Anaesthetics & ICU Evidence Rundown — August 2026

ANAESTHETICS & ICU EVIDENCE RUNDOWN — ISSUE 7 — AUGUST 2026 — UK EDITION

Anaesthetics & ICU Evidence Rundown

Monthly evidence for UK anaesthetists and intensivists — emevidence.org

Jake Turner

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

Lead: The SNaPP trial (Lancet Resp Med, July 2026, n~7,000) — the largest RCT ever of sugammadex vs neostigmine — demonstrates a small but statistically significant reduction in the primary composite of postoperative pulmonary complications or death (19.0% vs 21.5%, RRR 12%) with sugammadex, driven mainly by atelectasis. The dapagliflozin perioperative AKI trial (JAMA 30 Jul, RCT) cuts AKI incidence from 52% to 28% in elective cardiac surgery — but 30-day mortality and other clinical outcomes are unchanged, raising the question of whether this AKI reduction matters clinically. Major UK structural change: FICM became the independent College of Intensive Care Medicine (CICM) on 1 July 2026. The FFICM is now the FCICM. All ICM trainees and consultants need to update their credentials. Safety: Association of Anaesthetists updated consent for anaesthesia guidelines (Anaesthesia, 15 Jul). MHRA ChloraPrep recall (sterility breach, Class 2). MHRA cyclizine lactate 50mg/ml recall (GMP deficiencies, Class 3).

BOTTOM LINE UP FRONT — AUGUST 2026

ACT ON THIS NOW

CHANGE THIS MONTH SNaPP trial: Sugammadex vs neostigmine — pulmonary complications/death 19.0% vs 21.5% (RRR 12%, ARD 2.5%). Mainly atelectasis. Supports NHS guidance preferring sugammadex. Review your rocuronium reversal policy.

CHANGE THIS MONTH Dapagliflozin cardiac surgery AKI: RCT — AKI 28% vs 52% (ARD -24%, NNT ~4). But 30-day mortality unchanged. Consider perioperative dapagliflozin — discuss with cardiac surgery teams.

SAFETY MHRA ChloraPrep 1 mL recall (EL(26)A/34): Sterility breach. Used for regional anaesthesia and central lines. Replace stock immediately.

SAFETY MHRA Cyclizine Lactate 50mg/ml recall (EL(26)A/29): GMP deficiencies. Perioperative PONV management — check stocks and substitute if needed.

GUIDELINE New consent guidelines: Association of Anaesthetists updated Consent for Anaesthesia guidance (Anaesthesia, 15 Jul, DOI 10.1111/anae.70283). Includes what patients must be told about anaesthetic risks. All anaesthetists must read and update their consent practice.

KNOW FOR NEXT TIME

INFORMING PRACTICE CICM rebrand: FICM became the College of Intensive Care Medicine (CICM) on 1 July 2026. FFICM is now FCICM. Exam sittings from October 2026 onwards are branded FCICM. Update all correspondence and credentials.

GUIDELINE NICE QS216 Perioperative Care: New quality standard (1 Jul 2026). Covers preoperative, intraoperative, and postoperative care across secondary care. Builds on NG180 (2020). Implement and audit against these standards.

INFORMING PRACTICE ICS research priorities: 10 new James Lind Alliance-style ICU research priorities (1 Jul 2026). Includes delirium prevention, PICS, ICU rehabilitation, family involvement. Align departmental QIP projects.

INFORMING PRACTICE BJA intraoperative BP SR/MA: Shalabi et al. — individualised BP management (10 RCTs) — no reduction in AKI, MI, or mortality. Possible benefit for delirium only. The evidence base for tight MAP targets is weaker than widely taught.

INFORMING PRACTICE DOLVI trial / VL for DLT: BJA — videolaryngoscopy improves first-pass intubation rates, visualisation, and reduces malpositions for double-lumen tube intubation. Consider as first-line for thoracic anaesthesia intubation.

FINAL FRCA AnaesthEasier — Oil/Blood Gas coefficients: MAC, speed of onset/offset, blood:gas and oil:gas partition coefficients for all major volatile agents. Published 27 Jul. Core Final FRCA pharmacology.

