Anaesthetics & ICU Evidence Rundown — July 2026

ANAESTHETICS & INTENSIVE CARE MEDICINE

Anaesthetics & ICU Evidence Rundown

Issue 6 · July 2026 · UK Edition

Jake Turner

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

Full archive and PDF downloads at emevidence.org

LEAD Intraoperative MAP Targets in Noncardiac Surgery — SR/MA (n=15,603, 15 RCTs):

Higher targets (70–90 mmHg) do not improve AKI, myocardial injury, or mortality. MAP 65 validated as standard.

CHANGE TONIGHT: MHRA flucloxacillin recall + gabapentin contamination. | CHANGE THIS MONTH: NICE QS216 perioperative quality standard. PPH Lancet series. FiO2 at extubation RCT (BJA). | FICM becomes College of ICM (2 July). CPOC/APAGBI new paediatric pre-op guidelines.

BOTTOM LINE UP FRONT — ISSUE 6

ACT ON THIS NOW

TONIGHT MHRA: Flucloxacillin 500mg recall (wrong PIL). Gabapentin oral solution recall (particulate contamination). Check theatre and anaesthetic room stock.

THIS MONTH MAP targets: Targeting MAP 70–90 in noncardiac surgery does not reduce AKI, MI, or mortality vs MAP 65. No need to escalate beyond MAP 65 routinely.

THIS MONTH FiO2 at extubation: BJA RCT — high FiO2 washout (100%) causes more atelectasis. Use 40% FiO2 during washout phase to protect lung recruitment.

THIS MONTH Enteral Mg: Non-inferior to IV in stable ICU patients with NGT access. Reduces IV burden.

THIS MONTH NICE QS216: First NICE perioperative quality standard (1 Jul). CQC benchmark. Review now.

KNOW FOR NEXT TIME

GUIDELINE NICE NG258 Anaphylaxis: 3 tryptase samples required (30-120 min, 3-4h, baseline). 4-6h obs minimum. Allergy referral mandatory — update perioperative protocol.

GUIDELINE PPH 2026 (Lancet): Three-paper series. Coagulopathy in obstetric bleeding — new evidence on fibrinogen-first strategy.

GUIDELINE CPOC/APAGBI paeds pre-op: New 2026 national guidelines. Assessment ≥2 weeks before procedure. Non-invasive Hb recommended.

INFORMING PADDI + diabetes: Intraoperative dexamethasone 8mg causes clinically significant hyperglycaemia in diabetic patients — plan glucose monitoring.

INFORMING OFA in VATS: SR/MA — opioid-free anaesthesia reduces PONV and chronic pain in thoracic surgery without worsening haemodynamics.

INFORMING PENG block: RCT confirms PENG block reduces pain and improves prehabilitation in femoral neck fractures.

UK DATA Workforce: RCoA census — 2,147 anaesthetist shortfall; 1.5 million operations blocked annually.

This month's issue is led by Euroanaesthesia 2026's landmark blood pressure finding: targeting MAP above 65 in noncardiac surgery — despite a compelling mechanistic case — does not improve outcomes in 15,603 patients across 15 RCTs. Two BJA articles this month demand protocol updates: a clear FiO2 washout signal (high oxygen causes atelectasis) and a PADDI preplanned analysis showing dexamethasone causes meaningful hyperglycaemia in diabetic patients. In obstetrics, the Lancet's three-paper PPH series consolidates the evidence for fibrinogen-first haemostasis. And the MHRA has issued two drug recalls requiring immediate stock checks.

WHAT'S INSIDE — ISSUE 6

01 Key Evidence · 7 items incl. LEAD · MAP targets SR/MA, FiO2 RCT, PENG block, OFA VATS, Enteral Mg, VExUS, REBOARREST 02 Guidelines & UK Updates · 6 items · MHRA recalls, NICE QS216, NICE NG258, CPOC/APAGBI paeds, FICM/CICM, Ockenden/Amos 03 ICU & Critical Care · 3 items · DigiSep RCT, Bicarb synthesis, GASTRIC-PICU 04 Obstetric Anaesthesia · 2 items · PPH Lancet series, PADDI dexamethasone + diabetes 05 Quick Hits · 4 items 06 Action Points · 07 Trials to Watch

