Anaesthetics & ICU Evidence — Q2 2026 State of the Science

ANAESTHETICS & ICU — QUARTERLY REVIEW

Q2

2026

Anaesthetics & ICU Evidence Rundown

State of the Science — April–June 2026

Anaesthesia, Intensive Care & Perioperative Medicine — UK Edition

Jake Turner · EM Registrar, West Midlands

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

118 primary evidence items · 5 issues published · emevidence.org

Table of Contents

Anaesthetics & ICU Evidence Rundown — Q2 2026 · 9 Chapters · 118 Items

CH 1

Q2 Quarter in Review

The bicarbonate collapse · DAS 2025 · GLP-1 safety · ICS SOA26 preview

CH 2

Airway Management

DAS 2025 guidelines · VL first-line · Prehospital airway · Extubation · Tracheostomy

CH 3

Sepsis & Resuscitation

BIHCA · MARCH · SODa-BIC · ANDROMEDA-SHOCK-2 · SSC 2026 · ARISS · BICARICU-2 preview

CH 4

Mechanical Ventilation & Respiratory

DESIGNATION · R2D2-ICU · SHOSREB · ACTiVE · SCCM NMB · Driving pressure

CH 5

Cardiac ICU & Haemodynamics

NICE Impella · SOHO · ERC/ESICM post-resus · ELSO · FLOWVENTIN · LVAD

CH 6

Neuro-ICU & Sedation

ABCDEF bundle · Esketamine paediatric emergence delirium · EEG-guided anaesthesia · Pupillometry

CH 7

Renal, Metabolic & Critical Care Pharmacology

BigPAK-2 · BICARICU-2 · Noradrenaline dosing · Vasopressin · Electrolytes

CH 8

Perioperative Medicine

Obstetric anaesthesia · GLP-1 agonists · Multimodal analgesia · Regional · Haemostasis · POCD · Obesity · Drug safety

CH 9

Regional Anaesthesia

PENG block · DPE · ESP/SAP · ESAIC antithrombotic · Fascial plane blocks · NAP8

CH 10

Guidelines, Quality & Trials to Watch

GPICS V3 · NICE TXA · CPOC · SSC paediatric · ICS SOA26 · EVIS UK · BEST-DKA

CHAPTER ONE

Q2 2026: Quarter in Review

The bicarbonate collapse · Airway revolution · Perioperative safety · ICS SOA26

The second quarter of 2026 delivered a rare sequence of high-impact negative trials in critical care, a landmark revision of the UK airway management guidelines, and a cluster of perioperative safety signals that demand immediate attention. Writing on the final day of Q2, with ICS SOA26 opening in Birmingham today, this review captures 118 primary evidence items across five monthly issues.

The Bicarbonate Evidence Collapse and Its ICU Implications

Three trials published within weeks of one another in Q2 2026 have effectively ended routine sodium bicarbonate administration across nearly every common ICU indication. BIHCA (JAMA, n=779, 21 Danish hospitals) tested bicarbonate during in-hospital cardiac arrest and found sustained ROSC of 39% versus 37% (RR 1.05, p=0.62) — a definitively null result, achieved at the cost of alkalosis in 35% of the bicarbonate group (versus 20%) and hypernatraemia in 42% (versus 29%). The only evidence-based indications for bicarbonate in cardiac arrest that survive this trial are hyperkalaemia and sodium-channel blocker/TCA toxicity — everything else is now actively contraindicated by the harm data. SODa-BIC (Issue 7, n=500, 55 ICUs, 7 countries) addressed the next obvious question — bicarbonate for metabolic acidosis on vasopressors — and found MAKE30 of 40.2% versus 39.4% (adj difference +1.2%, p=0.78). Meta-analysis pooling 1,111 patients suggests a possible reduction in RRT requirement (RR 0.69), which is why the SSC 2026 guidelines preserve a narrow indication: pH ≤7.2 plus AKI Stage 2-3 plus vasopressor dependence. Outside this specific phenotype, bicarbonate for metabolic acidosis should be abandoned. MARCH (NEJM, n=1,956) added a further dimension: carbocisteine — a mucolytic with a plausible biological rationale — increased GI bleeding risk eightfold in ventilated patients (RR 6.51), while high-tidal-saline nebulisation caused bronchoconstriction (RR 5.73) and acute hypoxia during treatment (RR 13.29), without any meaningful reduction in mechanical ventilation duration from either agent. The wider lesson from MARCH is the most important: biological plausibility is not evidence. Practitioners should apply this same critical lens to every empirical ICU intervention that lacks trial data.

ICU Practice Change: Stop routine bicarbonate in IHCA. Reserve for hyperkalaemia and sodium-channel blocker toxicity. For metabolic acidosis on vasopressors, restrict to pH ≤7.2 + AKI Stage 2-3. Stop carbocisteine and HTS nebulisation in ventilated patients.

BIHCA — Sustained ROSC: 39% vs 37%, RR 1.05, p=0.62

SODa-BIC — MAKE30: 40.2% vs 39.4%, adj diff +1.2%, p=0.78

MARCH — Carbocisteine GI bleed RR 6.51 · HTS hypoxia RR 13.29

Airway Management: The DAS 2025 Revolution Lands in Full

The DAS 2025 Difficult Airway Guidelines (BJA 2025, covered in Issue 1) represent the most significant revision to UK airway practice in over a decade. The central change is the repositioning of videolaryngoscopy from rescue device to first-line instrument for all RSI in high-risk patients: obesity, predicted difficult airway, and reduced functional residual capacity all now mandate VL as the primary technique. The familiar Plan A, B, C, D framework is retained but substantially revised. The surgical airway threshold has been lowered in a clinically important way — front-of-neck access should now be triggered within the second intubation attempt cycle in can't-intubate can't-oxygenate scenarios, rather than after all conventional options are exhausted. Supraglottic airways in obstetric emergencies are explicitly endorsed as a bridge to definitive airway management, addressing a previously ambiguous area of practice. For the haemodynamically compromised patient requiring drug-assisted intubation, ketamine plus rocuronium is formalised as the preferred induction combination. The parallel prehospital update (PHEA 2026 guidelines) aligns with DAS 2025: all emergency intubations should use VL as first-line where available, with the evidence strongest in difficult and critical airways, obesity, and restricted-access environments including HEMS.

Airway Practice: VL is now first-line for all RSI in high-risk patients. FONA threshold is lower. Document your plan at induction. The DAS eFONA registry is open for submissions — contribute your cases.

DAS 2025 Key Change — VL first-line in high-risk RSI, not rescue

FONA threshold lowered — trigger within 2nd attempt cycle in CICO

Perioperative Highlights: GLP-1 Safety and Vasopressor Dosing in Obesity

Two perioperative findings from Q2 2026 carry immediate patient safety implications. The GLP-1 receptor agonist gastric emptying systematic review (Can J Anaesth, n=3,700, PMID 42087044) quantified the delayed gastric emptying associated with semaglutide, liraglutide, dulaglutide, and tirzepatide at a mean of 74 additional minutes — a magnitude that substantially increases pulmonary aspiration risk in any patient presenting for anaesthesia. The RCoA guidance (June 2025) already directs that these patients should be managed as if they have a full stomach, with extended preoperative fasting (up to 24 hours for liquids in some patients), validated gastric emptying scores, and ultrasound gastric assessment where feasible. With GLP-1 agonist prescribing now widespread across primary care for type 2 diabetes and obesity management, almost every anaesthetic list will include affected patients. Preoperative assessment must routinely record GLP-1 agonist use and flag accordingly. The second signal comes from a retrospective cohort of over 10,000 obese patients with septic shock (Anesthesiology, PMID 42090639): absolute noradrenaline dosing (mcg/min) was associated with significantly better outcomes than weight-based dosing (mcg/kg/min). The mechanism is straightforward — weight-based dosing produces systematically inadequate tissue levels in obese patients at conventionally "equivalent" doses. Practitioners should switch to absolute dosing for all vasopressors in obese patients with septic shock.

GLP-1 Safety Alert: Treat all GLP-1 agonist patients as full stomach at induction. Extended fast. Gastric ultrasound. Document in preoperative checklist. This applies at every grade and every list.

GLP-1 agonists — delayed gastric emptying +74 min mean (n=3,700)

Absolute NE dosing — superior outcomes in obese septic shock (n >10,000)

ICS SOA26 Preview: BICARICU-2 Presenting Today

ICS State of the Art 2026 opens in Birmingham today, 30 June, running through 2 July. The headline session is BICARICU-2: the first large definitive RCT of sodium bicarbonate versus standard care in severe metabolic acidosis combined with acute kidney injury (n=640). Pre-published results confirm no 90-day mortality benefit from bicarbonate, but with a clinically significant reduction in RRT requirement of 15.5% relative risk reduction. This result does not contradict the SSC 2026 guidance — it provides the RCT substrate on which that narrow indication was built. BICARICU-2 should be read alongside SODa-BIC: bicarbonate does not save lives in this population, but in the specific AKI-dominant phenotype it may reduce dialysis requirement. The full data will be presented at the afternoon plenary session on 30 June. ANDROMEDA-SHOCK-2 also receives its full conference session at SOA26, with a deep-dive on CRT methodology and its incorporation into SSC 2026. The MARCH trial will be discussed in the context of prescribing culture and ICU research standards.

ICS SOA26 — Birmingham, 30 June – 2 July: BICARICU-2 full plenary today. ANDROMEDA-SHOCK-2 full session. MARCH prescribing culture discussion. Watch for live summaries at emevidence.org.

BICARICU-2 — No 90-day mortality benefit. RRT reduction: -15.5% RRR (n=640)

Q2 Practice Changes: Summary Table

CHAPTER TWO

Airway Management

DAS 2025 · VL first-line · Prehospital airway · RSI pharmacology · Extubation · Tracheostomy

Q2 2026 marks the full clinical implementation phase for the DAS 2025 Difficult Airway Guidelines, the most substantial revision to UK airway practice in a generation, repositioning videolaryngoscopy from rescue to first-line and lowering the threshold for front-of-neck access. Parallel updates to prehospital airway management and RSI pharmacology — including the landmark NEJM ketamine vs etomidate trial — complete a quarter in which airway practice has been meaningfully redesigned from first principles.

DAS / BJA 2025 · ISSUE 1

DAS 2025 Difficult Airway Guidelines — Landmark Revision

GUIDELINE UPDATE FINAL FRCA

The DAS 2025 guidelines represent a fundamental reassessment of how UK anaesthetists approach every intubation in high-risk patients. The headline change is the elevation of videolaryngoscopy to first-line status for all RSI in patients with obesity, predicted difficult airway, reduced functional residual capacity (including pregnancy), or haemodynamic instability — no longer a rescue measure, but the expected default. The rationale is robust: VL consistently improves first-pass success rates, reduces failed intubation, and provides superior glottic view without compromising success rates even in straightforward airways.

The Plan A, B, C, D framework survives but has been substantially revised. Plan A failure should now prompt immediate and structured escalation through the remaining plans without hesitation. The surgical airway threshold is materially lower than in previous iterations: in a can't-intubate can't-oxygenate situation, FONA should be triggered within the second intubation attempt cycle — not after all supraglottic and tracheal options have been serially exhausted, which the evidence shows costs critical time and increases hypoxic injury. Supraglottic airways in obstetric emergencies are now explicitly endorsed as a bridge to definitive management, a long-overdue formalisation of what experienced practitioners have done in extremis.

For drug-assisted intubation in the haemodynamically compromised patient, the guidelines formalise ketamine (1–2 mg/kg) plus rocuronium (1.2 mg/kg for full RSI dose) as the preferred induction combination. The DAS eFONA registry and National Difficult Airway Registry are both open for submissions — every difficult airway case should be reported to drive ongoing improvement in the evidence base.

DAS 2025 — Five Key Changes: (1) VL first-line for all high-risk RSI. (2) Plan A–D framework revised with lower escalation threshold. (3) FONA triggered within 2nd attempt cycle in CICO. (4) SGAs endorsed as bridge in obstetric emergencies. (5) Ketamine + rocuronium formalised for haemodynamic compromise.

VL improves first-pass success vs DL in difficult airway (consistent meta-analysis data)

NEJM · ISSUE 1

NEJM RSI Trial: Ketamine vs Etomidate — Ketamine Non-Inferior, Preferred in Shock

CHANGE THIS MONTH FINAL FRCA

This landmark NEJM trial directly compared ketamine and etomidate as induction agents for emergency RSI across emergency department and ICU settings. Ketamine was non-inferior to etomidate on the primary composite outcome (intubation success with acceptable haemodynamics). Critically, in the subgroup of haemodynamically unstable patients, ketamine demonstrated superiority — its sympathomimetic properties maintain cardiac output and systemic vascular resistance where etomidate's adrenal suppression and variable haemodynamic effects are disadvantageous.

Etomidate causes dose-dependent cortisol suppression for up to 24 hours post-single dose — a concern in critically ill patients already at risk of adrenal insufficiency. While this trial does not eliminate etomidate from the formulary, it provides robust evidence that ketamine is at minimum equivalent and clinically preferable in the shocked patient, aligning with DAS 2025 guidance. For trainees preparing for Final FRCA, this trial resolves a long-standing controversy: ketamine is the evidence-based choice for RSI in haemodynamic compromise.

Clinical Practice: Use ketamine as the default induction agent for emergency RSI in haemodynamically unstable patients. Etomidate remains acceptable in stable patients where ketamine's dissociative effects are undesirable (e.g., known psychiatric history).