July 2026 closes with two papers that will reset practice expectations in perioperative medicine. The SNaPP trial — 7,000+ patients, multicentre RCT, landmark ANZCA clinical trials network — delivers what the sugammadex literature has long been building toward: a modest but real reduction in postoperative pulmonary complications when sugammadex replaces neostigmine. The 2.5% absolute risk reduction is driven largely by atelectasis, which will prompt debate about clinical significance. But in a surgical population numbering millions, that 12% relative reduction has a public health argument. The dapagliflozin cardiac surgery trial makes the opposite point: a 24% absolute reduction in AKI (28% vs 52%) sounds dramatic — and it is, statistically — but if 30-day mortality, reoperation rates, and length of stay are unchanged, what are we protecting patients from? These two papers belong together in any serious discussion of perioperative outcome metrics. On the UK governance front, FICM becoming CICM on 1 July is the most significant structural change in UK critical care training since the Faculty's creation in 2010 — every intensivist needs to know what their new college is called and what their qualification is now named. The Association of Anaesthetists' updated consent guidelines close a loop that the Montgomery ruling opened in 2015 and that consent practice in UK anaesthesia has been catching up to ever since.

WHAT'S INSIDE — ISSUE 7, AUGUST 2026

• LEAD: SNaPP trial — sugammadex vs neostigmine (n~7,000)
• Dapagliflozin RCT — perioperative AKI cardiac surgery (JAMA)
• FICM → CICM: major structural change 1 July 2026
• New consent for anaesthesia guidelines (Assoc. of Anaesthetists)
• NICE QS216: Perioperative care in adults
• ICS: 10 new ICU research priorities
• BJA: Intraoperative BP SR/MA (no benefit on hard outcomes)
• BJA: DOLVI trial — VL for double-lumen intubation
• BJA: Butyrylcholinesterase deficiency — genetic testing SR
• ESAIC consensus: sustainability in ICU (environmental impact)
• NEXIS trial: in-bed cycling + amino acids in ICU (null result)
• MHRA: ChloraPrep recall + Cyclizine recall
• AnaesthEasier: Oil/Blood Gas coefficients (Final FRCA)
• AnaesthEasier: Anxious patient & slow induction

• Quick Hits + Core Revision: Volatile Anaesthetic Agents Pharmacology

CHANGE TONIGHT CHANGE THIS MONTH GUIDELINE INFORMING PRACTICE SAFETY FINAL FRCA UK SPECIFIC

FOAMED

S1 Key Trials | S2 UK Guidance & Safety | S3 Journals & Critical Appraisal | S4 FOAMed & Final FRCA | S5 Quick Hits | Core Revision: Volatile Agents

SECTION 1 — KEY TRIALS

LEAD CHANGE THIS MONTH UK SPECIFIC

SNaPP Trial: Sugammadex Reduces Postoperative Pulmonary Complications vs Neostigmine in Abdominal/Thoracic Surgery (Lancet Resp Med, n~7,000)

ANZCA Clinical Trials Network. Lancet Respiratory Medicine. Published online July 2026. ANZCA announcement

Design: Large, multicentre, randomised, controlled phase 4 trial comparing sugammadex versus neostigmine for reversal of rocuronium- or vecuronium-induced neuromuscular blockade in patients aged 40 years and over undergoing abdominal or thoracic surgery. Primary outcome: composite of postoperative pulmonary complications (POPC) or death up to hospital discharge or postoperative day 7.

• 19.0% SUGAMMADEX ARM (POPC/DEATH)
• 21.5% NEOSTIGMINE ARM (POPC/DEATH)
• ARD 2.5% NNT ~40 TO PREVENT 1 POPC
• Phase 4 MULTICENTRE RCT — N~7,000

Key results: Postoperative pulmonary complications or death occurred in 19.0% of sugammadex patients vs 21.5% of neostigmine patients — a statistically significant difference (p<0.05). There were no meaningful differences in pneumonia, pulmonary aspiration, unplanned ICU/HDU admission, days alive and at home at 30 days, or health-related quality of life at 3 months. The reduction in the primary outcome was mainly driven by a lower incidence of atelectasis. Authors describe the absolute risk reduction as small and note that the clinical significance of atelectasis is uncertain.

UK clinical significance: SNaPP is the largest RCT ever of a neuromuscular reversal agent and provides the first definitive outcome data (rather than mechanistic data) for sugammadex. NHS NICE guidance and the 2023 ASA guideline already recommend sugammadex as preferred reversal at deep, moderate, and shallow block depth over neostigmine; SNaPP now provides outcome-level support for this recommendation. The NNT of ~40 means that for every 40 patients reversed with sugammadex instead of neostigmine, approximately one pulmonary complication is avoided. Whether that is good value depends on the relative cost and availability of sugammadex at your trust. This should be discussed at departmental governance and formulary review.