TAG LEGEND

CHANGE TONIGHT CHANGE THIS MONTH CHANGE WHEN GUIDELINE UPDATES

INFORMING PRACTICE FINAL FRCA PAEDS UK DATA LEAD

01 — KEY EVIDENCE & TRIALS

SYSTEMATIC REVIEW & META-ANALYSIS (15 RCTS, N=15,603) · EUROANAESTHESIA 2026 · JUNE 2026

Intraoperative Blood Pressure Targets in Noncardiac Surgery — Higher MAP (70–90) Does Not Improve Outcomes vs MAP 65

LEAD CHANGE THIS MONTH FINAL FRCA

• Null AKI — RR 0.95 (NS)
• Null MYOCARDIAL INJURY (NS)
• RR 0.73 DELIRIUM — INCONCLUSIVE
• n=15,603 15 RCTS

This SR/MA (15 RCTs, n=15,603) presented at Euroanaesthesia 2026 in Rotterdam is the most comprehensive evaluation of intraoperative blood pressure targets yet assembled. Two parallel trials — the Veelo 3,500-patient Amsterdam trial and the IMPROVE-multi 1,300-patient German multicentre trial — anchored the analysis. Both stopped early for futility.

Primary findings: Higher MAP targets (70, 80, or 90 mmHg, individualised or fixed) compared with routine MAP 65 showed no difference in: (1) AKI (RR 0.95, 95% CI 0.85–1.06); (2) Acute myocardial injury (RR 1.02, 95% CI 0.94–1.12); (3) In-hospital or 30-day mortality (RR 1.00). The one signal was postoperative delirium (pooled RR 0.73, p=0.04) but trial sequential analysis confirmed this remained inconclusive — insufficient cumulative evidence for firm conclusions.

CRITICAL APPRAISAL

This is a robust finding. The physiological rationale for higher MAP targets — improved coronary and renal perfusion pressure — is compelling, but the clinical trials consistently fail to demonstrate patient benefit. Likely explanations: (1) Most surgery patients have adequate autoregulation at MAP 65, so higher targets add vasopressor exposure without end-organ benefit; (2) The trials may not have captured the patients most likely to benefit (those with impaired cerebrovascular autoregulation). The delirium signal (RR 0.73) is hypothesis-generating and supports the ASPIRE 85 trial now recruiting. Crucially: this does not mean hypotension is safe — profound hypotension (MAP <60 for >5 minutes) remains associated with harm and should be corrected urgently regardless of target strategy.

UK PRACTICE IMPLICATION

MAP 65 mmHg remains the validated standard for intraoperative blood pressure management in noncardiac surgery. Routine vasopressor use to maintain MAP >70 or >80 is not supported by RCT evidence and exposes patients to unnecessary vasopressor side effects (tachycardia, arrhythmia, peripheral ischaemia). However: individualise. Known cerebrovascular disease, severe aortic stenosis, or impaired cerebral autoregulation are scenarios where individual MAP targets above 65 remain clinically justified — these populations were often excluded from trials.

TELL YOUR DEPARTMENT

Target MAP ≥65 mmHg as the primary intraoperative blood pressure goal in elective noncardiac surgery. Do not routinely target MAP >70 without patient-specific indication. Correct any MAP <60 promptly regardless of baseline strategy.

Source: Euroanaesthesia 2026 SR/MA. Veelo D (Amsterdam) + Saugel B (Hamburg). IMPROVE-multi: doi 10.1007/s00134-026-08490-7. Presented at Euroanaesthesia, Rotterdam, June 2026. PubMed review on intraop BP

BRITISH JOURNAL OF ANAESTHESIA · RCT · JUNE 2026 (DOI: 10.1016/J.BJA.2026.04.056)

High vs Low FiO2 During Anaesthetic Washout Before Extubation — High FiO2 Increases Postoperative Atelectasis: RCT

CHANGE THIS MONTH FINAL FRCA

• More atelectasis FIO2 100% WASHOUT ARM
• Less atelectasis FIO2 40% WASHOUT ARM
• EIT measured ELECTRICAL IMPEDANCE TOMOGRAPHY

The practice of administering high-flow 100% oxygen during the washout phase before extubation (to ensure rapid volatile agent clearance and pre-oxygenate against apnoea) is almost universal. This BJA RCT challenges that convention. Patients were randomised to FiO2 100%, 70%, or 40% during the washout period. Atelectasis was measured by electrical impedance tomography. The FiO2 100% arm showed significantly higher postoperative atelectasis on EIT compared with FiO2 40%. This is consistent with absorption atelectasis physiology: high FiO2 depletes nitrogen from alveoli, which are then absorbed by pulmonary capillary blood, causing alveolar collapse.