LANCET RESPIRATORY MEDICINE · ISSUE 2

Prehospital Intubation Survival in Major Trauma

INFORMING PRACTICE FINAL FRCA

This Lancet Respiratory Medicine analysis examined survival outcomes for prehospital intubation versus hospital-based intubation in major trauma across UK HEMS and ground-based systems. The data reinforce that prehospital RSI by trained practitioners in appropriate patients (GCS ≤8 with major trauma, ongoing hypoxia, or risk of airway compromise) improves survival compared to rapid transport with supraglottic airway alone. The survival benefit is concentrated in patients with TBI and those with impending airway compromise from maxillofacial, neck, or inhalational injury. Critically, the benefit is contingent on operator expertise: HEMS RSI success rates exceed 99% first-pass in experienced systems; untrained attempts in the prehospital environment worsen outcomes. The PHEA 2026 guideline update aligns with DAS 2025 — VL should be first-line for all prehospital emergency intubations where equipment is available, with the largest gains in obese patients, those with restricted access, and anatomically difficult airways.

HEMS RSI first-pass success >99% in high-volume systems with VL

BJA · ISSUE 2

FIBERTRACH: Fibreoptic vs Standard Tracheostomy Position Confirmation

INFORMING PRACTICE FINAL FRCA

FIBERTRACH evaluated fibreoptic bronchoscope guidance for percutaneous dilational tracheostomy versus standard (Seldinger technique without direct bronchoscopic guidance) in ICU patients. Bronchoscopic guidance significantly reduced the incidence of posterior tracheal wall injury, paratracheal insertion, and tube misplacement. Given the increasing complexity of ICU patients undergoing PDT — including obesity, abnormal neck anatomy, and prior airway interventions — the evidence now favours routine bronchoscopic guidance for all PDT in the ICU. Departments that do not currently use bronchoscopic guidance should review their PDT protocol in light of this evidence and the parallel DAS 2025 message about airway safety as a systemic priority, not just an individual skill.

ICU Practice: Bronchoscopic guidance for PDT reduces posterior tracheal wall injury and misplacement. Consider as standard for all ICU tracheostomies, particularly in obese patients or those with abnormal neck anatomy.

BJA / A&A · ISSUE 3

Video Stylet vs Videolaryngoscopy in High Arne Score Patients

INFORMING PRACTICE FINAL FRCA

This prospective comparison evaluated video stylets (e.g. Shikani, Clarus) against standard videolaryngoscopy in patients with high Arne difficult airway scores (predicted difficult laryngoscopy). In the high-Arne subgroup, VL maintained superior first-pass success and operator confidence. Video stylets showed utility as an adjunct when VL alone provided inadequate tube passage despite good view, suggesting a complementary rather than competing role. For consultant anaesthetists managing predicted difficult airways, the practical message is familiarity with both device types: VL as the primary instrument, with video stylet as a problem-solving adjunct when VL view does not translate to easy tube passage — particularly in anterior airways.

ANESTHESIOLOGY 2026;144(4):978-997 · ISSUES 4 & 5

Era of Sugammadex: Airway Strategy Implications of Reliable Reversal

INFORMING PRACTICE FINAL FRCA

This invited review in Anesthesiology synthesises how the universal availability of sugammadex changes airway management strategy beyond simple reversal. The core argument is that reliable, rapid reversal of full-dose rocuronium (1.2 mg/kg) with sugammadex 16 mg/kg creates a genuine "can't intubate — reverse and wake up" option that did not reliably exist with neostigmine. This changes the risk calculus for RSI in predicted difficult airway: high-dose rocuronium RSI with sugammadex rescue is a credible alternative to awake fibreoptic intubation in some scenarios. The review acknowledges this strategy requires departmental protocols, immediate sugammadex availability, and recognition that profound hypoxia may develop too rapidly for reversal to rescue the situation in some high-risk patients. The evidence strongly supports sugammadex as the default reversal agent (over neostigmine) for all rocuronium/vecuronium patients: lower rates of PORC, fewer postoperative respiratory complications, and lower rates of unplanned ICU admission (n >50,000 in SR/MA from Issue 2).

Sugammadex availability: Sugammadex 200 mg and 500 mg should be immediately available in every anaesthetising location. Protocol for 16 mg/kg rescue dosing should be in place wherever RSI is performed.

DAS · ISSUE 5

DAS eFONA Registry & National Difficult Airway Registry — Open for Submissions

GUIDELINE UPDATE FINAL FRCA

The DAS has launched the eFONA (emergency front-of-neck access) registry alongside the broader National Difficult Airway Registry as the evidence-gathering infrastructure to underpin future guideline iterations. The eFONA registry captures technique, device, anatomical context, complications, and outcome for all cases of surgical and percutaneous emergency airway access. Consultants and trainees encountering a CICO scenario should submit to both registries. The data generated will directly inform DAS 2030 guidelines and provide the granular epidemiological evidence currently lacking for FONA outcomes. This is a professional obligation as much as a research activity: the DAS 2025 changes are already evidence-limited in some areas due to the rarity of CICO events, and the registries are the mechanism to fix this.

CHAPTER THREE

Sepsis & ICU Resuscitation

BIHCA · MARCH · SODa-BIC · ANDROMEDA-SHOCK-2 · SSC 2026 · ARISS · BICARICU-2 preview

The defining story of Q2 2026 in critical care resuscitation is the near-simultaneous collapse of the bicarbonate evidence base across three separate RCTs — BIHCA in cardiac arrest, MARCH in ventilated patients (carbocisteine/HTS), and SODa-BIC in metabolic acidosis on vasopressors — combined with the definitive SSC 2026 endorsement of capillary refill time as a resuscitation co-endpoint following ANDROMEDA-SHOCK-2. These trials collectively redefine what evidence-based ICU resuscitation looks like in 2026.

JAMA · ISSUE 7 / EM 18

BIHCA: Bicarbonate During In-Hospital Cardiac Arrest — Definitively Null

CHANGE THIS MONTH FINAL FRCA

BIHCA enrolled 779 patients across 21 Danish hospitals in a pragmatic RCT of intravenous sodium bicarbonate (50 mmol bolus, up to 3 doses) versus standard care during in-hospital cardiac arrest. The trial was powered to detect a 10% absolute improvement in sustained ROSC — a clinically meaningful and achievable threshold given prior observational data. Sustained ROSC: 39% bicarbonate versus 37% standard care (RR 1.05, 95% CI 0.87–1.27, p=0.62). No signal of benefit on any pre-specified secondary outcome including 30-day survival, favourable neurological outcome, or time to ROSC.

The harms are clinically important: alkalosis developed in 35% of the bicarbonate group versus 20% of controls, and hypernatraemia in 42% versus 29%. These are not trivial: alkalosis shifts the oxygen dissociation curve leftward, reducing oxygen delivery to tissues during a period of critical ischaemia; hypernatraemia worsens neurological outcomes post-arrest. The overall signal is not merely neutral — bicarbonate during IHCA is likely harmful in unselected patients. The evidence-based indications that survive this trial are limited to two: hyperkalaemia (where bicarbonate is one component of a temporising strategy) and sodium-channel blocker or TCA toxicity (where alkalinisation is a targeted antidote mechanism). Every other routine indication — lactic acidosis, prolonged arrest, presumed metabolic acidosis — is without evidence and now refuted.

Practice Change — Immediate: Stop routine bicarbonate in IHCA. Update cardiac arrest protocols, arrest trolley documentation, and teaching. The two surviving indications (hyperkalaemia, TCA/sodium-channel blocker toxicity) must be explicitly documented when bicarbonate is given during arrest.

Sustained ROSC: 39% vs 37%, RR 1.05, p=0.62 (n=779, 21 hospitals)

Alkalosis: 35% vs 20% · Hypernatraemia: 42% vs 29%

NEJM · ISSUE 7 / EM 18

MARCH: Carbocisteine and HTS in Ventilated ICU Patients — Both Harmful

CHANGE THIS MONTH FINAL FRCA

MARCH (NEJM) enrolled 1,956 mechanically ventilated ICU patients in a 2×2 factorial design testing carbocisteine (a mucolytic) and hypertonic saline (HTS) nebulisation versus matched placebos. Neither agent was expected to cause harm — both had plausible biological mechanisms and were in routine use across many UK ICUs. The results were shocking in their severity.

Carbocisteine increased GI bleeding risk with a relative risk of 6.51, a near-eightfold increase in an already vulnerable patient population receiving concurrent prophylaxis agents. Mechanistically, carbocisteine disrupts mucin glycoprotein production in the gastric mucosa, reducing its protective function — a harm pathway not previously appreciated from observational data. HTS nebulisation caused bronchoconstriction in 5.73 times as many patients and acute hypoxia during nebulisation in 13.29 times as many — haemodynamically significant events in patients already on ventilatory support. Neither agent reduced mechanical ventilation duration, ventilator-free days, or any secondary ICU outcome.

The broader lesson — emphasised in the accompanying NEJM editorial and the ICS SOA26 discussion session — is one of prescribing culture. Carbocisteine has a compelling biological rationale for mucolysis. It is precisely because the mechanism was plausible that it went untested for so long and became entrenched in practice. MARCH is a template for why ICU interventions require RCT evidence before widespread adoption: biological plausibility is necessary but not sufficient. Apply the same critical standard to every other empirical intervention in your ICU that lacks a positive RCT — sucralfate, nebulised NAC, routine albumin, and several others remain in this category.

Immediate Practice Change: Stop carbocisteine and stop HTS nebulisation routinely in mechanically ventilated patients. Review ICU prescribing charts today. Carbocisteine should not appear on ventilated patient drug charts without documented specific indication (e.g. primary ciliary dyskinesia, not "secretion management").

Carbocisteine — GI bleed RR 6.51 (n=1,956)

HTS — Bronchoconstriction RR 5.73 · Hypoxia during nebulisation RR 13.29

MV duration reduction: neither agent — nil effect

ICM · ISSUE 7

SODa-BIC: Bicarbonate for Metabolic Acidosis on Vasopressors — A Narrow Remaining Indication

CHANGE THIS MONTH FINAL FRCA

SODa-BIC enrolled 500 critically ill patients across 55 ICUs in 7 countries to answer whether bicarbonate infusion improves outcomes in patients with severe metabolic acidosis requiring vasopressors. The primary outcome, MAKE30 (Major Adverse Kidney Events at 30 days — a composite of mortality, RRT, or persistent kidney dysfunction), was 40.2% in the bicarbonate group versus 39.4% in controls (adjusted difference +1.2%, 95% CI −4.8 to +7.2%, p=0.78). The result is unambiguously null for the primary endpoint.

The pre-planned meta-analysis pooling SODa-BIC with prior bicarbonate trials in acidosis (total n=1,111) identified a reduction in RRT requirement (RR 0.69, 95% CI 0.54–0.88) without mortality benefit. This signal — modest, indirect, driven by a composite meta-analysis rather than a single definitive trial — is the sole evidentiary basis for the SSC 2026 narrow indication. The SSC 2026 guideline position (weak recommendation, low-quality evidence) is: consider bicarbonate infusion only in patients meeting all three criteria simultaneously — pH ≤7.2, AKI Stage 2-3, and vasopressor dependency. Outside this phenotype, bicarbonate for metabolic acidosis in the ICU is not supported by evidence and should not be prescribed. BICARICU-2 (ICS SOA26, 30 June) will further refine this: preliminary data confirm no 90-day mortality benefit but a -15.5% RRR for RRT in the severe AKI + acidosis population.

SSC 2026 Indication — Narrow and Specific: Bicarbonate only when pH ≤7.2 AND AKI Stage 2-3 AND vasopressor-dependent. Document the indication explicitly. Do not extrapolate to all acidotic ICU patients.

MAKE30: 40.2% vs 39.4%, adj diff +1.2%, p=0.78 (n=500, 55 ICUs, 7 countries)

Meta-analysis RRT: RR 0.69 (n=1,111) — no mortality benefit

JAMA · ISSUE 6 / EM 17

ANDROMEDA-SHOCK-2: CRT-Guided Resuscitation Endorsed in SSC 2026

CHANGE THIS MONTH FINAL FRCA

ANDROMEDA-SHOCK-2 (JAMA) randomised patients with septic shock to capillary refill time (CRT)-guided resuscitation versus lactate-guided resuscitation, building on the original ANDROMEDA-SHOCK trial. The CRT-guided group achieved superiority on the composite clinical outcome, received 250 mL less fluid on average over the study period, and achieved equivalent 28-day all-cause mortality. The mechanism is clinically intuitive: CRT is a real-time, bedside, non-invasive marker of peripheral tissue perfusion that responds faster to resuscitation than lactate clearance, enabling more responsive titration without the lag inherent in serial lactate measurement.

SSC 2026 has incorporated CRT as a co-resuscitation endpoint alongside lactate, marking the first time a clinical examination finding has been formally endorsed as a primary resuscitation target in international sepsis guidelines. The practical message is straightforward: assess CRT at the fingertip (normal ≤2 seconds, assessed with 5 seconds of pressure) as part of every septic shock resuscitation assessment. When CRT is prolonged despite adequate initial fluid resuscitation, escalate vasopressors. The integration with lactate guidance is: CRT and lactate should both normalise; neither alone is sufficient as the single endpoint.

SSC 2026: CRT (≤2 seconds, fingertip) is now a validated co-resuscitation endpoint in septic shock. Assess at every resuscitation review. Use alongside lactate — do not replace lactate with CRT.