Critical appraisal: The primary composite endpoint (POPC or death) includes atelectasis as a component — atelectasis is common, often subclinical, and of variable clinical significance. Excluding atelectasis, the sugammadex advantage loses statistical significance in several analyses. The trial also included only abdominal and thoracic surgery in adults aged ≥40 — generalisability to other surgical contexts should be assessed. The key message: sugammadex is now evidence-backed at RCT level, but the magnitude of benefit is modest and driven by radiological atelectasis. Quantitative neuromuscular monitoring (TOF ratio ≥0.9) before extubation remains the gold standard regardless of reversal agent choice.

CHANGE THIS MONTH PERIOPERATIVE MEDICINE

Dapagliflozin Reduces Perioperative AKI in Elective Cardiac Surgery by 24% (ARD) — But 30-Day Clinical Outcomes Unchanged (JAMA RCT)

JAMA. Published online 30 July 2026. PMID: 42530951. DOI: 10.1001/jama.2026.9268

Design: Randomised clinical trial. Dapagliflozin (10 mg/day oral) initiated 1 day before elective cardiac surgery vs placebo. Primary outcome: incidence of acute kidney injury (AKI) within the first 7 days post-surgery. Key secondary outcomes: 30-day mortality, reoperation rate, atrial fibrillation, major adverse cardiac events.

• 28% DAPAGLIFLOZIN ARM AKI
• 52% PLACEBO ARM AKI
• NNT ~4 ARD 24% (IMPRESSIVE)
• Same 30-DAY CLINICAL OUTCOMES

Bottom line: Dapagliflozin starting 1 day before cardiac surgery significantly reduced AKI incidence (28% vs 52%), which is a dramatic absolute effect. However, 30-day mortality, reoperation rates, AF incidence, and MACE were similar between groups. Adverse events including atrial fibrillation were comparable.

Interpretation and UK applicability: The AKI reduction is statistically large, and AKI is a valid perioperative outcome (associated with longer ICU stay, dialysis requirement, and higher long-term mortality in other contexts). The absence of a mortality or reoperation signal may reflect insufficient power, short follow-up, or that this biochemical AKI is less severe. This is an important paper for cardiac anaesthesia and perioperative medicine. The existing UK guidance on SGLT2 inhibitor withholding before surgery (historically: hold 3-4 days before elective surgery) may need revisiting if this data is replicated. Discuss with your cardiac surgical and nephrology colleagues before implementing. The ACEI/ARB AKI data (Brazilian cohort, n=249, aOR 2.79 — periop AKI with continued ACEI/ARB) provides a complementary perspective: the renal axis in cardiac surgery is clearly important and merits individualised drug management.

SECTION 2 — UK GUIDANCE & SAFETY

MAJOR UK CHANGE UK SPECIFIC

FICM Becomes the College of Intensive Care Medicine (CICM) — 1 July 2026 — FFICM Is Now FCICM

FICM/CICM, effective 1 July 2026. RCoA statement: rcoa.ac.uk | ICS statement: ics.ac.uk

On 1 July 2026, the Faculty of Intensive Care Medicine (FICM) formally became the College of Intensive Care Medicine (CICM) — an independent Royal Medical College, no longer a faculty hosted by the eight parent Royal Medical Colleges (including the Royal College of Anaesthetists).

Key changes:

• Name: Faculty of Intensive Care Medicine → College of Intensive Care Medicine (CICM)
• Qualification: FFICM (Fellowship of the Faculty of Intensive Care Medicine) → FCICM (Fellowship of the College of Intensive Care Medicine). Exam sittings from October 2026 are branded FCICM.
• Trainees: All ICM trainees enrolled before 1 July 2026 will have their qualification renamed automatically — no re-examination required. Certificates already issued remain valid.
• Website: ficm.ac.uk is expected to transition to cicm.ac.uk; check for redirect updates.

Action required: Update your CV, GMC profile notes, consultant contracts, and any academic correspondence where FICM/FFICM is cited. Trainees sitting the FFICM exam from October 2026 onwards should be aware of the rebranding. Departments should update job descriptions and person specifications. The GPICS V3 quality standards (January 2026) continue to apply and are now CICM standards. AICM training documents and ePortfolio entries may also require updating — check with your TPD.

GUIDELINE UK SPECIFIC ACT NOW

Association of Anaesthetists: Updated Consent for Anaesthesia Guidelines — What Must Patients Be Told? (Anaesthesia, 15 Jul 2026)

Association of Anaesthetists. Anaesthesia. Published online 15 July 2026. DOI: 10.1111/anae.70283 | PMID: 42453045. pubmed

The Association of Anaesthetists has published updated guidelines on consent for anaesthesia — the first major revision since 2017 and the first explicitly post-Montgomery guidance document from the Association. The update reflects the decade of case law and NHS guidance that followed the Supreme Court's 2015 Montgomery ruling on patient consent and material risk disclosure.