IMPLEMENTATION: CHANGE YOUR WASHOUT PROTOCOL

During the anaesthetic washout phase (end of surgery, before extubation): use FiO2 40–50% rather than 100%. This maintains adequate oxygenation during the washout period whilst preventing absorption atelectasis. The volatile agent will clear slightly more slowly at lower FiO2, but SpO2 remains safe with this approach in non-obese, non-compromised patients. For high-risk airways, obesity, OSA, or known difficult extubation: individualise — the safety margin from pre-oxygenation may justify FiO2 100% in these specific cases.

Source: BJA 2026. doi: 10.1016/j.bja.2026.04.056

ANESTHESIA & ANALGESIA · RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL · JUNE 2026

PENG Block in Femoral Neck Fractures — Prehabilitation and Pain: RCT Confirms Benefit

CHANGE THIS MONTH FINAL FRCA

The pericapsular nerve group (PENG) block targets sensory branches supplying the hip joint capsule (femoral nerve, obturator nerve accessory, articular branches) with a simple ultrasound-guided injection anterior to the hip capsule. This RCT specifically examined PENG block for prehabilitation in femoral neck fractures — the block was given early after fracture diagnosis (not just preoperatively) to enable patient mobilisation and physiotherapy before surgery.

Key findings: Patients receiving PENG block versus placebo had significantly reduced pain scores, were able to participate in prehabilitation physiotherapy, required less opioid analgesia before surgery, and had reduced postoperative opioid requirements. Femoral neck fractures in older adults are common ED presentations — offering PENG block in the acute setting (even before anaesthetic review) is feasible and evidence-supported.

UK PRACTICE: CONSIDER PENG BLOCK AT POINT OF CARE

PENG block for femoral neck fractures: straightforward technique (in-plane linear probe, 20mL 0.25–0.375% levobupivacaine, injection between iliopsoas and iliopectineal eminence). Can be performed by trained anaesthetists, emergency physicians, or orthopaedic surgeons in the ED or pre-assessment. The block provides analgesic benefit for 12–18h and allows earlier mobilisation. Review your trust's pathway for hip fractures — early PENG block should be available before operative anaesthetic review.

Source: Anesth Analg 2026. PENG block prehabilitation RCT. PubMed search: PENG block femoral neck 2026

BMC ANESTHESIOLOGY · SR/MA OF RCTS · JUNE 2026

Opioid-Free Anaesthesia in VATS — SR/MA: Significantly Reduces PONV and Chronic Pain Without Compromising Haemodynamics

INFORMING PRACTICE FINAL FRCA

• Less PONV SIGNIFICANT REDUCTION
• Less chronic pain SIGNIFICANT REDUCTION
• Bradycardia HIGHER IN OFA BUT NO BP DIFF
• VATS RCTs SR/MA OF TRIALS

Opioid-free anaesthesia (OFA) typically combines dexmedetomidine, ketamine, lidocaine (and often local/regional anaesthesia) as opioid-sparing multimodal analgesia. This SR/MA specifically examined OFA in video-assisted thoracoscopic surgery (VATS), where PONV is a major issue due to thoracic manipulation and single-lung ventilation. Results: OFA significantly reduced PONV and chronic postoperative pain compared with opioid-based approaches. Intraoperative bradycardia was more frequent with OFA (predominantly due to dexmedetomidine), but hypotension rates were similar. This evidence supports OFA adoption for elective VATS in eligible patients.

CRITICAL APPRAISAL

The chronic pain reduction is the most clinically significant finding — persistent post-thoracotomy/post-VATS pain is underappreciated and contributes significantly to post-discharge opioid use. The mechanism may be opioid-induced hyperalgesia prevention. However, OFA requires a well-structured multimodal protocol (dexmedetomidine infusion, epidural or ESPB/ICNB, paracetamol + NSAID, ketamine bolus) and careful patient selection — not appropriate for haemodynamically unstable patients or those with severe bradyarrhythmia risk. Ensure your institution has an OFA protocol before adoption.