CRT group: superior composite outcome, -250 mL fluid, equivalent 28-day mortality

SCCM/SSC · ISSUES 5 & 6 / EM 16

SSC 2026 Adult Sepsis Guidelines — Key Changes for Anaesthesia and ICU

GUIDELINE UPDATE FINAL FRCA

The Surviving Sepsis Campaign 2026 adult guidelines consolidate a decade of negative fluid trials with an unambiguous restrictive fluid position: 30 mL/kg initial bolus is no longer the default, with dynamic fluid responsiveness assessment replacing fixed-volume algorithms. Earlier peripheral vasopressor initiation is endorsed — vasopressors should not await central access if a reliable peripheral line is available, consistent with accumulating evidence that time-to-vasopressor matters more than route. CRT is incorporated as a co-resuscitation endpoint alongside lactate clearance (see ANDROMEDA-SHOCK-2 above). Earlier vasopressin (within 6 hours of noradrenaline commencement) is recommended to reduce noradrenaline exposure and its attendant arrhythmia risk. Corticosteroids are recommended for refractory septic shock (consistent with ADRENAL/APROCCHSS evidence).

The SSC 2026 guidelines were not endorsed by ACEP, which issued a dissenting statement citing concerns about the strength of evidence for several recommendations, particularly the peripheral vasopressor endorsement and the CRT endpoint. This divergence is relevant context for EM-ICU interface care. For UK ICU practice, the FICM/ICS GPICS V3 framework (Issue 1) provides the structural scaffolding within which SSC 2026 recommendations are implemented.

SSC 2026 Key Points: Restrictive fluids (30 mL/kg not default). Peripheral vasopressors early. CRT + lactate co-endpoints. Earlier vasopressin. Corticosteroids in refractory shock. Narrow bicarbonate indication only.

JAMA 2026 · ISSUE 3

ARISS Trial: Albumin NOT Superior to Crystalloid in Septic Shock

CHANGE THIS MONTH FINAL FRCA

ARISS enrolled patients with septic shock to compare albumin-based resuscitation versus balanced crystalloid. The primary outcome — 90-day all-cause mortality — was not significantly different between groups. ARISS adds to the accumulating body of evidence (SAFE, ALBIOS, CRISTAL) that albumin does not confer mortality benefit in septic shock despite its theoretical advantages of oncotic pressure, anti-inflammatory properties, and reduced chloride load. The cost differential between albumin and balanced crystalloid is substantial in UK NHS practice. Given the absence of mortality benefit in ARISS and consistent prior trials, albumin should not be used as routine resuscitation fluid in septic shock. SSC 2026 makes no recommendation for albumin as a primary resuscitation fluid, and ARISS reinforces this position. Targeted albumin administration (for hypoalbuminaemia <25 g/L or specific clinical indications such as spontaneous bacterial peritonitis) remains a separate and evidence-supported practice.

Practice: Do not use albumin as routine resuscitation fluid in septic shock. Use balanced crystalloid. Reserve albumin for specific indications (severe hypoalbuminaemia, SBP, hepatorenal syndrome adjunct therapy).

ICS SOA26 · 30 JUNE 2026

BICARICU-2: Bicarbonate in Severe AKI + Acidosis — First Large Definitive RCT (TODAY)

TONIGHT / SOA26 FINAL FRCA

BICARICU-2 is the most anticipated trial at ICS SOA26 2026, presenting at the afternoon plenary on 30 June. This is the first large, adequately powered, definitive RCT of sodium bicarbonate versus standard care in ICU patients with severe metabolic acidosis plus AKI (n=640). Pre-published results confirm no 90-day all-cause mortality benefit from bicarbonate administration. However, a clinically significant 15.5% relative risk reduction in requirement for renal replacement therapy was observed in the bicarbonate group — a finding that, if sustained in the full data, provides the most robust RCT evidence to date for the SSC 2026 narrow bicarbonate indication.

The critical question for ICS SOA26 discussion is whether RRT avoidance — a process outcome — translates to meaningful patient benefit. RRT itself carries risk (complications, resource implications, delay to other therapies), so a reduction in RRT requirement is patient-relevant even if it does not independently reduce mortality. The pre-specified subgroup analyses by AKI stage, acidosis severity, and vasopressor dose will be essential to refining the indication. Read the full data in the context of SODa-BIC: the two trials together define the bicarbonate landscape in ICU acidosis for the next decade.

BICARICU-2 — Pre-published summary: No 90-day mortality benefit. RRT requirement reduced by -15.5% RRR (n=640). Full data presenting at ICS SOA26 plenary, 30 June, Birmingham.

BICARICU-2: No 90-day mortality benefit · RRT: -15.5% RRR · n=640

LANCET 2026 · ISSUE 4

Sepsis 2026: Lancet Seminar — Endotypes, Immunomodulation, Precision Medicine

CHANGE THIS MONTH FINAL FRCA

This Lancet Seminar represents the most comprehensive synthesis of the evolving sepsis paradigm in 2026. The central thesis is that sepsis is not a single disease but a heterogeneous syndrome comprising at least two immunological endotypes (SRS1: hyperinflammatory, and SRS2: immunosuppressed) with fundamentally different pathophysiology, treatment responses, and prognoses. The hyperinflammatory SRS1 endotype — characterised by high IL-6, activated macrophages, and HLA-DR suppression — may be a candidate for immunomodulatory therapy (anti-IL-6, IL-1 blockade, complement inhibition). The SRS2 endotype — characterised by lymphopenia, immunoparesis, and relative anti-inflammatory dominance — may benefit from immune stimulation rather than suppression.

For current clinical practice, endotyping is not yet routine — the tools are research-grade, not bedside-available. The practical implication is caution with blanket anti-inflammatory strategies (corticosteroids, IL-6 inhibition) without phenotyping, and anticipation that precision medicine approaches to sepsis immunomodulation will enter trials in 2026-2028. The Seminar also covers the evolving role of metabolomics, transcriptomics, and AI-assisted phenotyping in sepsis stratification — relevant to trainees planning academic careers.

CHAPTER FOUR

Mechanical Ventilation & Respiratory Support

DESIGNATION · R2D2-ICU · SHOSREB · ACTiVE · SCCM NMB · SOHO · Sex-based TV disparities

Mechanical ventilation evidence in Q2 2026 advances on three fronts: driving pressure as the preferred PEEP optimisation metric (DESIGNATION), definitive evidence against liberal physical restraint in ventilated patients (R2D2-ICU), and the emergence of remimazolam as a viable ICU sedation alternative to propofol (SHOSREB). The SOHO trial settles the HFNO debate in hypoxaemic respiratory failure with a nuanced result that requires careful interpretation.

JAMA · ISSUE 1

DESIGNATION: Driving Pressure-Guided PEEP Optimisation in ARDS

CHANGE THIS MONTH FINAL FRCA

DESIGNATION tested a driving pressure-guided PEEP strategy (targeting the PEEP level that minimises driving pressure while maintaining oxygenation targets) against standard PEEP titration approaches in ARDS. The driving pressure-guided group demonstrated reduced 28-day mortality, fewer ventilator-free days lost, and lower rates of barotrauma. Driving pressure (plateau pressure minus PEEP) reflects the actual stress applied to lung parenchyma per breath, accounting for individual variation in lung compliance that static PEEP strategies ignore.

The practical implementation requires regular plateau pressure and PEEP recording to calculate driving pressure (target <15 cmH₂O for most ARDS patients). Incremental PEEP trials should be performed at a standardised tidal volume (6 mL/kg IBW), with the PEEP selected that minimises driving pressure rather than maximises oxygenation. This shifts clinical thinking from "higher PEEP is protective" to "the PEEP that minimises mechanical stress on individual lung architecture is protective." Final FRCA candidates should be able to define driving pressure, explain its physiological basis, and describe the DESIGNATION trial methodology.

ARDS Ventilation: Target driving pressure <15 cmH₂O. Titrate PEEP to minimise driving pressure at 6 mL/kg IBW tidal volume. Record plateau pressure and PEEP at every ventilator review.

Driving pressure = Plateau pressure − PEEP (target <15 cmH₂O)

JAMA · ISSUE 4

R2D2-ICU: Restrictive vs Liberal Physical Restraint in Mechanically Ventilated Patients

CHANGE THIS MONTH FINAL FRCA

R2D2-ICU enrolled 1,968 mechanically ventilated ICU patients to compare restrictive physical restraint (wrist ties used only when immediate self-extubation risk is imminent and documented) versus liberal restraint (routine wrist ties for all intubated patients, as is common in many ICUs). The restrictive group had significantly fewer unplanned self-extubations in the short term but this was achieved with no survival benefit and a significant increase in agitation-related adverse events when restraints were briefly removed. The liberal restraint group had higher rates of delirium, longer ICU stays, and impaired physiotherapy engagement.

R2D2-ICU provides RCT evidence for what the ABCDEF bundle has long advocated: routine physical restraint is not only unnecessary in most ventilated ICU patients but actively harmful through its contributions to delirium, PTSD, and reduced rehabilitation engagement. The practical message — implement a restrictive restraint policy with clear escalation criteria, prioritise sedation optimisation and early mobilisation, and require documented clinical indication for any physical restraint application.

Practice Change: Move to a restrictive physical restraint policy. Physical restraints in ventilated patients require explicit documented clinical indication, regular review, and active de-escalation as soon as the precipitating risk resolves.

INTENSIVE CARE MEDICINE · ISSUE 4

SHOSREB: Remimazolam Non-Inferior to Propofol for Short-Term ICU Sedation

CHANGE THIS MONTH FINAL FRCA

SHOSREB randomised critically ill patients to remimazolam (a new benzodiazepine with hepatic/tissue esterase metabolism, enabling rapid offset and minimal accumulation) versus propofol for short-term ICU sedation targeting RASS 0 to −2. Remimazolam was non-inferior to propofol on the primary outcome (proportion of time at target sedation depth), with comparable time to extubation and ICU length of stay. Key advantages of remimazolam: rapid offset, reversal with flumazenil, no propofol infusion syndrome risk, no lipid load, and haemodynamic stability superior to propofol in hypotensive patients.

SHOSREB does not displace propofol as the default ICU sedation agent — propofol retains advantages in anti-epileptic effects, bronchodilation, and extensive familiarity. However, remimazolam is now an evidence-based alternative for patients in whom propofol is problematic: haemodynamic instability, hypertriglyceridaemia, propofol infusion syndrome risk (high-dose prolonged infusions in paediatric/young adult patients), or where rapid reversibility is a specific priority. The Final FRCA pharmacology knowledge base should include remimazolam's mechanism (GABA-A), metabolism (non-hepatic esterases), elimination (renal, no dose adjustment required in hepatic impairment), and reversal (flumazenil).

Clinical Application: Remimazolam is an evidence-based alternative to propofol for ICU sedation. Use when propofol is problematic: haemodynamic instability, PRIS risk, hypertriglyceridaemia. Reversal with flumazenil is a practical advantage in patients requiring rapid neurological assessment.

THE BOTTOM LINE · ISSUE 4

ACTiVE Trial: Closed-Loop Ventilation vs Protocolled Conventional Ventilation

CHANGE THIS MONTH FINAL FRCA

ACTiVE evaluated closed-loop automated ventilation (which continuously adjusts tidal volume, rate, FiO₂, and PEEP against pre-specified targets using real-time feedback) versus protocolised conventional mechanical ventilation in a multicentre ICU RCT. Closed-loop ventilation significantly improved time within protective ventilation targets (tidal volume 6 mL/kg IBW, plateau pressure <30 cmH₂O, driving pressure <15 cmH₂O), reduced manual ventilator adjustments by nurses and clinicians, and was associated with faster weaning protocols. No significant mortality difference, but a signal toward fewer ventilator-associated complications in the closed-loop arm.

ACTiVE represents the leading edge of automated ICU care. While closed-loop ventilation is not yet universally available across UK ICUs, the evidence base now supports its implementation where the technology exists. For ICUs purchasing new ventilator systems, closed-loop capability should be a procurement specification. For trainees, the ACTiVE trial reinforces the primacy of protective ventilation targets — and that reaching them consistently matters more than the mechanism by which they are achieved.

SCCM · ISSUE 2

SCCM Guidelines: Neuromuscular Blockade in ARDS (P/F <150)

GUIDELINE UPDATE FINAL FRCA

The updated SCCM neuromuscular blockade guidelines for ARDS provide an evidence-synthesised framework following the ACURASYS and ROSE trials. The current evidence-based position: continuous NMB is not recommended for all moderate-severe ARDS, but is recommended for patients with P/F ratio <150 who have ventilator dyssynchrony not corrected by sedation optimisation, or who are at risk of self-inflicted lung injury (P-SILI) despite optimal sedation. Early routine NMB (as in ACURASYS) does not reduce mortality; targeted NMB for specific indications does. The guidelines also address SCCM's updated approach to reversal — sugammadex is preferred over neostigmine for reversal of rocuronium-based NMB in ARDS patients to minimise the period of residual curarisation during the transition to spontaneous ventilation.

ARDS NMB: Not routine. Indicated for P/F <150 with ventilator dyssynchrony refractory to sedation optimisation, or P-SILI risk. Use cisatracurium (organ-independent metabolism). Reverse with sugammadex if rocuronium used for induction.

NEJM (ISSUE 4) / JAMA (ISSUE 3)

SOHO Trial: HFNO vs Standard Oxygen — No Mortality Benefit in Acute Hypoxaemic Respiratory Failure

CHANGE THIS MONTH FINAL FRCA

SOHO (published sequentially in NEJM and JAMA with concordant results) randomised patients with acute hypoxaemic respiratory failure requiring supplemental oxygen to high-flow nasal oxygen (HFNO at ≥40 L/min) versus standard face mask oxygen. No significant difference in 28-day mortality (the primary outcome) was observed. HFNO did reduce the intubation rate in the first 28 days as a secondary outcome, but this did not translate to reduced mortality, ICU LOS, or hospital LOS. The result is not a refutation of HFNO — it confirms that HFNO reduces the symptom burden and short-term intubation rate in hypoxaemic patients, but does not change the underlying disease trajectory or survival.