Core changes from the previous version (key themes):

• Clearer guidance on what constitutes a "material risk" — risks that a reasonable person in the patient's position would want to know, including low-probability high-consequence risks (e.g., dental damage, awareness, nerve damage)
• Explicit guidance on timing of consent discussions — the day-of-surgery consent discussion is no longer adequate as the only consent event; pre-operative discussions should occur with adequate time for reflection and questions
• Documentation requirements strengthened — the "conversation" must be documented, not just the signing of the form
• Guidance on consent for high-risk patients, patients with learning disabilities, and patients who decline certain interventions
• Airway management discussions as part of anaesthetic consent — patients should be informed of the plan and backup airway options

Practice implication: All anaesthetists should read this guideline and review their current consent practice against it. The key update is the shift from a form-focused to a conversation-focused model — the consent form is merely documentation of a conversation that must already have happened. Pre-assessment anaesthetic consultations are the ideal venue; same-day-of-surgery consent for elective anaesthesia is now explicitly inadequate as the sole consent event.

NICE UK SPECIFIC

NICE QS216: Perioperative Care in Adults — New Quality Standard Published 1 July 2026

NICE Quality Standard QS216, published 1 July 2026. nice.org.uk/guidance/qs216

NICE published Quality Standard QS216 on perioperative care in adults on 1 July 2026. This is a Quality Standard (QS), not a full guideline — it distils the key measurable quality statements from the existing NICE guideline NG180 (perioperative care in adults, 2020) into auditable statements for secondary care trusts.

Scope: Adults (≥18 years) in secondary/tertiary care having surgical or other interventional procedures under anaesthesia (general, regional, or monitored anaesthesia care). Excludes outpatient minor surgery.

Anaesthetic department action: Review against QS216 quality statements. These typically form the basis for CQC inspection criteria and trust clinical governance KPIs. Key areas covered: preoperative assessment and optimisation, shared decision-making and consent, enhanced recovery after surgery (ERAS) pathways, postoperative monitoring and pain management. Audit against the quality statements before the CQC visit, not after. Full quality statements at nice.org.uk/guidance/qs216.

SAFETY MHRA

MHRA Safety Alerts July 2026: ChloraPrep Sterility Recall + Cyclizine GMP Recall + July Roundup

MHRA, July 2026. gov.uk/drug-device-alerts

SAFETY ALERTS — ANAESTHETIC PRACTICE

ChloraPrep 1 mL applicators — Class 2 Recall (EL(26)A/34) Becton Dickinson UK Ltd. Sterility breach due to potential packaging process failure. ChloraPrep (2% chlorhexidine gluconate in 70% isopropyl alcohol) is widely used for skin antisepsis before regional anaesthesia (spinals, epidurals, peripheral nerve blocks), central line insertion, and surgical site preparation. Action: remove all affected stock immediately. Check batch numbers against recall list. Switch to alternative chlorhexidine preparation. Full recall details at gov.uk/drug-device-alerts. Cyclizine Lactate 50 mg/mL Solution for Injection — Class 3 Recall (EL(26)A/29) Orbit Pharma Limited. GMP deficiency at manufacturing site. Cyclizine is commonly used perioperatively as an antiemetic (alternative to ondansetron for PONV; less QTc-prolonging). Action: check ward stock and remove affected batches. Alternative PONV agents: ondansetron 4mg IV, dexamethasone 4-8mg IV, or metoclopramide (if appropriate). MHRA Safety Roundup July 2026 (published 30 Jul): Domperidone contraindicated in patients with confirmed or suspected phaeochromocytoma (risk of severe hypertension). Note for anaesthetic pre-assessment: if a patient is on domperidone and has features of possible phaeochromocytoma, escalate to the surgical team. Bladder anticholinergic medicines and dementia risk — small but not excluded increase noted; see Roundup for full details.

SECTION 3 — JOURNALS & CRITICAL APPRAISAL

INFORMING PRACTICE BJA JULY 2026

BJA: Individualised Intraoperative BP Management SR/MA (10 RCTs) — No Reduction in AKI, MI, or Mortality; Possible Benefit for Delirium Only (Shalabi et al.)

Shalabi et al. British Journal of Anaesthesia. Volume 136, Issue 7. Published 2 July 2026. bjanaesthesia.org

Study: Meta-analysis of 10 RCTs examining whether individualised, goal-directed intraoperative blood pressure management (maintaining MAP above a patient-specific baseline, typically above 65 mmHg or adjusted for the individual) reduces postoperative AKI, myocardial injury, delirium, or 30-day mortality compared with conventional blood pressure targets.