Source: BMC Anesthesiology SR/MA 2026. Pain Research Forum summary

CRITICAL CARE MEDICINE · NON-INFERIORITY RCT · JUNE 2026 · MCMASTER SCORE: 6/7

Enteral vs IV Magnesium Replacement in Critically Ill Adults — Non-Inferior at 72 Hours

CHANGE THIS MONTH FINAL FRCA

• Non-inferior SERUM MG AT 72H
• Less IV burden NURSING HOURS SAVED
• NGT required STABLE PATIENTS ONLY
• McMaster 6/7 ICU POPULATION

Hypomagnesaemia (serum Mg <0.75 mmol/L) is present in 40–65% of ICU patients and is associated with refractory hypokalaemia, atrial arrhythmias, and prolonged ventilation. Standard replacement is IV magnesium sulphate (10–20 mmol over 60 minutes, repeated daily). This non-inferiority RCT (McMaster 6/7) demonstrates enteral magnesium via NGT achieves equivalent serum levels at 72 hours with less IV access requirement and fewer phlebitis events in haemodynamically stable ICU patients. For surgical ICU patients in the early postoperative period with NGT in situ: enteral Mg is a practical and evidence-based alternative to IV.

Source: Crit Care Med 2026. McMaster EvidenceAlerts 27 Jun 2026.

CRITICAL CARE MEDICINE · SR/MA · JUNE 2026

VExUS Venous Excess Ultrasound Grading System — SR/MA Confirms Predictive Value; IVC-Gating Limitation in ICU

INFORMING PRACTICE FINAL FRCA

VExUS (IVC diameter + hepatic, portal, and intrarenal Doppler) Grade 2–3 reliably predicts AKI and poor outcomes in critical illness, as confirmed by this SR/MA. Increasingly relevant for perioperative fluid management: post-cardiac surgery and post-major abdominal surgery patients accumulate venous congestion that causes end-organ injury. A technical caveat for ICU use: IVC dilatation (≥2 cm) as an entry criterion misses organ Doppler abnormalities in patients where IVC is not dilated — assess hepatic and portal Doppler directly if congestion is clinically suspected.

Source: Crit Care Med 2026. McMaster EvidenceAlerts 25 Jun 2026.

CRITICAL CARE · INTERNATIONAL RCT · JUNE 2026

REBOARREST: Prehospital REBOA in Non-Traumatic OHCA — Neutral on All Outcomes

INFORMING PRACTICE

REBOA in non-traumatic OHCA aimed to improve coronary and cerebral perfusion during CPR. REBOARREST found no improvement in ROSC, survival, or neurological outcome versus standard ALS. Consistent with ECPR data — the intervention complexity appears to eliminate any haemodynamic gain in non-traumatic arrest. Does not apply to traumatic cardiac arrest (zone-1 REBOA for haemorrhagic arrest). For anaesthetists involved in cardiac arrest response: do not adopt REBOA for medical OHCA based on current evidence.

Source: St Emlyn's, June 2026. stemlynsblog.org/reboarrest/

02 — GUIDELINES & UK UPDATES

MHRA · FIELD SAFETY NOTICES · 22–30 JUNE 2026

MHRA June 2026 — Flucloxacillin Capsule Recall and Gabapentin Oral Solution Defect

CHANGE TONIGHT UK DATA

IMMEDIATE STOCK CHECK REQUIRED CLASS 3 RECALL: FLUCLOXACILLIN CAPSULES 500MG (FLAMINGO PHARMA) — Packs contain

PIL for Amoxicillin 500mg instead of Flucloxacillin. Risk of dosing confusion. Check anaesthetic room, theatres, wards. IV flucloxacillin unaffected. Cefazolin is an RCT-validated alternative for MSSA (non-inferiority confirmed, NEJM 2026).

CLASS 4 DEFECT: GABAPENTIN 50MG/ML ORAL SOLUTION (RELONCHEM) — Visible particulate

contamination in bottles. Do not administer. Remove from stock. Gabapentin tablets unaffected.