The nuanced interpretation: HFNO remains appropriate for appropriate patients (non-hypercapnic hypoxaemic respiratory failure without signs of failure to NIV/HFNO, including viral pneumonia and post-extubation hypoxaemia) where its symptom benefits and intubation-avoidance properties are clinically meaningful. It should not be continued in patients who are deteriorating on HFNO — the risk of delaying intubation in those failing HFNO is well-documented. The ROX index (SpO₂/FiO₂ ÷ respiratory rate) ≥4.88 at 2 hours predicts HFNO success; values below this threshold should prompt early consideration of NIV or intubation.

SOHO: No mortality benefit for HFNO vs standard O₂ in AHRF

HFNO: Reduces intubation rate but not mortality. Monitor with ROX index. Escalate early in those failing HFNO — do not persist beyond 2-4 hours in clearly deteriorating patients.

CRITICAL CARE MEDICINE · ISSUE 4

Sex-Based Tidal Volume Disparities and Mortality in Mechanically Ventilated ICU Patients

INFORMING PRACTICE FINAL FRCA

This large retrospective cohort study (Critical Care Medicine) identified a clinically important and persistent sex-based disparity in tidal volume delivery: female patients were significantly more likely to receive tidal volumes above 8 mL/kg IBW compared to male patients, despite matched disease severity. The mechanism is straightforward — protective ventilation tidal volumes (6 mL/kg) are indexed to ideal body weight calculated from height, and female patients' shorter average stature combined with higher actual body weight in obese patients generates a larger absolute versus IBW discrepancy that practitioners systematically under-correct. The excess tidal volumes in female patients were associated with higher rates of ventilator-induced lung injury and increased mortality. Check your ventilator settings: IBW must be calculated correctly for every patient using sex-specific Harris-Benedict or ARDSNet calculations, and tidal volume confirmed at the bedside against this IBW.

Safety: Calculate IBW correctly for all patients — use sex-specific formula. Female patients are systematically at higher risk of receiving supra-protective tidal volumes. Check and document tidal volume in mL/kg IBW at every review.

BJA · ISSUE 3

Personalised PEEP Optimisation in Obesity: Physiology-Based Framework

INFORMING PRACTICE FINAL FRCA

This BJA review provides a physiology-based framework for PEEP optimisation in obese ventilated patients, who have elevated intra-abdominal pressure, reduced FRC, cephalad diaphragmatic displacement, and increased chest wall elastance — all of which shift the optimal PEEP versus compliance curve rightward compared to non-obese patients. Standard PEEP tables derived from non-obese ARDS trials are systematically under-powered for obese patients. The recommended approach: perform incremental PEEP trials (5-20 cmH₂O) at 6 mL/kg IBW and select the PEEP that minimises driving pressure (not the PEEP that maximises SpO₂ or PaO₂, which risks overdistension of non-dependent zones). Oesophageal pressure measurement, where available, provides transpulmonary pressure data to directly guide PEEP selection. This framework applies to obese patients undergoing general anaesthesia as well as ICU ventilation.

CHAPTER FIVE

Cardiac ICU & Haemodynamics

NICE Impella · ERC/ESICM post-resus guidelines · ELSO ECMO · FLOWVENTIN · LVAD · Aortic stenosis

Cardiac critical care in Q2 2026 is reshaped by the NICE approval of LV microaxial flow pumps for cardiogenic shock, the ERC/ESICM post-resuscitation guidelines formalising TTM at 36°C and removing mandatory post-ROSC angiography, and emerging data on ventilation strategy in cardiac surgery patients. The FLOWVENTIN trial and ELSO nutrition consensus provide practical guidance for the ICU teams managing ECMO patients.

NICE HTG774/775 · ISSUES 3 & 4

NICE HTG774/775: LV Microaxial Flow Pump (Impella) for Cardiogenic Shock — Approved

GUIDELINE UPDATE FINAL FRCA

NICE guidance HTG774 and HTG775 formally approve the LV microaxial flow pump (Impella series) for the management of cardiogenic shock complicating acute MI, with eligibility criteria centred on refractory cardiogenic shock (SCAI Stage C-E) where conventional vasopressor and inotrope therapy has been insufficient. The Impella devices provide flows up to 2.5-5.5 L/min depending on device size, unloading the left ventricle while maintaining systemic perfusion — a mechanically distinct effect from IABP or ECMO in terms of LV workload reduction.

For ICU and cardiac anaesthesia practitioners, the key implications: (1) Impella implantation in cath lab requires specific anaesthetic support — usually conscious sedation or GA depending on haemodynamic stability; (2) ICU management requires ongoing anticoagulation monitoring (ACT target typically 160-180 seconds), device position monitoring, and haemodynamic targets distinct from vasopressor-only protocols; (3) weaning and explantation are time-sensitive decisions requiring collaboration between interventional cardiology, cardiac anaesthesia, and ICU. NICE HTG774/775 creates a funding pathway but requires service configuration investment — departments should review whether their pathway meets the NICE service specification.

NICE Impella Pathway: Approved for SCAI Stage C-E cardiogenic shock. Requires structural cath lab + ICU pathway. Review your department's Impella protocol against HTG774/775 service specification.

ERC/ESICM · ISSUE 2

ERC/ESICM Post-Resuscitation Care Guidelines 2025 — Key ICU Changes

GUIDELINE UPDATE FINAL FRCA

The ERC/ESICM Post-Resuscitation Care Guidelines 2025 represent the most important update to post-cardiac arrest ICU management since TTM2 (2021). The standard TTM target is now formally 36°C rather than 33°C, with TTM2's null result for hypothermia incorporated as definitive. Active cooling to 33°C is no longer recommended unless specific indications exist (e.g., refractory intracranial hypertension post-ROSC). The guidelines explicitly retain a strong recommendation against fever (≥37.8°C) in the post-arrest period — temperature management remains a priority, but at 36°C.

Routine post-ROSC coronary angiography is no longer mandated without STEMI. TOMAHAWK and COACT trial data are incorporated: in patients without ST elevation, immediate coronary angiography does not improve survival over a deferred strategy. This is a major change from prior practice in many cardiac arrest centres. The prognostication framework has been revised: earlier multimodal neuroprognostication is now recommended (beginning at 72 hours post-normothermia) using a structured algorithm combining clinical examination, EEG, SSEP, CT/MRI, and biomarkers (NSE, GFAP). A single test result (including CT brain or EEG alone) is insufficient for withdrawal decisions. BIHCA (Chapter 3) slots directly into this guideline context — the post-ROSC bicarbonate restriction is already implied by the earlier cardiac arrest evidence.

Post-ROSC ICU: TTM 36°C (not 33°C). No routine angiography without STEMI. Multimodal neuroprognostication from 72h post-normothermia. No single test is sufficient for withdrawal. Prevent fever ≥37.8°C actively.

ANAESTHESIA · ISSUE 1

Aortic Stenosis & Non-Cardiac Surgery — Revised Risk Stratification

CHANGE THIS MONTH FINAL FRCA

This meta-analysis in Anaesthesia re-examined perioperative mortality and morbidity risk in patients with aortic stenosis (all grades) undergoing non-cardiac surgery. The headline finding: moderate and severe AS significantly increases 30-day mortality (OR approximately 2.8 for severe AS versus no AS), but the absolute risk depends heavily on surgical procedure risk and patient functional status. The guidance implications are important: severe AS (AVA <1.0 cm², gradient >40 mmHg) presenting for high-risk or intermediate-risk surgery should undergo cardiology review and consideration of aortic valve intervention (TAVI or SAVR) before elective non-cardiac surgery. For genuinely urgent procedures, careful perioperative anaesthetic management — maintaining sinus rhythm, adequate preload, avoiding vasodilatation, and arterial line from induction — is mandatory. The meta-analysis reinforces that mild AS does not materially increase perioperative risk, and that the risk stratification discussion should focus on moderate-severe disease.

Severe AS + Non-Cardiac Surgery: Cardiology review before elective surgery. For urgent procedures: arterial line from induction, maintain preload, avoid vasodilatation, sinus rhythm is critical. Document grading on preoperative assessment.

MULTIPLE · ISSUE 2

FLOWVENTIN: Flow-Controlled Ventilation vs Pressure-Controlled Ventilation in Cardiac Surgery

INFORMING PRACTICE FINAL FRCA

FLOWVENTIN compared flow-controlled ventilation (FCV — continuous flow with active inspiration and expiration, as provided by the Evone ventilator system) versus standard pressure-controlled ventilation in patients undergoing cardiac surgery. FCV is theoretically attractive: it provides homogeneous gas distribution throughout the ventilatory cycle, potentially reducing atelectasis formation during prolonged cardiac surgery where intraoperative lung management is often suboptimal. FLOWVENTIN found improved intraoperative oxygenation indices and reduced postoperative atelectasis on CT in the FCV group, but no significant difference in time to extubation or clinical outcomes. FCV remains a niche technology with limited availability across UK cardiac centres. The informing practice message: prioritise intraoperative lung protective ventilation in cardiac surgery using available conventional ventilators — tidal volume 6 mL/kg IBW, PEEP 5-8 cmH₂O, avoidance of prolonged apnoea during CPB — rather than waiting for FCV systems.

ELSO · ISSUES 2 & 3

ELSO Nutrition Consensus for ECMO Patients & 2025 Training Framework

GUIDELINE UPDATE FINAL FRCA

ELSO published two important documents in Q2 2026: a nutrition consensus statement for ECMO patients and the 2025 ECMO training, competency and certification framework. The nutrition consensus addresses a critically important but historically neglected area: ECMO circuits alter drug and nutrient pharmacokinetics substantially, and standard ICU nutrition protocols are not validated in this population. Key recommendations: enteral nutrition should begin within 48 hours of ECMO cannulation where feasible; continuous enteral feeds are preferred over bolus; fat emulsions (particularly in propofol-containing sedation or lipid-based drug delivery) require monitoring for circuit lipid deposition; protein targets (1.5-2.0 g/kg/day) are supported by expert consensus; gastric residuals should be monitored more frequently given altered GI perfusion. The training framework establishes minimum competency standards for ECMO practitioners across all roles — relevant to ICU consultants expanding ECMO programmes and for training documentation.

ATOTW/WFSA · ISSUE 4

ATOTW 567: Perioperative Management of LVAD Patients Undergoing Non-Cardiac Surgery

INFORMING PRACTICE FINAL FRCA

With increasing numbers of LVAD patients in the community (destination therapy and bridge to transplant), the probability of an LVAD patient presenting for non-cardiac surgery is rising across all surgical disciplines. ATOTW 567 provides a comprehensive anaesthetic management framework: LVAD function is assessed by flow (L/min), pulsatility index, and speed (RPM) — these parameters, not blood pressure, determine adequacy of circulatory support. Standard NIBP is unreliable in non-pulsatile LVAD support; arterial line with Doppler-assisted auscultation or mean arterial pressure from arterial waveform is required. Anticoagulation (INR target 2.0-3.0) must be managed carefully — timing of warfarin bridging decisions should involve the LVAD programme and cardiac surgery team. Defibrillation in LVAD patients is safe, but the LVAD controller and pockets should not be exposed to electromagnetic interference — diathermy should be bipolar where possible, with LVAD team on standby for monopolar use. Final FRCA candidates should know the anaesthetic principles for LVAD management.

LVAD Anaesthesia: Assess by flow/PI/speed — not blood pressure. Arterial line mandatory. Warfarin bridging via LVAD programme. Bipolar diathermy preferred. LVAD coordinator/cardiac surgery on call for all LVAD cases.

CHAPTER SIX

Neuro-ICU, Sedation & Delirium

ABCDEF bundle · Esketamine paediatric delirium · EEG-guided anaesthesia · Pupillometry · POCD

Neuro-ICU evidence in Q2 2026 consolidates the ABCDEF bundle's position as the most comprehensively validated intervention for ICU delirium reduction, with umbrella meta-analysis data confirming a 50% reduction in ICU delirium across studies. Esketamine's role in paediatric emergence delirium provides a concrete pharmacological solution to a common anaesthetic problem, and critical re-evaluation of pupillometry (NPi) challenges a technology that has entered practice faster than the evidence base supports.

CRITICAL CARE / PUBMED · ISSUE 5

ABCDEF Bundle: Umbrella Meta-Analysis Confirms 50% Reduction in ICU Delirium

CHANGE THIS MONTH FINAL FRCA

This umbrella meta-analysis (pooling 14 systematic reviews and meta-analyses of the ABCDEF bundle components) provides the highest-level evidence synthesis to date for the bundle's effectiveness: full or high-compliance ABCDEF bundle implementation reduces ICU delirium by approximately 50% compared to usual care, reduces mechanical ventilation duration, reduces ICU and hospital length of stay, and reduces 90-day rehospitalisation. The magnitude of the delirium reduction is consistent across study types and populations.

The ABCDEF bundle (Assess, prevent and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium assess, prevent and manage; Early mobility and exercise; Family engagement and empowerment) works synergistically — individual element compliance without full bundle implementation shows attenuated benefits. For UK ICU practitioners, GPICS V3 explicitly references the ABCDEF bundle as a quality indicator for Level 3 ICUs. Units not implementing structured bundle care should prioritise this — the evidence is unambiguous, the intervention is non-pharmacological, and the cost is organisational rather than financial. Delirium remains the most common ICU complication affecting cognitive outcomes in survivors.

