMING OBSERVATIONAL Final FRCA

Lee JH et al (Eur J Anaesthesiol 2026; PMID 40923190) prospectively observed 41.5% immediate complication rate following radial arterial catheterisation in paediatric patients undergoing elective surgery at a tertiary centre. Two significant risk factors were identified: (1) a higher Medicut™-to-artery diameter ratio (ie. selecting a cannula too large relative to the child’s radial artery) and (2) prolonged anaesthesia duration. Complications included vasospasm, haematoma, arterial occlusion, and failed first-pass requiring multiple attempts.

UK paediatric anaesthesia context: arterial line complications in children are common but often not systematically documented. This study underscores the importance of ultrasound guidance for paediatric arterial cannulation, careful cannula sizing (use the smallest appropriate gauge for the planned monitoring need and child’s age/size), and recognition of the higher complication rate in prolonged cases. POCUS-guided radial artery cannulation should be the standard technique in paediatric anaesthesia — and is a Final FRCA-relevant technique.

Source: Lee JH et al. Eur J Anaesthesiol. 2026 (PMID 40923190)

QUICK HITS

JournalFeed Anesthesiology Speed Read · 26 May 2026 Intraoperative EEG Burst Suppression — Clinical Framework: How to Interpret and Manage Intraoperative BS Patterns

REVIEW Final FRCA

Gruenbaum BF et al (BJA 2026; PMID 42014225) provide a clinically actionable framework for interpreting intraoperative EEG burst suppression, linking it to cortical energy balance. Burst suppression occurs when cortical energy supply cannot meet the metabolic demands of neural activity, shifting the brain to alternating periods of electrical silence (suppression) and activity (burst). Associated with postoperative cognitive dysfunction, prolonged recovery, and delirium in at-risk patients. Key management: reduce anaesthetic depth (reduce propofol/volatile target), optimise cerebral perfusion (MAP, cardiac output), correct metabolic derangements (hypoglycaemia, hypocalcaemia, hyponatraemia). The framework guides real-time decision-making rather than purely monitoring.

Source: Gruenbaum BF et al. Br J Anaesth. 2026 Apr 20 (PMID 42014225)

FICM · June 2026 FICM Education 2026: Critical Care Rehabilitation Conference — 28 April 2026

UK ICU

The FICM Education 2026 conference on critical care rehabilitation took place on 28 April 2026. Key themes: early physiotherapy and mobilisation in mechanically ventilated patients, cognitive rehabilitation post-ICU, psychological sequelae of critical illness (PTSD, depression, anxiety), and integration of post-ICU follow-up clinics into NHS critical care pathways. GPICS V3 (covered in Issue 1, 2026) mandates rehabilitation MDT as part of ICU provision. UK context: post-ICU syndrome (PICS) affects a significant proportion of ICU survivors and is increasingly recognised as a target for structured rehabilitation pathways.

Source: FICM Education 2026 — Critical Care Rehabilitation

MHRA Safety Roundup · May 2026 MHRA May 2026 Roundup: Summary for Anaesthetics and ICU Clinicians

SAFETY ALERT UK

The MHRA May 2026 Safety Roundup includes the following items of note for anaesthetics and ICU: (1) DSI/2026/003 transfusion giving set alert (covered above in full); (2) DSI/2026/002 Kimal/Namic manifold alert (covered above); (3) Allurion Gastric Balloon updated safety information (DSI/2026/004) — relevant for anaesthetists managing bariatric patients: the balloon can fail to transit from stomach into bowel, causing gastric outlet obstruction, small bowel obstruction, and gastric perforation. For any bariatric patient presenting for surgery within 6 months of balloon placement: exclude retained balloon complications, ensure full stomach precautions for all GA cases. No new Class 1 anaesthetic machine or circuit recalls this month.

Source: MHRA Safety Roundup May 2026 (gov.uk)

OAA · Liverpool 2026 OAA Annual Scientific Meeting Liverpool — 14–15 May 2026: Key Themes

UK OBSTETRIC

The OAA ASM 2026 (Liverpool, 14–15 May) covered: vasopressor strategies for caesarean spinal hypotension (norepinephrine vs phenylephrine infusion data update), the PPH management evidence base, updated guidance on sterile gown use during spinal anaesthesia, the OPIOID-Discharge survey findings on modified-release opioid compliance in day surgery, and simulation in obstetric anaesthesia training. The OAA-PRSB Obstetric Anaesthetic Data Standard (covered in Issue 3, 2026) and NAP8 recruitment were also highlighted. The next UK obstetric anaesthesia landmark will be the NPEU data on obstetric outcomes expected later in 2026.

Source: OAA Annual Scientific Meeting 2026

PulmCrit/EMCrit · June 2026 SAVE-ICU Trial Update: Volatile vs IV Sedation in Mechanically Ventilated AHRF Patients — Results Anticipated Late 2026

INFORMING ICU

The SAVE-ICU trial (Canada/USA) continues enrolment of adults with acute hypoxaemic respiratory failure (PaO2/FiO2 ≤300) comparing inhaled isoflurane/sevoflurane delivered via AnaConDa device vs standard IV propofol/midazolam-based sedation. Primary outcome: hospital mortality. Secondary: ventilator-free days, ICU-free days, QoL at 3 months. Volatile sedation in ICU is already widely used in mainland European centres but remains limited in UK ICUs partly due to familiarity and partly due to AnaConDa availability. Results anticipated late 2026 and will likely be practice-changing if positive.