MHRA drug device alerts

NICE · QS216 · 1 JULY 2026

NICE QS216 — First National Quality Standard for Perioperative Care in Adults

CHANGE THIS MONTH UK DATA

The first-ever NICE quality standard for perioperative care in adults was published 1 July 2026. QS216 covers preoperative, intraoperative, and postoperative care in secondary and tertiary settings. Quality standards are used by CQC and commissioners as inspection benchmarks. Anaesthetic departments and surgical teams should review quality statements against local practice. Expect focus on: preoperative optimisation, frailty assessment, shared decision-making documentation, and post-operative outcome monitoring. Full quality statements available at nice.org.uk/guidance/qs216.

Source: NICE QS216

NICE · NG258 · 27 MAY 2026 (REPLACES CG134)

NICE NG258 Anaphylaxis — Three Tryptase Samples Now Required; 4–6h Observation; Perioperative Protocol Update Needed

CHANGE WHEN GUIDELINE UPDATES FINAL FRCA

PERIOPERATIVE ANAESTHESIA POINT

Perioperative anaphylaxis most commonly occurs at induction. For any suspected intraoperative anaphylactic reaction: (1) stop all agents and list ALL drugs given; (2) draw first tryptase at 30–120 min from event onset — this is time-critical and often missed in post-event management; (3) draw second tryptase at 3–4 hours; (4) arrange baseline tryptase at 24h or outpatient follow-up; (5) make allergy referral before patient leaves hospital. Update your departmental perioperative anaphylaxis protocol and anaesthetic record template to capture all three sample timings.

Source: NICE NG258

CPOC / APAGBI · JUNE 2026 · RCOA/FICM · JULY 2026

CPOC/APAGBI New Paediatric Pre-Operative Guidelines 2026 — and FICM Becomes College of Intensive Care Medicine

CHANGE WHEN GUIDELINE UPDATES PAEDS UK DATA

CPOC/APAGBI 2026 Paediatric Pre-op Guidelines: The first comprehensive national guidance for preoperative care in children and young people in England. Key requirements: formal assessment ≥2 weeks before procedure; non-invasive haemoglobin measurement to reduce venepuncture in children; individualised anaesthetic planning for neurodiverse or anxious children. Any anaesthetist on paediatric lists should review the full guidance at apagbi.org.uk.

FICM becomes College of ICM (CICM) — 2 July 2026: Governance change only. FICM previously operated as a faculty under eight Royal Medical Colleges; now independent. ICM trainees: update correspondence. No change to training curricula or examinations at this time. The RCoA Workforce Census 2025 (published June 2026) documents 2,147 anaesthetist shortfall blocking 1.5 million operations annually — the most cited figure in UK anaesthetics workforce discussions.

Sources: CPOC | CICM | RCoA Workforce Census 2025

RCOA / OAA JOINT RESPONSES · JUNE–JULY 2026

Ockenden Nottingham Review and Baroness Amos Maternity Report — Obstetric Anaesthesia Implications

CHANGE WHEN GUIDELINE UPDATES UK DATA

Two major UK maternity safety reports (Ockenden Nottingham Review, 24 June; Baroness Amos Final Report, 30 June) both call for binding national maternity standards. RCoA and OAA have jointly endorsed recommendations. Both reports highlight inadequate anaesthetic presence in maternity emergencies and communication failures between teams. OAA leads should: (1) review 24-hour anaesthetic cover arrangements for obstetric units; (2) audit emergency team communication protocols; (3) review consent and communication practices for women from Black and Asian backgrounds regarding epidural provision and pain management. Binding standards from government are anticipated to follow.

Ockenden Nottingham Report | Baroness Amos Final Report

03 — ICU & CRITICAL CARE

INTENSIVE CARE MEDICINE · RCT · PMID: 42377463 · 30 JUNE 2026

DigiSep Trial: Clinical Metagenomics in Sepsis — RCT Impact on Outcomes, Costs, and Quality of Life

INFORMING PRACTICE FINAL FRCA

• RCT GERMAN MULTICENTRE (15 CENTRES)
• Metagenomics VS STANDARD MICROBIOLOGY
• Sepsis/SS ICU POPULATION

Clinical metagenomics (sequencing all microbial DNA in a blood or bronchoalveolar sample simultaneously, bypassing culture) is an emerging diagnostic approach for ICU sepsis. The DigiSep trial — the first adequately powered RCT — evaluated whether metagenomics-guided management improved outcomes in sepsis/septic shock patients compared with standard culture-based microbiology. Outcomes included clinical outcomes, healthcare costs, and health-related quality of life. Published by the German Society of Anaesthesiology and Intensive Care (GSAIC) Trials Group in ICM, 30 June 2026.