Results: No significant reduction in AKI, myocardial injury (non-cardiac surgery) or mortality in patients receiving individualised versus conventional BP targets. A possible benefit for postoperative delirium was found, but this did not reach conventional significance thresholds and varied across included trials.

Context: The individualised BP management hypothesis — essentially, "patients differ; treat their MAP to avoid a drop from their personal baseline, not a fixed 65 mmHg" — has been attractive because it is physiologically plausible. POISE-3 and related data has shown MAP <65 mmHg is associated with adverse events. Shalabi et al. challenge the premise that personalised targets do better than pragmatic fixed targets. The delirium signal warrants further investigation. Practical implication: maintain MAP ≥65 mmHg intraoperatively as a minimum; there is no strong evidence that a more complex individualised target improves outcomes in unselected patients. Known severely hypertensive patients (>180/110 at baseline) may warrant higher targets — clinical judgement applies.

CHANGE THIS MONTH AIRWAY

DOLVI Trial: Videolaryngoscopy for Double-Lumen Tube Intubation — Improved First-Pass Success, Visualisation, and Fewer Malpositions (BJA)

DOLVI trial. British Journal of Anaesthesia. Volume 136, Issue 7, July 2026. bjanaesthesia.org

Study: RCT examining videolaryngoscopy (VL) versus direct laryngoscopy (DL) for double-lumen tube (DLT) intubation in thoracic anaesthesia. Primary outcomes: first-pass intubation success rate, glottis visualisation grade, and malposition rate confirmed by fibreoptic bronchoscopy.

Results: VL demonstrated increased first-pass intubation rates, improved glottis visualisation, reduced procedural difficulty scores, and fewer DLT malpositions compared with DL. An accompanying BJA editorial (Rowland et al.) argues this supports VL as first-line for DLT intubation.

Clinical implication: DLT intubation is technically more challenging than single-lumen tube intubation due to the tube's bulk and curvature. Malposition requires repositioning via fibreoptic bronchoscopy and prolongs the anaesthetic. This trial provides RCT evidence for VL as first-line in thoracic anaesthesia. If your thoracic anaesthesia practice still defaults to DL for DLT, this evidence supports switching. Ensure VL with an appropriate blade (e.g., Macintosh-style or hyperangulated depending on anatomy) is available in your thoracic operating suite.

BJA FINAL FRCA

Genetic Testing for Butyrylcholinesterase Deficiency Improves Perioperative Safety — SR/MA Supports Integration into Diagnostic Pathways (BJA)

Systematic review. British Journal of Anaesthesia. Published online 29 July 2026. BJA on X, 29 Jul 2026

Suxamethonium apnoea (prolonged neuromuscular blockade following suxamethonium due to deficiency of pseudocholinesterase/butyrylcholinesterase) is a known but underdiagnosed perioperative risk. This systematic review examines whether integrating genetic testing for butyrylcholinesterase (BChE) variants into diagnostic pathways — rather than relying on post-event enzyme activity testing alone — would improve perioperative safety. The review found that genotyping improves diagnostic accuracy and that pre-operative or post-event genotyping could identify at-risk individuals before a second anaesthetic and guide family counselling.

Final FRCA relevance: Butyrylcholinesterase deficiency is a classic FRCA viva topic. The heterozygous "dibucaine number" test and gene variants (Eu, Ea, Ef, Es) remain core knowledge. The new angle from this paper is that genetic testing is increasingly available and more accurate than dibucaine number alone. If you encounter a patient with known or suspected BChE deficiency, document clearly, alert surgical and anaesthetic teams, and consider discussing genotyping with biochemistry. Sugammadex is the reversal of choice if rocuronium has been used (avoids suxamethonium entirely if risk factors identified pre-operatively).

ESAIC CONSENSUS ICU

ESAIC 2026 Consensus: Sustainability and Mitigation Strategies in Intensive Care Medicine — Including Environmental Impact of Volatile ICU Sedation

ESAIC. Published 14 July 2026. esaic.org

The European Society of Anaesthesiology and Intensive Care published a new consensus document on 14 July 2026 covering sustainability and environmental mitigation strategies specifically for ICU medicine. This includes: energy use reduction in ICU facilities, waste management (PPE, drug waste), medication use (particularly the environmental impact of volatile anaesthetic agents used for ICU sedation via AnaConDa/MIRUS devices), and ethical frameworks for ICU sustainability decisions.