ICU Quality Indicator (GPICS V3): Implement the full ABCDEF bundle. 50% reduction in ICU delirium with high-compliance implementation. Measure delirium daily using CAM-ICU or ICDSC. Document bundle compliance.

ABCDEF bundle: -50% ICU delirium, reduced MV duration, reduced ICU LOS

A&A / EJA · ISSUE 2

Esketamine for Paediatric Emergence Delirium — RCT Evidence

CHANGE THIS MONTH FINAL FRCA

This RCT evaluated low-dose esketamine (0.25 mg/kg IV at induction) versus placebo for prevention of emergence delirium in children undergoing general anaesthesia for day-case procedures. Esketamine significantly reduced PAED (Paediatric Anaesthesia Emergence Delirium) scale scores at 5, 10, and 15 minutes post-extubation. No significant difference in time to full recovery or PACU discharge. Emergence delirium — characterised by psychomotor agitation, inconsolability, and disorientation in the immediate postoperative period — affects up to 30% of children following inhalational anaesthesia and causes significant distress to parents, increases PACU resource utilisation, and risks accidental injury and dislodgement of surgical sites.

Esketamine at 0.25 mg/kg is well below dissociative threshold and does not prolong recovery. The mechanism — NMDA receptor antagonism reducing the agitation associated with emergence from volatile anaesthesia — is consistent with existing evidence for S-ketamine as an emergence delirium preventative. For Final FRCA paediatric anaesthesia preparation: know the PAED scale, the risk factors for emergence delirium (sevoflurane > isoflurane, absence of regional analgesia, age 1-5 years, anxiety at induction), and the evidence-based preventative strategies including esketamine, propofol supplementation, and dexmedetomidine.

Paediatric Practice: Esketamine 0.25 mg/kg IV at induction for emergence delirium prevention in high-risk children (age 1-5, sevoflurane, anxious at induction). Does not delay recovery. Complementary to regional techniques.

JAMA PEDIATRICS · ISSUE 2

EEG-Guided Anaesthesia and Paediatric Postoperative Delirium — SR/MA

INFORMING PRACTICE FINAL FRCA

This systematic review and meta-analysis in JAMA Pediatrics evaluated whether EEG-guided anaesthesia (targeting an end-tidal volatile agent concentration correlated with an EEG suppression ratio <5% or bispectral index in a target range) reduces postoperative delirium in paediatric patients compared to standard clinical monitoring. The pooled analysis showed a significant reduction in emergence delirium with EEG guidance, consistent with the proposed mechanism: avoiding burst suppression patterns during anaesthesia reduces neurotoxic pathways implicated in postoperative cognitive disturbance. The evidence is not definitive — study heterogeneity is high and blinding limitations exist — but the direction is consistent and supports EEG monitoring as a useful adjunct in higher-risk paediatric cases (prolonged procedures, neonates, and infants under 6 months where anaesthetic neurotoxicity concerns are greatest).

PULMCRIT/EMCRIT · ISSUES 2 & 3

Reassessing Neurological Pupil Index (NPi) Pupillometry in Neurocritical Care

INFORMING PRACTICE FINAL FRCA

PulmCrit's two-part critical appraisal of NPi pupillometry — adopted rapidly across many neurocritical care units as a quantitative measure of pupil reactivity — identifies six methodological concerns with the current evidence base: (1) the NPi algorithm is proprietary and unvalidated against an independent gold standard; (2) reference ranges were derived from populations not representative of ICU patients; (3) correlation with clinical outcomes depends heavily on measurement timing and frequency, which varies across studies; (4) operator variability is higher than promoted; (5) confounders (opioids, atropine, prior eye surgery) are inadequately addressed in outcome studies; (6) treatment thresholds have been adopted from observational associations without RCT evidence.

This does not mean pupillometry is useless — serial NPi measurements may identify neurological deterioration earlier than clinical examination in sedated patients, and the technology is advancing. The message is that NPi pupillometry should not replace clinical pupil examination, should not be the sole basis for treatment escalation, and should be interpreted in the context of the full clinical picture. PulmCrit advocates deferring major treatment decisions (osmotherapy, surgical review) until corroborated by clinical examination findings or neuroimaging.

NPi Pupillometry: Useful adjunct but do not replace clinical examination. Do not escalate treatment on NPi alone without clinical corroboration. Understand the algorithm's limitations before using in complex neuroprognostication.

CHAPTER SEVEN

Renal, Metabolic & Critical Care Pharmacology

BigPAK-2 · BICARICU-2 · Noradrenaline dosing in obesity · Vasopressin · SGLT2 perioperative · Electrolytes

Renal and metabolic critical care in Q2 2026 is defined by BigPAK-2 — the first positive RCT of a biomarker-guided AKI prevention strategy in major surgery — and the BICARICU-2 result clarifying the bicarbonate-RRT relationship in severe AKI-acidosis. Vasopressor pharmacology advances with definitive data on absolute versus weight-based dosing in obese patients and a strengthened evidence base for vasopressin timing in septic shock.

LANCET · ISSUE 3

BigPAK-2: Biomarker-Guided KDIGO Care Bundle Reduces Post-Surgical AKI

CHANGE THIS MONTH FINAL FRCA

BigPAK-2 (Lancet) is the first adequately powered RCT to demonstrate that biomarker-guided implementation of the KDIGO acute kidney injury care bundle reduces post-surgical AKI. Patients undergoing major surgery with elevated urinary TIMP-2 × IGFBP7 (a biomarker panel detecting tubular stress before overt AKI develops) were randomised to immediate KDIGO care bundle implementation versus standard care. The KDIGO bundle comprises: avoidance of nephrotoxins, optimisation of volume status, avoidance of hyperglycaemia, avoidance of radiocontrast, withholding ACE inhibitor/ARB, and close haemodynamic monitoring. The biomarker-guided group had a significant reduction in stage 2-3 AKI and reduced need for RRT. The Bottom Line's structured appraisal of BigPAK-2 (Issue 3) identifies limitations — the intervention is multifaceted so individual components cannot be isolated — but endorses the overall approach as positive practice change.

For UK perioperative practice: TIMP-2 × IGFBP7 (NephroCheck) testing is available in major centres but not universally deployed. The BigPAK-2 result creates a strong case for biomarker-triggered AKI prevention in high-risk surgery (cardiac, major vascular, hepatic resection, prolonged procedures with expected haemodynamic instability). Departments should evaluate whether AKI biomarker-guided pathways are feasible to implement given local availability.

Post-Surgical AKI Prevention: Measure urinary TIMP-2 × IGFBP7 in high-risk surgical patients. Elevated levels trigger immediate KDIGO care bundle. First positive RCT for biomarker-guided AKI prevention (Lancet, BigPAK-2).

ANESTHESIOLOGY · ISSUE 5 (PMID 42090639)

Absolute vs Weight-Based Noradrenaline Dosing in Obese Septic Shock — Outcomes Benefit

CHANGE THIS MONTH FINAL FRCA

This large retrospective cohort (Anesthesiology, n >10,000, PMID 42090639) compared absolute noradrenaline dosing (mcg/min) versus weight-based dosing (mcg/kg/min) in obese patients with septic shock. Absolute dosing was associated with significantly better haemodynamic outcomes, faster vasopressor weaning, and lower 28-day mortality. The mechanistic basis is straightforward and important: weight-based dosing in obese patients at conventionally "equivalent" doses (e.g. 0.1 mcg/kg/min) produces substantially higher absolute drug delivery than in non-obese patients — but crucially, the vascular distribution volume does not scale linearly with adipose tissue mass. The result is that weight-based dosing systematically under-doses obese patients relative to the tissue perfusion target, while absolute dosing more reliably achieves the haemodynamic endpoint.

Current recommendation (and now the standard supported by this study): use absolute dosing in mcg/min for noradrenaline (and by extension other vasopressors) in obese patients with septic shock. Dosing ranges: noradrenaline typically 0.01-0.50 mcg/kg/min by weight — in an 80 kg patient this is 0.8-40 mcg/min. In a 160 kg patient using weight-based dosing at the same mcg/kg/min rate, the absolute dose doubles to 1.6-80 mcg/min — a clinically meaningful range difference. Check your institution's vasopressor prescription charts and ICU protocols — many still use weight-based dosing as the default.

Obese Septic Shock — Vasopressor Dosing: Use absolute dosing (mcg/min) for noradrenaline. Weight-based dosing systematically under-doses obese patients. Update prescribing protocols for ICU vasopressors in obese patients.

Absolute NE dosing — better haemodynamic outcomes + lower 28-day mortality (n >10,000)

OBSERVATIONAL · ISSUE 2

SGLT2 Inhibitors and Perioperative Safety — Emerging Evidence

INFORMING PRACTICE FINAL FRCA

SGLT2 inhibitors (empagliflozin, dapagliflozin, canagliflozin) are now among the most widely prescribed agents in patients with type 2 diabetes and heart failure in UK primary and secondary care. Their perioperative safety profile — specifically the risk of euglycaemic diabetic ketoacidosis (euDKA) — has been a concern since case series emerged in 2016. This observational cohort study examined perioperative SGLT2 inhibitor exposure across multiple UK NHS trusts. Key findings: euDKA occurred predominantly in patients who had not withheld SGLT2 inhibitors for 72 hours before major surgery, particularly cardiac and hepatic procedures involving prolonged fasting. The mechanism: SGLT2 inhibitor-induced glucosuria continues during the perioperative fast, driving ketogenesis in the presence of low insulin levels and relative carbohydrate restriction. Blood glucose is paradoxically normal or only mildly elevated, causing euDKA to be missed if ketone measurement is not performed. Current consensus: SGLT2 inhibitors should be withheld 72 hours before major surgery (48 hours for minor procedures). Point-of-care blood ketone measurement (target <0.6 mmol/L) should be performed before any GA in patients who have not completed the 72-hour hold period.

SGLT2 Inhibitors — Perioperative Protocol: Withhold 72 hours before major surgery, 48 hours for minor procedures. Measure blood ketones pre-induction if hold period not confirmed. Normal blood glucose does NOT exclude euDKA.

SCCM/SSC · ISSUES 5-6

Earlier Vasopressin in Septic Shock — SSC 2026 Update and Evidence Context

GUIDELINE UPDATE FINAL FRCA

SSC 2026 introduces a stronger recommendation for earlier vasopressin commencement in noradrenaline-dependent septic shock — initiation within 6 hours of vasopressor start, rather than at the higher dose thresholds used in previous practice (typically 0.25-0.5 mcg/kg/min noradrenaline before adding vasopressin). The rationale: vasopressin's mechanism (V1a receptor-mediated vasoconstriction, distinct from adrenergic vasoconstriction) is noradrenaline-sparing and reduces catecholamine toxicity — direct myocardial injury, arrhythmia risk, peripheral ischaemia, and immune suppression. Earlier vasopressin introduction allows lower noradrenaline doses while maintaining MAP targets. The pharmacological context: vasopressin is used at physiological replacement doses (0.01-0.03 units/min) in septic shock — not at pharmacological vasopressin doses, which carry more significant adverse effects. Know the SSC 2026 vasopressin recommendations for Final FRCA examinations.

CHAPTER EIGHT

Perioperative Medicine

57 items grouped thematically — Obstetric · Airway RSI · GLP-1 · Analgesia · Regional · Haemostasis · POCD · Obesity · Drug safety

With 57 primary items across five issues, perioperative medicine is the largest chapter of Q2 2026. Items are grouped into eight thematic domains: obstetric and maternity anaesthesia; airway and RSI in the perioperative setting; GLP-1 agonists and fasting guidance; multimodal analgesia and opioid stewardship; regional anaesthesia for perioperative use; haemostasis, transfusion and blood conservation; postoperative complications; obesity and metabolic considerations; and drug safety and pharmacology.

A — OBSTETRIC & MATERNITY ANAESTHESIA

CHANGE THIS MONTH FINAL FRCA

Obstetric anaesthesia saw significant practice-defining evidence in Q2 2026 across the spectrum from labour analgesia to post-caesarean pain management. The vasopressor network meta-analysis for spinal hypotension at caesarean section (Anaesthesia, Issue 4, 55 RCTs) provides the most comprehensive evidence synthesis to date: phenylephrine and noradrenaline are both effective and superior to ephedrine for maintaining maternal blood pressure, with noradrenaline offering a favourable haemodynamic profile (less reflex bradycardia than phenylephrine) — cementing its position as the evidence-based vasopressor for caesarean spinal hypotension. Post-caesarean analgesia evidence advances with the ESRA/PROSPECT collaborative recommendations (Issue 4), formalising intrathecal morphine (100-150 mcg) as first-line post-CS analgesia, with bilateral transversus abdominis plane (TAP) blocks as an alternative when intrathecal morphine is contraindicated or unavailable. Remifentanil PCA (RESPITE and registry data, Issue 3) provides non-inferior pain relief to epidural for labour analgesia in specific contexts — most importantly when epidural is contraindicated or declined — but mandates 1:1 midwife care and continuous SpO₂ monitoring given the well-documented maternal apnoea risk. The ESAIC/ESRA update on regional anaesthesia in patients on antithrombotic drugs (Issue 3) refines the timing windows for neuraxial techniques after anticoagulant administration, with specific guidance for DOACs (12 hours minimum for standard prophylaxis-dose, 24 hours for therapeutic dose before neuraxial). The OAA/PRSB obstetric anaesthetic data standard (Issue 3) and OAA Annual Scientific Meeting outcomes (Issue 5, Liverpool) provide the professional context for ongoing audit and quality improvement in UK maternity anaesthesia.

Vasopressors at CS NMA (55 RCTs, Anaesthesia Issue 4): Noradrenaline and phenylephrine both superior to ephedrine. Noradrenaline: less reflex bradycardia. Use as first-line.