CLINICAL SIGNIFICANCE

Clinical metagenomics offers pathogen identification within 6–12 hours (vs 24–72h for standard cultures) and detects organisms missed by conventional culture (fungi, atypical bacteria, viruses, polymicrobial infections). The DigiSep result will determine whether faster pathogen identification translates to antibiotic deescalation, shorter ICU stays, or improved mortality. This trial is highly relevant to UK ICUs considering whether to commission metagenomics services. Watch for the full results at PubMed PMID: 42377463.

SYNTHESIS · POST-ICS SOA26 · BIHCA (JAMA) + SODA-BIC (NEJM) + BICAR-ICU (LANCET)

Sodium Bicarbonate in the ICU — When the Evidence Says Stop

INFORMING PRACTICE FINAL FRCA

ICU BICARB PROTOCOL — THE EVIDENCE-BASED THRESHOLD

Bicarb in ICU is only supported by RCT evidence at: pH ≤7.20 AND AKI Stage 2-3 AND on vasopressors (BICAR-ICU criteria). Outside this: BIHCA and SODa-BIC confirm bicarb does not improve outcomes and causes hypernatraemia and alkalosis. Update your ICU default prescribing accordingly. Bicarb remains appropriate for: TCA overdose (QRS prolongation), hyperkalaemic arrest, and metabolic alkalosis correction in specific scenarios — but not for routine acidosis management in shock.

JAMA · RCT · JUNE 2026 · MCMASTER 5/7

GASTRIC-PICU: Routine Gastric Residual Volume Monitoring in Mechanically Ventilated Children — No Benefit

INFORMING PRACTICE PAEDS

Routine 4-hourly GRV checks in ventilated PICU patients do not improve feeding tolerance, VAP rates, or outcomes versus symptom-driven monitoring. Mirrors adult ICU evidence. Remove routine GRV monitoring from PICU nursing observation charts. Respond to clinical intolerance signs rather than arbitrary GRV cut-offs.

GASTRIC-PICU, JAMA 2026 Jun 29. JAMA

04 — OBSTETRIC ANAESTHESIA

THE LANCET · THREE-PAPER SERIES · JUNE 2026

Postpartum Haemorrhage 2026 — Lancet Series: Epidemiology, Prevention, and Diagnosis & Treatment

CHANGE WHEN GUIDELINE UPDATES FINAL FRCA

The Lancet published a major three-paper PPH series in June 2026, consolidating the evidence base for the most common cause of maternal mortality globally. Each paper covers a distinct phase of the PPH challenge:

KEY PRACTICE CHANGES — OBSTETRIC ANAESTHESIA

The strongest new messages: (1) Fibrinogen replacement (not FFP) first when ROTEM/TEG or fibrinogen <2g/L — fibrinogen concentrate or cryoprecipitate; (2) TXA 1g IV should be given early in PPH (not just in severe haemorrhage) consistent with WOMAN trial; (3) Cell salvage should be immediately available for high-risk deliveries; (4) Black and Asian women have higher PPH risk — ensure parity of documentation, early escalation, and access to cell salvage regardless of patient preference regarding autologous blood.

Source: The Lancet June 2026. Three-paper PPH series. thelancet.com

BRITISH JOURNAL OF ANAESTHESIA · PADDI TRIAL PREPLANNED ANALYSIS · JUNE 2026

Intraoperative Dexamethasone 8mg and Glycaemic Response in Patients with Diabetes — PADDI Preplanned Analysis

CHANGE THIS MONTH FINAL FRCA

Dexamethasone 8mg IV is now near-universal in elective surgery as antiemetic prophylaxis. The PADDI trial (over 8,000 patients) evaluated whether dexamethasone increased surgical site infections — it did not. This preplanned subgroup analysis of patients with diabetes mellitus examines the glycaemic consequences specifically. Dexamethasone 8mg at induction caused clinically significant hyperglycaemia in diabetic patients, peaking 2–4 hours post-administration and persisting into the postoperative period.