Environmental impact of volatiles in ICU: Isoflurane, sevoflurane, and desflurane have significant global warming potentials (GWP). Desflurane's GWP is ~2,500 times that of CO2 over 100 years and is now banned in the UK (MHRA 2024). Isoflurane (GWP ~510) is used in ICU sedation via AnaConDa/MIRUS; the consensus recommends agent reflection systems and minimising waste. The consensus is directly relevant to UK ICU sustainability strategy and should be reviewed by department leads and ICU pharmacists alongside NHS England's Green Plan requirements.

ICU REHABILITATION AJRCCM

NEXIS Trial: Combined In-Bed Cycling + Intravenous Amino Acids in Critically Ill Patients — Safe but No Improvement in 6-Minute Walk Distance (AJRCCM)

Needham DM et al. Am J Respir Crit Care Med. Published 13 July 2026. DOI: 10.1093/ajrccm/aamag287

Design: Randomised controlled trial of combined in-bed cycling exercise plus IV amino acid supplementation versus usual care in critically ill patients. Primary outcome: 6-minute walk distance at hospital discharge.

Results: The combined intervention appeared safe (no significant increase in adverse events). However, the primary outcome — 6-minute walk distance at discharge — was not significantly improved compared with usual care. Secondary outcomes including ICU length of stay and ventilator-free days were also similar.

Interpretation: NEXIS follows a series of trials (including BIKE and MRC-ICU) that have failed to show clear functional benefit from in-bed exercise in mechanically ventilated patients, despite the physiological rationale. The result does not negate early mobilisation and rehabilitation in ICU — active mobilisation (sitting out, walking) where possible remains best practice per GPICS V3. It suggests that in-bed passive cycling plus parenteral amino acids alone is insufficient to prevent ICU-acquired weakness. The ICS SOA26 iRehab trial presented at the conference is expected to report on a more comprehensive rehabilitation package in a UK population — watch for that publication.

SECTION 4 — FOAMED & FINAL FRCA (ANAESTHEASIER)

ANAESTHEASIER FINAL FRCA

AnaesthEasier: Oil/Blood Gas Coefficients for Volatile Agents — MAC, Potency, Speed of Onset/Offset (27 July 2026)

AnaesthEasier. Published 27 July 2026. anaestheasier.com

Source note: AnaesthEasier is a high-quality anaesthesia educational resource cited here for its direct Final FRCA relevance. Not a primary research source. This item and the core revision section below are aligned — the AnaesthEasier post provides the conceptual framework; the core revision on page 3 gives the full table of values.

This AnaesthEasier post covers the pharmacokinetic basis of volatile anaesthetic behaviour through the lens of partition coefficients — the key pharmacology linking molecular properties to clinical behaviour at the bedside. The core concept: volatile agents behave differently not because of their MAC (which measures potency at steady state) but because of their partition coefficients, which determine how quickly they move between compartments.

Key conceptual framework: Blood:gas partition coefficient (Ostwald coefficient): Measures how much agent dissolves in blood per unit dissolved in alveolar gas at equilibrium. Low = fast onset (desflurane 0.45, sevoflurane 0.65); high = slow onset (halothane 2.5, diethyl ether 12). Reflects speed of induction and emergence. Oil:gas partition coefficient: Measures lipid solubility. Correlates with potency (MAC). Higher oil:gas = lower MAC. Halothane (224, MAC 0.75%) vs desflurane (18.7, MAC 6%). The Meyer-Overton correlation. Age correction: MAC decreases ~6% per decade above 40 years. Neonates have lower MAC (sevoflurane ~3.3%) due to different receptor sensitivity. This post is directly assessed in the Final FRCA pharmacology paper. Full values in core revision below.

ANAESTHEASIER FINAL FRCA

AnaesthEasier: Why Your Anxious Patient Takes Ages to Go to Sleep — Uptake, Distribution, and the Second Gas Effect (23 July 2026)

AnaesthEasier. Published 23 July 2026. anaestheasier.com

This post addresses a familiar clinical scenario — the anxious, hyperventilating patient who appears to take longer to reach surgical depth of anaesthesia than expected. The explanation is pharmacokinetic: increased minute ventilation accelerates delivery of volatile agent to the alveolus, but also increases cardiac output (via sympathetic activation), which increases uptake from the alveolus into blood — slowing the rise in alveolar partial pressure (FA/FI ratio).

Final FRCA pharmacology: The Mapleson curves describe FA/FI over time. Factors that accelerate FA/FI rise (faster induction): high fresh gas flow, high concentration (concentration effect — high concentrations reduce relative uptake effect), low blood:gas solubility, low cardiac output, decreased uptake. Factors that slow FA/FI rise (slower induction): high cardiac output (anxiety, catecholamines), high blood:gas coefficient, high inspired concentration of a second gas (N2O concentration effect/second gas effect works in the other direction — the concentration effect of N2O accelerates co-administered volatile agent alveolar partial pressure rise).