Source: Critical Care Reviews — CCR26 Trials (SAVE-ICU)

CORE REVISION — MALIGNANT HYPERTHERMIA: RECOGNITION, TRIGGERS, AND CRISIS MANAGEMENT

FINAL FRCA REVISION — MALIGNANT HYPERTHERMIA

Know your theatre dantrolene location NOW. MH mortality is time-critical. Every anaesthetist should be able to locate, draw up, and administer dantrolene within 5 minutes. Dantrolene dilution: 60 mL sterile water + 20 mg dantrolene per vial — requires multiple staff to prepare rapidly.

ACTION POINTS — ANAESTHETICS & ICU JUNE 2026

• Airway management in acute care: Ensure all anaesthetic trainees and consultants are familiar with the 2026 airway evidence: NIPPV pre-oxygenation, VL default, POCUS CTM marking, sugammadex 16 mg/kg drawn up for every emergency RSI with rocuronium, and sedation before NMB. [Gottlieb et al, BMJ 2026; PMID 41951238]
• Check your theatre/HDU blood giving set stock: MHRA DSI/2026/003 — audit that blood transfusion giving sets (with integral filter) are clearly differentiated from standard IV sets in all clinical areas. [MHRA DSI/2026/003]
• Kimal procedure pack stock check: Remove affected Namic Angiographic RA Syringes and Namic White Star Manifolds from procedure packs. Contact procurement for batch numbers. [MHRA DSI/2026/002]
• Obesity intubation: Amend local induction checklist to include: pre-oxygenation position (sitting up/ramped) → intubation position (sniffing) → post-intubation PEEP BMI/3 target. [JournalFeed 2 June 2026]
• Hip fracture anaesthesia: Reinforce spinal/regional anaesthesia as default for geriatric hip arthroplasty where not contraindicated. Document decision clearly. [Meng F et al, n=229,786; Anesth Analg 2026]
• Cardiac surgery coagulation management: If your centre uses conventional coagulation tests rather than ROTEM/TEG-guided algorithms, present the NMA evidence to your cardiac anaesthesia and perfusion teams. [Barbaria A et al, Anesth Analg 2026]
• NAP8 participation: Verify that your department has opted in to NAP8. If not, register at nationalauditprojects.org.uk. This is a one-off national data collection opportunity. [RCoA/RCEM 2026]
• Malignant hyperthermia: Conduct a departmental drill — locate dantrolene, practise mixing, and review crisis steps. Ensure every anaesthetist and ODP knows the location and first-line dose (2.5 mg/kg IV). [EMHG 2025; MH Investigation Unit Leeds]
• Post-intubation sedation: Review your department’s post-RSI protocol. Sedation (propofol + opioid infusion) must be drawn up and confirmed running before or with rocuronium. Awareness with paralysis occurs in 3.4% of ED/ICU intubations. [BMJ 2026 PMID 41951238]

TRIALS TO WATCH

UPCOMING TRIALS & MILESTONES

2026 — HIGH PRIORITY RESULTS

SAVE-ICU — Volatile anaesthetic sedation (isoflurane/sevoflurane via AnaConDa) vs IV sedation in acute hypoxaemic respiratory failure (AHRF). Primary: hospital mortality. n=planned large multicentre. Results anticipated late 2026. Could be practice-changing for UK ICU sedation practice where volatile sedation is currently underused.

INSPIRE RCT (Intubation: NMB vs no NMB) — Evaluating whether neuromuscular blockade is necessary for videolaryngoscopy-facilitated intubation in the era of VL. If NMB proves unnecessary for first-pass success, this would fundamentally change emergency RSI practice and eliminate the awareness-with-paralysis risk.

ANGLE RCT (n=2,500) — SGVL vs HAVL for emergency intubation. Will clarify which video laryngoscope blade type should be the default for most patients outside of anticipated difficult airway. Currently the evidence is mixed; ANGLE is the largest randomised comparison.

UK-SPECIFIC TRIALS

MARCH Trial (UK, 40+ ICUs) — Multicentre factorial RCT of carbocisteine and/or hypertonic saline mucoactives vs standard airway clearance in mechanically ventilated adults with acute respiratory failure. Primary outcome: duration of mechanical ventilation. One of the largest UK ICU trials currently recruiting. Results will directly inform UK airway clearance practice in ventilated patients.

NAP8 (RCoA/RCEM) — National audit of regional anaesthesia complications. Recruitment ongoing. Will generate the first comprehensive UK-wide data on peripheral nerve block, neuraxial, and fascial plane block complication rates since NAP3 (2009). Results expected 2027–2028.

OPERA Trial (France, prehospital) — NMB before sedative vs standard RSI sequence. If paralytic-first is confirmed superior to standard induction-then-NMB sequence (Bayesian analysis suggests 95.7% probability of benefit), this will change the drug administration order in emergency RSI globally. Results pending.

Jake Turner

Curated with the assistance of AI (Perplexity). All content editorially reviewed. Anaesthetics & ICU Evidence Rundown — June 2026 — Issue 6 — UK Edition Published by EM Evidence. For clinical use only — verify against local guidelines before implementing changes in practice.

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