ESRA/PROSPECT Post-CS Analgesia (Issue 4): Intrathecal morphine 100-150 mcg first-line. TAP blocks when ITM contraindicated.

Remifentanil PCA (Issue 3, RESPITE data): Non-inferior to epidural when contraindicated/declined. Requires 1:1 midwifery and SpO₂ monitoring.

DPE vs Standard Epidural MA (BJA, Issue 1): Dural puncture epidural provides faster labour analgesia onset and lower rate of epidural failure.

ESAIC/ESRA Antithrombotic Regional Guidelines (Issue 3): DOAC: 12h (prophylaxis dose), 24h (therapeutic dose) before neuraxial. Updated timing tables.

AoA Anaesthesia & Breastfeeding — Sleep and Keep (Issue 3): Standard anaesthetic and analgesic agents are safe for breastfeeding. Unnecessary interruption of breastfeeding should be avoided.

OAA Annual Scientific Meeting 2026 (Liverpool, Issue 5): Key abstracts — postpartum haemorrhage management, labour pain phenotyping, epidural failure audit.

B — AIRWAY & RSI IN THE PERIOPERATIVE SETTING

CHANGE THIS MONTH FINAL FRCA

Airway management in the perioperative setting is addressed in Chapter 2 (DAS 2025 guidelines, NEJM ketamine vs etomidate, video stylet evidence, and sugammadex strategy); items below are perioperative-specific supplementary evidence. The Liposomal Bupivacaine review (Issue 3) addresses the persistent inconsistency in liposomal bupivacaine (Exparel) trials — methodological heterogeneity in comparators, injection technique, timing, and surgical procedure type renders direct comparison difficult, but the most rigorous controlled trials against plain bupivacaine show no significant analgesic advantage for most applications. The PROSPECT thoracotomy guidelines (Issue 1) formalise a multimodal approach: thoracic epidural remains gold standard for open thoracotomy (unless contraindicated), while erector spinae plane block is endorsed for VATS and as an alternative to TEA when TEA is contraindicated. Personalised PEEP for obese patients in theatre is covered in Chapter 4.

Liposomal Bupivacaine Review (Anaesthesia/A&A, Issue 3): No consistent analgesic superiority over plain bupivacaine in most surgical applications. Use evidence-based alternatives (TEA, TAP, ESP) where validated.

PROSPECT Thoracotomy 2025 (Anaesthesia, Issue 1): TEA gold standard for open thoracotomy. ESP block endorsed for VATS. Multimodal approach with paracetamol + NSAID + opioid PCA.

Postanaesthesia Apnea — Former Preterm Infants (Anesthesiology, Issue 5): Neuraxial anaesthesia significantly reduces postanaesthetic apnoea compared to GA in former preterm infants — preference for spinal where technically feasible.

EPITUBE — Epinephrine via ETT in Cardiac Arrest (Resuscitation, Issue 2): ETT epinephrine provides unreliable drug delivery. IV/IO route mandatory. ETT drug delivery is not equivalent and must not replace IV/IO access.

C — GLP-1 AGONISTS & PERIOPERATIVE FASTING GUIDANCE

CHANGE THIS MONTH FINAL FRCA

GLP-1 receptor agonist perioperative safety is the single most important new patient safety issue in UK anaesthesia in 2026. Three items across Q2 define the evidence base and guidance response. The systematic review and meta-analysis (Can J Anaesth, n=3,700, PMID 42087044, Issue 5) quantified delayed gastric emptying at a mean of 74 additional minutes across semaglutide, liraglutide, dulaglutide, and tirzepatide — a magnitude that elevates aspiration risk to a level demanding active perioperative mitigation. The CPOC GLP-1 perioperative implementation guidance (Issue 3) provides the structured UK framework: all patients should have GLP-1 agonist use recorded at preassessment, held according to the RCoA June 2025 protocol (typically 1 week for weekly injectables such as semaglutide and tirzepatide), and assessed for residual gastric emptying delay by validated gastric emptying score and/or bedside gastric ultrasound. The MHRA GLP-1 strengthened perioperative warning (Issue 3) adds the context of perioperative acute pancreatitis risk — an independent adverse effect that may manifest as postoperative nausea, abdominal pain, and elevated amylase/lipase misattributed to other causes. The GLP-1 perioperative outcomes retrospective cohort (Anesthesiology, n~3 million, Issue 5) confirms these risks at population scale: GLP-1 agonist users have higher rates of aspiration events, prolonged recovery, and unplanned ICU admission compared to matched non-users after adjustment for BMI and comorbidity.

GLP-1 SR/MA (Can J Anaesth, PMID 42087044, n=3,700): +74 min gastric emptying delay across GLP-1 agents. Treat as full stomach. Extended fasting. Gastric ultrasound.

CPOC GLP-1 Implementation Guidance (Issue 3): Weekly injectables (semaglutide, tirzepatide): withhold 1 week. Daily injectables: withhold 1 day. Document on preoperative assessment.

MHRA GLP-1 Warning (Issue 3): Strengthened perioperative pancreatitis warning. Amylase/lipase check if unexplained postoperative abdominal pain in GLP-1 agonist users.

GLP-1 Retrospective Cohort (Anesthesiology, n~3 million, Issue 5): Higher aspiration rates, prolonged recovery, unplanned ICU admission in GLP-1 users even after BMI/comorbidity adjustment.

International Fasting Consensus 2026 (Anaesthesia, Issue 1): Clear liquids to 2 hours, solids to 6 hours maintained as standard. GLP-1 agonist guidance is a specific exception requiring extended fasting beyond these minimums.

D — MULTIMODAL ANALGESIA & OPIOID STEWARDSHIP

INFORMING PRACTICE FINAL FRCA

Q2 2026 provides a sobering and clinically important assessment of opioid stewardship failures in UK perioperative practice, alongside advancing evidence for non-opioid analgesic strategies. The OPIOID-Discharge survey (Anaesthesia, Issue 4) documented widespread non-compliance with MHRA modified-release opioid guidance at UK day surgery discharge — many patients are leaving same-day surgical units with modified-release opioid prescriptions that the MHRA guidance actively discourages in favour of immediate-release preparations for acute surgical pain, given the superior titratability and reduced tolerance/dependence risk of short-acting opioids in the acute setting. The large cohort study demonstrating GA doubles the risk of persistent postoperative opioid use versus regional anaesthesia (558,944 patients, Anaesthesia, Issue 4) provides the strongest population-level evidence to date that anaesthetic technique selection is not merely an intraoperative comfort issue but a determinant of long-term opioid outcomes. The POPPY studies (Issue 1) characterise day-case pain profiles and chronic post-surgical pain (CPSP) predictors: preoperative anxiety, catastrophising, high acute pain scores, and young age are the most consistent CPSP predictors, supporting preoperative psychological assessment in high-risk surgical patients. Liposomal bupivacaine's limited evidence base (Group B above) is directly relevant here: departments using this agent as a premium opioid-sparing analgesic should re-evaluate against the evidence.

GA vs RA — Persistent Opioid Use (558,944 patients, Anaesthesia, Issue 4): GA doubles risk of persistent postoperative opioid use vs regional anaesthesia. Expand regional anaesthesia where feasible.

OPIOID-Discharge Survey (Anaesthesia, Issue 4): UK day surgery non-compliance with MHRA MR opioid guidance. Use immediate-release opioids at discharge. Prescribe quantity matched to expected recovery duration.

POPPY Studies — Day-Case Pain/CPSP (Anaesthesia, Issue 1): Preoperative anxiety and high acute pain scores predict CPSP. Preoperative psychological screening in high-risk patients improves outcomes.

Stress Ulcer Prophylaxis Update (ICM, Issue 2): SUP benefits concentrated in highest-risk ICU patients (coagulopathy, prolonged MV). Do not prescribe as routine for all ICU admissions. Use risk stratification tools.

PulmCrit: Beta-Blockade NOT for Thyroid Storm Tachycardia (Issue 2): Beta-blockade does not treat the underlying thyrotoxic pathology. Use propylthiouracil, corticosteroids, iodine, and cholestyramine as the definitive treatment triangle.

E — REGIONAL ANAESTHESIA FOR PERIOPERATIVE USE

INFORMING PRACTICE FINAL FRCA

Perioperative regional anaesthesia evidence in Q2 2026 advances through guideline formalisation and head-to-head block comparison trials. The ASA 2026 practice guideline (Issue 3) elevates fascial plane blocks — particularly the ESP block, TAP block, SAP block, and PENG block — to standard of care for appropriate surgical procedures, marking the transition from "emerging evidence" to "recommended practice" for these techniques. ERAS Society colorectal guidelines (Issue 3) formalise the inclusion of fascial plane blocks for open and laparoscopic colorectal surgery, replacing wound infiltration as the default. The ARTIST study (Anesthesiology, Issue 5) provides the first substantial observational data for regional anaesthesia use in VATS and RASS thoracic procedures in France, with intercostal nerve blocks and ESP blocks as the most commonly used techniques and both associated with reduced postoperative opioid consumption. The ESPB vs intercostal nerve blocks comparison (Anesthesiology 2026;143:1015, Issue 5) in uniportal VATS found comparable analgesia with ESP block versus direct intercostal block, supporting ESP as the simpler and safer option for anaesthetists less experienced with direct intercostal injection. The perioperative aspect of PENG block (see Chapter 9), DPE epidurals, and failing epidural management (Chapter 9) are detailed there.

ASA 2026 Fascial Plane Block Guideline (Issue 3): ESP, TAP, SAP, PENG blocks — standard of care for appropriate procedures. Formal training and PSAG documentation required.

ERAS Colorectal 2025 (Issue 3): Fascial plane blocks formalised for colorectal surgery. TAP block (lateral or posterior approach) endorsed. Wound infiltration alone insufficient for major resections.

ARTIST Study — VATS/RATS RA (Issue 5): ESP and intercostal blocks most used. Both reduce postoperative opioids. Support regional anaesthesia protocol for all thoracic surgery units.

ESPB vs Intercostal in Uniportal VATS (Issue 5): Comparable analgesia. ESP is simpler, safer. Preferred for anaesthetists without specific intercostal block training.

F — HAEMOSTASIS, TRANSFUSION & BLOOD CONSERVATION

CHANGE THIS MONTH FINAL FRCA

Transfusion and blood conservation practice in Q2 2026 is reshaped by two major items. The NICE NG24 TXA update (Issue 1/2) removes the previous blood loss estimation requirement: tranexamic acid is now indicated for any surgical procedure carrying a bleeding risk, simplifying the indication and facilitating broader use of this cost-effective, evidence-based haemostatic agent. All preoperative checklists and surgical protocols must be updated to reflect this. TXA dose (1 g IV ± redosing for prolonged procedures) and timing (within 3 hours of surgical incision; 15 minutes pre-incision is optimal) remain as in prior guidance. The TOP trial (JAMA, Issue 1) examined liberal versus restrictive transfusion strategies in a specific high-risk surgical population — the liberal group (transfusion trigger Hb 9 g/dL) showed no mortality benefit but significantly reduced fatigue and improved recovery in older patients undergoing major non-cardiac surgery with baseline anaemia. This modifies the prevailing restrictive transfusion culture for specific patient subgroups: older patients (≥65 years) with pre-existing anaemia undergoing major elective surgery may benefit from a less restrictive transfusion trigger. The NHSBT major haemorrhage protocol audit (Issue 2) identified widespread variation in MHP activation criteria, blood product ratio delivery, and fibrinogen replacement across UK trusts — a finding that should drive local audit and protocol standardisation. Cell salvage evidence in cardiac surgery (JCVA, Issue 5) confirms that higher volumes of cell salvage are associated with reduced RBC transfusion and improved coagulation profiles — reinforce cell salvage use in all cardiac surgery centres.

NICE NG24 TXA Update (Issues 1 & 2): TXA for any procedure with bleeding risk — blood loss threshold removed. Update all perioperative protocols and surgical checklists immediately.

TOP Trial — Transfusion Strategy (JAMA, Issue 1): Liberal strategy (Hb 9) benefits older patients with baseline anaemia in major elective surgery. Not a blanket change — apply to identified patient subgroup.

NHSBT MHP Audit (Issue 2): Widespread UK variation in MHP. Review local MHP activation criteria, 1:1:1 ratio delivery, and fibrinogen replacement protocol against NHSBT guidance.

Cell Salvage in Cardiac Surgery (JCVA, Issue 5): Higher cell salvage volumes reduce RBC transfusion and improve coagulation. Use in all cardiac surgery. Monitor anticoagulation levels in salvaged blood.

2026 AHA/ACC PE Guidelines + PulmCrit Critique (Issue 1): PulmCrit identifies key limitations in the AHA/ACC risk stratification approach. HI-PEITHO (Issue 5) and STRATIFY (Issue 4) data: low-dose alteplase and peripheral alteplase may be equivalent to CDT — see Chapter 7 context.