CLINICAL IMPLICATION

If you routinely give dexamethasone 8mg IV to all elective surgical patients (which is best practice for PONV prophylaxis), then for patients with diabetes (both type 1 and type 2, and steroid-dependent patients): plan glucose monitoring 2-4 hours post-induction and arrange postoperative glucose checks before discharge or within the first HDU check. Consider insulin sliding scale or modified VRIII protocol for high-risk diabetic patients receiving dexamethasone. This does not mean withholding dexamethasone — the PONV prevention benefit outweighs the manageable hyperglycaemia risk — but it requires active glucose management planning.

Source: BJA 2026. PADDI trial preplanned analysis (dexamethasone in diabetes). doi: via BJA June 2026 issue.

05 — QUICK HITS

SSC 2026 Update — Brief Summary (see Issues 3 & 4 for full coverage). The 2026 Surviving Sepsis Campaign guidelines (129 statements, 46 new) added several practical ICU points not previously highlighted: mucolytics (carbocisteine, HTS) are now explicitly NOT recommended in mechanically ventilated patients following the MARCH trial harm signal (carbocisteine: GI bleed RR 6.51; HTS: bronchoconstriction RR 5.73). Antibiotic deescalation upgraded from suggestion to recommendation when susceptibilities available. Source control within 6 hours where feasible.

ANZCA 2026 GLP-1 Agonist Perioperative Guidance Update (see Issues 3 & 5 for full coverage). ANZCA updated guidance recommends against routinely withholding GLP-1 agonists preoperatively — the risk of hyperglycaemia and disease disruption may equal or exceed the poorly-quantified aspiration risk. Individual assessment remains appropriate where clinical gastroparesis is present. RCoA/AAGBI UK-specific guidance expected. For patients with known GLP-1-related GI symptoms: extended fasting (8h solids) and consider RSI if any doubt about gastric emptying.

Thyroid, Parathyroid, and Phaeochromocytoma — Anaesthesia & Intensive Care Medicine Review Series (June 2026). Three-part review series relevant to Final FRCA: (1) thyroid hormones and calcium homeostasis; (2) recognition and management of phaeochromocytoma and paraganglioma; (3) thyroid disease and thyroid surgery anaesthesia. Available in Anaesthesia & Intensive Care Medicine (the "blue book" journal) June 2026 issue. Particularly useful for revision of phaeochromocytoma perioperative management (alpha-blockade first, then beta, PICU vs high-dependency decisions).

OFACAR Trial: Opioid-Free Anaesthesia in Cardiac Surgery (Anesthesiology, May 2026). Guinot et al. RCT. OFA (dexmedetomidine + ketamine + lidocaine) vs opioid-based anaesthesia in cardiac surgery. Reduced postoperative pulmonary complications in the OFA arm. Bradycardia was more common. Provides the strongest RCT evidence yet for OFA in cardiac surgery — reinforcing the trend toward multimodal, opioid-sparing techniques in high-risk surgery.

06 — ACTION POINTS — ISSUE 6

TRIALS TO WATCH

Q2–Q3 2026

• ASPIRE 85 Trial — Intraoperative MAP 85 vs 65 specifically targeting delirium reduction. Following the inconclusive delirium signal in the Euroanaesthesia SR/MA. Results expected 2026–2027.
• NAP8 — Regional Anaesthesia Complications Audit — Active UK-wide recruitment. Will provide UK-specific complication rates for all regional techniques. Critical for perioperative risk discussions.
• BEST-DKA (balanced vs saline in DKA, Phase 3) — Results late 2026. Final FRCA revision topic.

2026–2027

• FICM/CICM ACCP Scope of Practice Framework — Finalisation pending. Will define ACCP roles in UK ICUs and affect workforce governance.
• RCoA Response to Ockenden/Amos Maternity Reports — New obstetric anaesthetic service standards expected. Likely to mandate minimum anaesthetic cover levels.
• NICE NG51 Sepsis Update — Expected following SSC 2026 and new fluid trial data. Will update UK-specific sepsis thresholds.

Jake Turner

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

Anaesthetics & ICU Evidence Rundown — Issue 6 — July 2026 — UK Edition Published by EM Evidence. For clinical use only — verify against local guidelines before implementing changes in practice. emevidence.org · emevidence999@gmail.com