SECTION 5 — QUICK HITS

ICS: 10 NEW RESEARCH PRIORITIES FOR UK INTENSIVE CARE (1 JULY 2026)

ICS, 1 July 2026. ics.ac.uk

James Lind Alliance-style priority-setting exercise identified 10 research priorities: preventing/treating delirium; improving psychological recovery and PICS; family involvement in ICU care; ICU-to-rehabilitation transitions; improving the ICU environment; communication support for critically ill patients; infection diagnosis/treatment; and others. These shape the research agenda for UK ICU over the next 5 years — align departmental QIP projects accordingly.

RCoA/OAA JOINT RESPONSE TO OCKENDEN REVIEW (NOTTINGHAM MATERNITY) — 17 JULY 2026

RCoA and OAA joint statement, 17 July 2026. rcoa.ac.uk

The RCoA and Obstetric Anaesthetists' Association welcomed the Ockenden Report on Nottingham University Hospitals NHS Trust maternity services (published 24 June 2026) and issued a joint response on implications for obstetric anaesthesia. Relevant to all obstetric anaesthetists: review your departmental response to the Ockenden recommendations around maternity safety, obstetric anaesthesia presence, and emergency teamworking. NAP8 (Regional Anaesthesia) case registry is also now open — consider registering cases from your department.

NAP8 REGISTRY NOW OPEN — REGIONAL ANAESTHESIA COMPLICATIONS

RCoA, July 2026. rcoa.ac.uk

The Royal College of Anaesthetists has opened the NAP8 case registry, studying complications of regional anaesthesia — peripheral nerve blocks, central neuraxial blockade, local anaesthetic infiltration, and perioperative nerve injury. All UK anaesthetists are encouraged to submit cases. NAP8 data will form the basis for future UK guidance on regional anaesthesia safety. Register your department at rcoa.ac.uk.

REMIMAZOLAM VS PROPOFOL FOR CARDIAC SURGERY: SR/MA SHOWS COMPARABLE HAEMODYNAMICS WITH FEWER HYPOTENSION EVENTS (7 JUL 2026)

SR/MA. Published 7 July 2026.

Grade-assessed systematic review and meta-analysis comparing remimazolam versus propofol for cardiac surgery anaesthesia induction and maintenance. Found fewer hypotension events with remimazolam — consistent with its lower haemodynamic suppression profile. Remimazolam is not yet universally available on UK formularies; this data supports its use in haemodynamically at-risk cardiac patients where benzodiazepine-based TIVA is considered.

AnaesthEasier: "DO YOU ANAESTHETISE THIS SNOTTY CHILD?" — URTI DECISION FRAMEWORK (9 JULY 2026)

AnaesthEasier, 9 July 2026. anaestheasier.com — grey callout: not a primary evidence source; educational.

Practical framework for the anaesthetic decision when a child presents with an upper respiratory tract infection (URTI). Key points: recent (within 2 weeks) symptomatic URTI with productive cough — consider postponement if airway anaesthesia (LMA/ETT) required, especially in children under 1 year or with significant lower respiratory signs. If proceeding: avoid LMA in favour of ETT if significant secretions; higher risk of laryngospasm (10× background rate with URTI); have IV induction available as backup to inhalational; bronchodilators on standby; extra vigilance on emergence. Document clinical reasoning clearly.

ANAESTHETICS & ICU EVIDENCE RUNDOWN — CORE REVISION — ISSUE 7 — AUGUST 2026

Volatile Anaesthetic Agents: Pharmacology for Final FRCA

Partition coefficients, MAC, speed of onset, and clinical properties — Final FRCA edition

Goal: Understand how molecular properties (partition coefficients) translate to clinical behaviour (speed of onset/offset, potency, metabolism) — and how to use this to select the right volatile agent for each patient.

PARTITION COEFFICIENTS AT 37°C — ALL KEY VOLATILE AGENTS

Note: Desflurane is now banned in the UK (MHRA 2024) due to environmental impact (GWP ~2,500 × CO2). Values shown for examination completeness. MAC = minimum alveolar concentration to prevent movement in 50% of patients. MAC is affected by age, temperature, altitude, other drugs.

CLINICAL RULES — WHAT DO THESE NUMBERS MEAN?

WHAT CHANGES MAC?