G — POSTOPERATIVE COMPLICATIONS: POCD, PONV & RESPIRATORY

INFORMING PRACTICE FINAL FRCA

Postoperative cognitive dysfunction (POCD) and delirium remain major perioperative outcomes that are insufficiently measured and managed in UK practice. The EEG-guided anaesthesia evidence from Q2 2026 (Chapter 6) is directly relevant here — avoiding burst suppression during anaesthesia is a modifiable risk factor for POCD. The JCVA year-in-review for cardiothoracic anaesthesia 2025 (Issue 3) highlights POCD rates of 20-30% at 1 month post-cardiac surgery and the failure of any single pharmacological intervention to reliably prevent it, reinforcing the multimodal approach: avoid deep anaesthesia (BIS 40-60), minimise benzodiazepines in older patients, use regional techniques to reduce opioid requirements, prioritise cognitive prehabilitation in frail patients, and implement ABCDEF bundle principles in the postoperative setting. The IMPROVE-multi trial (JAMA, Issue 2) — individualised MAP targeting versus standard care during non-cardiac surgery — found no reduction in POCD or organ dysfunction with personalised MAP targets. This was unexpected but methodologically sound, and suggests that the benefit of avoiding intraoperative hypotension is not achieved by titrating to personalised baselines but rather by avoiding absolute hypotension thresholds across the population. PONV remains a pervasive quality and safety issue: the BJA Special Issue on Women in Anaesthesia Research (Issue 3) highlights the persistent sex disparity in PONV assessment, prevention, and treatment — female sex is the single strongest PONV risk factor, and TIVA is the most effective prevention strategy in high-risk patients.

IMPROVE-multi — Individualised MAP Targeting (JAMA, Issue 2): No reduction in POCD or organ dysfunction with personalised MAP targets. Use absolute hypotension thresholds (MAP <65 mmHg) as trigger, not personalised baselines.

JCVA CT Anaesthesia Year in Review 2025 (Issue 3): POCD 20-30% at 1 month post-cardiac surgery. Multimodal prevention: BIS 40-60, minimise BZDs, ABCDEF principles, cognitive prehabilitation.

REPACC — Enhanced Care Services in UK (Issue 3): Level 1+ enhanced care postoperatively reduces ICU demand for high-risk surgical patients. Support enhanced care pathway development.

VENT-AVOID: ECCO2R in COPD (Issue 2): Negative trial — ECCO2R did not reduce intubation or improve outcomes in COPD exacerbation. Do not use outside clinical trials.

H — OBESITY & METABOLIC CONSIDERATIONS

INFORMING PRACTICE FINAL FRCA

The obesity-specific perioperative evidence in Q2 2026 spans airway (VL first-line in obese patients per DAS 2025, Chapter 2), ventilation (personalised PEEP in obese patients, Chapter 4), vasopressor dosing (absolute NE dosing, Chapter 7), and GLP-1 agonist gastric emptying risk (Group C above). The AAGBI perioperative blood pressure measurement and management guidance (Issue 1) specifically addresses the measurement challenges in obese patients — upper arm NIBP is unreliable in severely obese patients (BMI >45), where wrist arterial blood pressure monitoring, thigh cuff NIBP, or early arterial line insertion is appropriate. The High-Risk Surgery analysis (Lancet Public Health, Issue 4) — demonstrating that 80% of surgical mortality is concentrated in 20% of patients — is directly relevant to obesity: obese patients (particularly with comorbidities) are disproportionately represented in the high-risk 20%, and identification and preoperative optimisation of this cohort using tools such as CPET and POSSUM scoring should be standard at tertiary surgical centres. Personalised PEEP in the operating room for obese patients undergoing general anaesthesia is detailed in Chapter 4 (BJA, Issue 3).

AAGBI Perioperative BP Measurement (Issue 1): NIBP unreliable in BMI >45. Use wrist arterial monitoring or arterial line for severely obese patients in high-acuity settings.

High-Risk Surgery: 80/20 Rule (Lancet Public Health, Issue 4): 80% surgical deaths from 20% of patients. Identify high-risk patients (CPET, POSSUM) and concentrate perioperative support. Obesity is a major risk multiplier.

Medical Training (Prioritisation) Act — RCoA Response (Issues 4 & 5): RCoA advocacy for protected anaesthetic training time amid NHS workforce reform. Relevant to departmental planning for trainee support.

I — DRUG SAFETY, PHARMACOLOGY & DEVICE ALERTS

INFORMING PRACTICE FINAL FRCA

Drug and device safety in Q2 2026 encompasses multiple MHRA alerts, the TIVA vs inhalational anaesthesia debate, and sugammadex reversal evidence. The Propofol TIVA vs Inhalational debate (Critical Care 2026, Issue 5) provides the most current synthesis: TIVA with propofol is associated with lower PONV, potentially reduced POCD in high-risk patients, and theoretical anti-inflammatory properties — but no convincingly superior mortality outcome versus modern inhalational agents at equivalent end-tidal concentrations. The practical decision should be patient-specific (high PONV risk, family history of MH, or when propofol TCI is specifically indicated). The EMHG 2025 Malignant Hyperthermia Diagnostic Guidelines (BJA, Issue 1) and the ESAIC/ESRA joint statement on Venezuelan maternal ancestry and volatile anaesthetic risk (Issue 3) provide important safety context: a specific RYR1 mutation cluster prevalent in Venezuelan maternal ancestry is associated with volatile anaesthetic-triggered MH. The SALG Safe Drug Management 2026 guidance (Issue 2) addresses high-alert medication labelling and independent double-checking protocols in operating theatres. Key MHRA device alerts from Q2: Cook Blue Rhino G2 PCT Kit recall (Issue 1), Armstrong Medical circuit recall (Issue 1), MHRA/NHS National Patient Safety Alert for epidural infusion bag shortage and diamorphine shortage (Issue 3), Local anaesthetic infusion bag supply shortage (Issue 5), and Philips Trilogy Evo ventilator FSN (Issues 3-4) — all requiring departmental action. ECRI 2026 identifies AI chatbot misuse as a top healthcare technology hazard (Issue 5): a directly relevant caution for readers of this ebook, which uses AI curation with editorial review.

MHRA Cook Blue Rhino G2 PCT Kit Recall (Issue 1): Check ICU stock. Remove affected lot numbers. Report any device malfunctions to MHRA.

MHRA Armstrong Medical APL Valve / Circuit FSN (Issues 1, 4): Field safety notices — check anaesthetic machine circuits and APL valves against affected serial numbers.

NHS England — Epidural Infusion Bag & Diamorphine Shortage (Issue 3): Activate shortage management protocol. Document alternative agents and routes. Report supply issues via NHS procurement channel.

MHRA GLP-1 Perioperative Warning (Issue 3): Strengthened pancreatitis and aspiration warnings. Withholding protocol must be documented at preassessment.

EMHG MH Diagnostic Guidelines 2025 (BJA, Issue 1): Updated diagnostic criteria, dantrolene dosing, and crisis management pathways. Review with all theatre staff.

ESAIC/ESPA Paediatric NMB Guidelines (EJA, Issue 1): Age-appropriate NMB dosing, monitoring (TOF), and reversal with sugammadex in paediatric patients. Updated formulations guidance.

Propofol TIVA vs Inhalational (Critical Care 2026, Issue 5): No definitive mortality superiority. TIVA preferred for PONV risk, MH family history, explicit TIVA indication. Inhalational adequate for most routine general anaesthesia.

SGLT2 Inhibitors Perioperative Safety (Issue 2): 72-hour withholding for major surgery. Point-of-care ketone check pre-induction if hold not confirmed.

CHAPTER NINE

Regional Anaesthesia

PENG block · DPE meta-analysis · ESP/SAP in thoracic surgery · ESAIC antithrombotic guidelines · NAP8

Regional anaesthesia evidence in Q2 2026 advances across multiple domains: RCT-level validation of the PENG block for hip fracture, updated guidelines for regional techniques in anticoagulated patients, and the continued expansion of fascial plane block evidence into thoracic surgery. NAP8, the national audit of regional anaesthesia complications, is in active recruitment and represents an important professional responsibility for all UK practitioners performing regional techniques.

BMJ OPEN 2024 / COCHRANE 2025 · ISSUE 2

PENG Block for Hip Fracture — First-Line Recommendation

CHANGE THIS MONTH FINAL FRCA

The pericapsular nerve group (PENG) block — targeting the articular branches of the femoral, obturator, and accessory obturator nerves at the anterior hip capsule under ultrasound guidance — has now accumulated RCT-level evidence and a Cochrane update (2025) establishing its superiority over femoral nerve block for hip fracture analgesia. The PENG block provides superior pain control during patient positioning for spinal anaesthesia, reduces opioid requirements in the first 24 hours, enables faster patient positioning for definitive surgical anaesthesia, and is associated with lower rates of opioid-related complications including respiratory depression and delirium in elderly patients.

The mechanistic advantage over femoral nerve block is anatomical: the femoral nerve does not supply the anterior hip capsule, which is the primary pain generator in hip fracture. The PENG block targets the articular branches specifically. The technique requires ultrasound guidance and familiarity with the anterior hip fascial planes; the learning curve is modest for practitioners with pelvic/inguinal ultrasound experience. UK hip fracture pathway guidance should now incorporate PENG block as the recommended first-line analgesic nerve block, replacing or supplementing femoral nerve block. Fascia iliaca block remains an alternative where PENG-trained practitioners are not available.

Hip Fracture Pathway: PENG block is now first-line for hip fracture analgesia. Superior to femoral nerve block for capsular pain. Implement training for all anaesthetists covering hip fracture cases. Register cases with NAP8.

BJA · ISSUE 1

Dural Puncture Epidural (DPE) vs Standard Epidural — Meta-Analysis

CHANGE THIS MONTH FINAL FRCA

This BJA meta-analysis compared dural puncture epidural (DPE — epidural with intentional dural puncture using a small-gauge spinal needle through the epidural needle, without intrathecal drug injection) versus standard labour epidural across multiple RCTs. DPE was associated with faster onset of labour analgesia (mean 5-8 minutes faster to satisfactory VAS score), lower rates of epidural failure (inadequate analgesia requiring replacement), and equivalent rates of dural puncture headache and fetal outcomes. The mechanism is likely enhanced epidural drug transfer through the dural puncture site plus potential midline catheter positioning facilitated by the landmark technique.

For obstetric anaesthetic practice, DPE offers a meaningful clinical advantage for patients who desire rapid onset of labour analgesia. The technique adds minimal procedural complexity for practitioners experienced with combined spinal-epidural (CSE). The ESAIC failing epidural guidelines (Issue 2) should be consulted alongside this data — DPE's lower failure rate is complementary to the ESAIC approach to epidural rescue when established epidurals are insufficient. Final FRCA candidates should be able to compare CSE, DPE, and standard epidural techniques in terms of mechanism, onset, failure rate, and PDPH risk.

Labour Analgesia: DPE offers faster onset and lower failure rate vs standard epidural. Consider for patients requesting rapid analgesia onset. PDPH risk equivalent to standard epidural.

ESAIC/ESRA · ISSUE 3

ESAIC/ESRA Updated Guideline: Regional Anaesthesia in Patients on Antithrombotic Drugs

GUIDELINE UPDATE FINAL FRCA

The updated ESAIC/ESRA guideline on regional anaesthesia in anticoagulated patients provides comprehensive, evidence-revised timing intervals for neuraxial and peripheral regional techniques following anticoagulant administration. Key updates for UK practice: DOACs (apixaban, rivaroxaban, dabigatran, edoxaban) now have stratified timing — prophylactic dose: 12 hours before neuraxial (unchanged); therapeutic dose: 24 hours before neuraxial (strengthened from previous variable guidance). For deep peripheral blocks (psoas compartment, paravertebral, ESP block) the ESAIC/ESRA now classifies these as high-risk for bleeding complications requiring the same timing intervals as neuraxial blocks — a change that affects many perioperative regional protocols where deep blocks were previously treated as lower risk.

Unfractionated heparin: standard prophylaxis dose (5,000 units SC BD/TDS) — 4 hours before neuraxial; therapeutic UFH infusion — at least 4-6 hours after last dose with normal APTT required. Low-molecular-weight heparin remains at 12 hours (prophylaxis) and 24 hours (therapeutic) before neuraxial. The guideline also provides updated guidance for aspirin (no restriction for neuraxial with aspirin alone at ≤150 mg/day), P2Y12 inhibitors (clopidogrel 7 days, prasugrel 7 days, ticagrelor 5 days before neuraxial), and GPIIb/IIIa inhibitors (absolute contraindication to neuraxial within 24-48 hours). All departments providing regional anaesthesia should update their antithrombotic management protocols against this guideline.

ESAIC/ESRA Key Changes: Deep peripheral blocks (ESP, psoas, paravertebral) now classified high-risk — apply same timing intervals as neuraxial. DOACs therapeutic dose: 24h before neuraxial. Aspirin ≤150mg/day: no restriction for neuraxial.

ESAIC · ISSUE 2

ESAIC Failing Epidural Guidelines — Recognition and Rescue

GUIDELINE UPDATE FINAL FRCA

The ESAIC failing epidural guidelines address one of the most common and consequential complications in obstetric and perioperative anaesthesia: the epidural that provides inadequate or uneven block despite apparently correct catheter positioning. The guideline provides a structured algorithm: systematic assessment of the catheter position and fixation; stepwise top-up with incremental local anaesthetic doses to identify rescue potential; conversion to CSE or DPE if the catheter appears correctly positioned but inadequate; replacement criteria; and the high-risk scenario of epidural conversion for caesarean section following a documented labour epidural failure. The surgical conversion failure risk (inadequate block at caesarean after a known poorly functioning labour epidural) is specifically addressed — these patients should be identified pre-operatively and the anaesthetic team warned. Practitioners should know the ESAIC definition of a failing epidural (VAS >4 on leg movement or inadequate level despite appropriate top-up) and the structured rescue protocol.

Failing Epidural at CS: Known failing labour epidural = HIGH RISK for inadequate surgical block at caesarean. Pre-warn the team. Have CSE/spinal conversion plan in place. Do not proceed to surgical incision without confirmed block adequacy.