Final FRCA Core Knowledge: Exam questions on volatile agents typically ask: (1) Explain why desflurane has faster onset than isoflurane (lower blood:gas = 0.45 vs 1.4 — less dissolves in blood — FA/FI ratio rises faster). (2) Why is halothane more potent than sevoflurane? (Higher oil:gas = 224 vs 47 — more lipid soluble — lower MAC). (3) What is the clinical consequence of Compound A with sevoflurane? (Nephrotoxicity in rats — not proven in humans at low flow rates ≥1 L/min; avoid <1 L/min low flow with sevoflurane for prolonged cases). (4) How do you calculate the total MAC of a combined anaesthetic? (Additive: each agent contributes its fraction of MAC). (5) What are the disadvantages of nitrous oxide? (Diffuses into closed gas spaces — bowel obstruction, pneumothorax, middle ear; bone marrow suppression with prolonged use; environmental impact GWP 265; PONV).

Anaesthetics & ICU Evidence Rundown — Core Revision — Issue 7 · emevidence.org

FINAL FRCA

Sources: AnaesthEasier (oil/blood gas coefficients, 27 Jul 2026) · LITFL (volatile agent reference) · Miller's Anaesthesia 9th edition · Peck, Hill & Williams — Pharmacology for Anaesthesia and Intensive Care

SECTION 6 — ACTION POINTS

• SNaPP trial and reversal policy: Review your department's neuromuscular reversal protocol. If neostigmine is still used as default for reversal of rocuronium/vecuronium, discuss a switch to sugammadex with your department lead and pharmacy team. SNaPP (n~7,000) is now the strongest evidence base for this recommendation. Ensure quantitative neuromuscular monitoring (TOF ratio ≥0.9 before extubation) is the departmental standard regardless of which reversal agent is used.
• Dapagliflozin cardiac surgery: Discuss with your cardiac surgery, cardiology, and renal teams whether a perioperative dapagliflozin protocol is appropriate for elective cardiac surgery patients. The AKI reduction is substantial (NNT ~4) but the absence of a mortality signal requires contextual interpretation. Check whether your trust's existing SGLT2i withholding policy needs review in light of this data.
• CICM rebrand — credentials update: All ICM consultants and trainees: update your CV, GMC profile annotations, job titles, and correspondence to reflect the FICM → CICM rebrand (effective 1 July 2026). The qualification is now FCICM. All departmental documents referring to FICM, FFICM, or Faculty of Intensive Care Medicine should be updated.
• Consent practice review: Read the updated Association of Anaesthetists consent guidelines (Anaesthesia, 15 Jul, DOI 10.1111/anae.70283). Audit your current consent practice: Are you having a pre-operative (not day-of-surgery) discussion? Are material risks documented as discussed? Does your airway plan discussion include backup plans? Update your local consent SOP if needed.
• MHRA safety alerts: (1) Remove all stocks of ChloraPrep 1 mL applicators (EL(26)A/34) from regional anaesthesia and central line procedure trays — sterility breach. (2) Check cyclizine lactate 50mg/ml stocks (EL(26)A/29) — GMP recall. Substitute with ondansetron 4mg IV or dexamethasone 4-8mg IV for PONV. Document replacement in anaesthetic room whiteboards.
• NICE QS216: Circulate the new quality standard to your perioperative medicine and anaesthetic department leads. Identify any gaps against the quality statements. Pre-operatively: assess and optimise? Shared decision-making? ERAS pathway adherence? Schedule a departmental audit against QS216 by end of Q3 2026.
• VL for double-lumen tubes: If your thoracic anaesthesia practice defaults to direct laryngoscopy for DLT placement, the DOLVI trial supports a switch to VL as first-line. Ensure an appropriate VL blade is stocked in your thoracic operating theatre and that the team is trained in its use for DLT intubation.
• NAP8 registration: Register your department with NAP8 (Regional Anaesthesia complications registry) at rcoa.ac.uk. Submit eligible cases. NAP8 data will be used to inform future UK guidance on regional anaesthesia safety — your department's contribution directly shapes national policy.

TRIALS TO WATCH

NEAR-TERM (Q3–Q4 2026)

2026–2027 HORIZON

NAP8

RCoA National Audit Project — regional anaesthesia complications. Case collection phase open. Report expected ~2027.

Jake Turner

Curated with the assistance of AI (Perplexity). All content editorially reviewed. Anaesthetics & ICU Evidence Rundown — Issue 7 — August 2026 Published by EM Evidence — emevidence.org For educational purposes only. Verify against local guidelines and protocols before implementing changes. All content editorially reviewed.

Previous issues archived at emevidence.org — emevidence999@gmail.com