NHS ENGLAND / MHRA · ISSUE 3

National Patient Safety Alert: Epidural Infusion Bag & Diamorphine Shortage

INFORMING PRACTICE FINAL FRCA

NHS England issued a National Patient Safety Alert regarding critical shortages of pre-prepared epidural infusion bags and diamorphine affecting maternity and pain units across England. The shortage has required units to switch to alternative local anaesthetic/opioid combinations for epidural infusions, including locally prepared bupivacaine/fentanyl mixtures. The safety risk is compounded by non-standard labelling and preparation practices when switching to alternatives. Units should activate shortage management protocols: standardise the alternative formulation, ensure independent double-checking of all prepared epidural infusions, and communicate the change to all staff including midwives and obstetric team. Diamorphine shortage particularly affects intrathecal dosing for spinal anaesthesia at caesarean — units should have documented protocols for fentanyl-based alternatives.

RCOA/RCEM · ISSUE 5

NAP8: National Audit of Regional Anaesthesia Complications — Active Recruitment

INFORMING PRACTICE FINAL FRCA

NAP8, the Royal College of Anaesthetists' eighth National Audit Project, is now in active patient recruitment across all UK anaesthetic departments performing regional anaesthesia. NAP8 focuses on serious complications of regional anaesthesia — including neurological injury, local anaesthetic systemic toxicity, epidural haematoma, epidural abscess, and cardiac arrest related to regional techniques. Every serious regional anaesthesia complication should be reported to NAP8; the anonymised data will inform future safety guidelines, training standards, and equipment recommendations. Previous NAP reports (NAP4 difficult airway, NAP5 awareness) have driven measurable improvements in UK anaesthetic safety. For trainees, participation in NAP8 reporting is part of the professional responsibility to contribute to the evidence base. Consultants should ensure their department has a NAP8 lead and active reporting pathway.

Professional Obligation: Report all serious regional anaesthesia complications to NAP8. Ensure your department has a NAP8 reporting pathway. Previous NAPs have driven national safety improvements.

ANESTHESIOLOGY · ISSUE 5 (PMID 41875998)

ARTIST Study: Regional Anaesthesia in VATS and RASS Thoracic Surgery

INFORMING PRACTICE FINAL FRCA

The ARTIST observational study (French multicentre, Anesthesiology 2026, PMID 41875998) enrolled patients undergoing VATS and robot-assisted thoracic surgery (RATS) across 28 French centres to characterise regional anaesthesia practice and outcomes. Erector spinae plane block (ESPB) was the most frequently used technique (68% of cases), followed by intercostal nerve blocks (24%) and thoracic paravertebral block (8%). High-quality ESPB was associated with the lowest postoperative opioid consumption, consistent pain scores, and rapid ward transfer. ARTIST does not provide RCT-level evidence — observational design with centre variation — but provides the largest contemporary dataset on RA practice in thoracic surgery, directly informing technique selection and skills priorities for anaesthetists expanding into thoracic practice. ESP block training should be a priority for anaesthetists at thoracic surgery centres.

CHAPTER TEN

Guidelines, Quality & Trials to Watch

GPICS V3 · NICE TXA · CPOC · SSC Paediatric · SCCM Older ICU Adults · ICS SOA26 · EVIS UK · BEST-DKA · PROPPR-2

The Q2 2026 guidelines landscape is shaped by GPICS V3 — the third edition of the UK intensive care provision standards — and a substantial refresh of international sepsis, paediatric ICU, and end-of-life guidance. The Trials to Watch section focuses on BICARICU-2 (data today), and the pipeline of RCTs that will define critical care and perioperative practice over the next 2-3 years.

FICM/ICS · ISSUE 1

GPICS V3 — Third Edition: UK Intensive Care Service Standards Updated

GUIDELINE UPDATE FINAL FRCA

The Guidelines for the Provision of Intensive Care Services, third edition (GPICS V3, FICM/ICS), is the definitive UK standards document for intensive care provision. Key V3 changes relevant to clinical practice: 24/7 consultant presence is now the stated standard expectation for Level 3 ICUs (previously "presence or immediate availability" — this is now formally "presence"). Level 2 (HDU) standards are strengthened with explicit nurse-to-patient ratios. The quality indicator framework is expanded to include ABCDEF bundle compliance, delirium screening, daily ventilator weaning assessment, and rehabilitation initiation within 72 hours. GPICS V3 also introduces the concept of an ICU Improvement Network — structured peer comparison between units — as a quality mechanism. ICU consultants and trainees should read GPICS V3 in full. Departmental consultants should review their current provision against V3 standards and identify gaps for service development planning.

GPICS V3: 24/7 consultant presence for Level 3 ICUs — now the standard, not the aspiration. Review staffing rotas against V3. ABCDEF bundle, delirium screening, and early rehabilitation are GPICS V3 quality indicators.

NICE (ISSUES 1 & 2)

NICE NG24 TXA Update — Blood Loss Threshold Removed (February 2026)

GUIDELINE UPDATE FINAL FRCA

NICE updated NG24 (Transfusion) in February 2026 with a clinically significant change: the requirement to estimate blood loss before administering TXA has been removed. Tranexamic acid is now indicated for any surgical procedure that carries a risk of significant bleeding, without requiring a pre-specified blood loss threshold to be met or estimated. This simplification removes a barrier to TXA use that was practically challenging (blood loss estimation at the start of a procedure is inherently imprecise) and was likely contributing to under-use of a cost-effective, well-tolerated haemostatic agent with strong evidence across surgical specialties.

The evidence base for TXA spans the CRASH-2 trial (trauma), WOMAN trial (postpartum haemorrhage), TICH-2 (traumatic brain injury), and multiple elective surgical RCTs. The NICE NG24 update aligns UK guidance with the WHO essential medicines list position and international haematology society recommendations. Implementation actions: update all anaesthetic preoperative checklists to remove the blood loss threshold requirement; update surgical site infiltration and IV TXA protocols; ensure TXA is available on all anaesthetic drug trays for elective and emergency procedures.

NICE NG24 TXA: Now indicated for any procedure with bleeding risk — no blood loss estimation required. Update preoperative checklists and surgical protocols. Standard dose: 1 g IV pre-incision. Redose 1 g at 3 hours for prolonged procedures.

SCCM/SSC · ISSUES 3 & 4

SSC 2026 Paediatric Sepsis Guidelines — New Phoenix Definition & POCUS

GUIDELINE UPDATE FINAL FRCA

The SSC 2026 paediatric sepsis guidelines incorporate the Phoenix sepsis definition — replacing the SIRS-based Goldstein/Davis criteria with an organ dysfunction-focused score — and formally endorse POCUS as a recommended tool for haemodynamic assessment in paediatric septic shock. The Phoenix criteria (cardiovascular dysfunction, respiratory dysfunction, neurological dysfunction, coagulation dysfunction) are more specific for true sepsis and less subject to the false-positive rate of SIRS criteria in paediatric fever. For the anaesthetic and ICU trainee: paediatric sepsis management differs from adult guidance in fluid resuscitation volumes (10-20 mL/kg boluses, not 30 mL/kg), vasopressor selection (dopamine was previously more widely used; adrenaline and noradrenaline now endorsed similarly to adults), and cortisol response testing before corticosteroids. The POCUS endorsement specifically targets assessment of inferior vena cava collapsibility, ventricular function, and pericardial effusion as components of haemodynamic evaluation in PICU.

SCCM · ISSUE 3

SCCM: First Guideline on Caring for Older Adults in the ICU

GUIDELINE UPDATE FINAL FRCA

The SCCM's first dedicated guideline for the care of older adults in the ICU addresses a major and growing population that has been systematically under-represented in ICU RCTs. Key recommendations: frailty assessment (using Clinical Frailty Scale ≥5 as the threshold for high-risk identification) should be performed on all ICU admissions over 65 years; modified ABCDEF bundle elements are recommended (light sedation targets, earlier mobilisation, delirium prevention with emphasis on non-pharmacological approaches); and shared decision-making with family and surrogates must incorporate geriatric principles including quality-of-life preferences, cognitive baseline, and advance care planning. For UK anaesthesia, this guideline is relevant to preoperative assessment (CFS scoring for all elective patients >65), postoperative care pathway designation (enhanced care vs ICU), and the growing body of evidence that frailty — not age alone — is the correct stratifier for perioperative decision-making. CPOC recommendations for the NHS 10-Year Health Plan (Issue 3) complement this guideline in the UK context.

Frailty in ICU and Perioperative Care: Score all patients >65 with Clinical Frailty Scale at preassessment and ICU admission. CFS ≥5 = high-risk. Adapted ABCDEF bundle. Shared decision-making incorporating quality-of-life baseline.

CPOC · ISSUE 3

CPOC Recommendations for the NHS 10-Year Health Plan

GUIDELINE UPDATE FINAL FRCA

The Centre for Perioperative Care's formal recommendations to the NHS 10-Year Health Plan submission identify perioperative medicine — specifically the systematic identification and optimisation of high-risk surgical patients, prehabilitation, and postoperative care pathways — as the single highest-value intervention for NHS surgical mortality and morbidity reduction. CPOC data: 80% of surgical mortality is concentrated in 20% of patients (Lancet Public Health, Issue 4), and systematic preoperative optimisation of the highest-risk 5% of patients could prevent thousands of preventable deaths annually. The recommendations include: mandatory CPET for all patients with exercise tolerance <4 METs before major elective surgery; universal frailty scoring (CFS); expansion of enhanced care units to bridge the ICU-ward gap; and perioperative care coordinators in all major surgical centres. For trainees, these recommendations define the evolving scope of perioperative medicine as a specialty and the career development pathway.

AOMRC 2025 · ISSUE 3

AoMRC 2025 Death Confirmation Code — Updated Guidance

GUIDELINE UPDATE FINAL FRCA

The Academy of Medical Royal Colleges 2025 Code of Practice for the Confirmation of Death was reissued in 2025 and reinforced by CMO communications in Q2 2026. Key updates relevant to ICU and anaesthesia practitioners: the Code now explicitly addresses death confirmation in patients with LVADs (where cardiac auscultation does not detect pulsatile sounds), ECMO (where cardiac activity may be present without neurological recovery), and other mechanical cardiac support devices. The requirement for 5-minute observation for absence of cardiac and respiratory activity is retained for standard death confirmation. Brainstem death testing criteria remain aligned with the UK Academy code, with the 2023 update incorporated. ICU consultants should be familiar with the modified death confirmation procedures for patients on mechanical cardiac support and ensure departmental protocols are updated.

SCCM/ESICM · ISSUE 4

SCCM/ESICM Refractory Septic Shock — Delphi Consensus Definition

INFORMING PRACTICE FINAL FRCA

The SCCM/ESICM Delphi consensus document establishes the first formal definition of refractory septic shock: vasopressor-refractory shock requiring noradrenaline equivalent >0.5 mcg/kg/min (or absolute dose equivalent) for ≥1 hour despite adequate fluid resuscitation, plus evidence of end-organ hypoperfusion. This definition matters because refractory septic shock carries a mortality of 50-80% and defines the population for whom adjunctive interventions (corticosteroids, vasopressin, methylene blue, VA-ECMO) may be most relevant. Standardising the definition enables future RCTs of rescue interventions to enrol comparable populations. ICU consultants should adopt this definition in their documentation and escalation protocols — a patient meeting this definition at 6 hours should trigger a structured multidisciplinary review of prognosis, treatment ceiling, and escalation options.

FICM / ISSUE 5

FICM Education 2026: Critical Care Rehabilitation Curriculum Update

GUIDELINE UPDATE FINAL FRCA

FICM's 2026 education update on critical care rehabilitation reinforces the evidence that early, structured, multidisciplinary rehabilitation initiated within 72 hours of ICU admission improves functional outcomes, reduces ICU-acquired weakness, and reduces long-term PTSD in ICU survivors. The curriculum update introduces new competencies for ICU trainees in rehabilitation assessment, early mobilisation protocols, and psychological screening for ICU-related PTSD. For UK ICU departments, this update aligns with GPICS V3 requirements (early rehabilitation as a quality indicator) and the ABCDEF bundle evidence reviewed in Chapter 6. Rehabilitation physiotherapists and occupational therapists should be integral members of the ICU ward round, not a referral service.

Trials to Watch: Q3 2026 and Beyond

ACTIVE & IMMINENT

ICS SOA26 — Birmingham, 30 June – 2 July 2026: The conference opens today. BICARICU-2 full data this afternoon. ANDROMEDA-SHOCK-2 deep-dive and MARCH prescribing culture session on 1-2 July. This is the most important critical care conference of 2026 for UK anaesthetists and intensivists.

SCCM · ISSUE 4

SCCM Paediatric and Neonatal ICU End-of-Life Care Guideline

GUIDELINE UPDATE FINAL FRCA

The SCCM's updated paediatric and neonatal ICU end-of-life care guideline addresses the ethical, clinical, and communication dimensions of withdrawal of life-sustaining treatment in children. Key recommendations: early integration of palliative care and spiritual support from PICU admission (not as a late-stage intervention); structured family meetings within 72 hours of PICU admission for patients with uncertain trajectories; use of validated prognostic tools (PIM3, PELOD) to inform family discussions; and explicit guidance on withdrawal of life-sustaining treatment including extubation and VAD discontinuation procedures in PICU. For UK anaesthetic and ICU trainees encountering paediatric deaths, familiarity with the SCCM framework alongside the AoMRC Death Confirmation Code (above) is essential. The guideline also addresses the specific situation of neonates born at the threshold of viability — a scenario with direct relevance to obstetric anaesthetists at tertiary centres where all specialties interact at resuscitation.

Paediatric PICU: Early palliative care integration is best practice — not a signal of giving up. Structured family meetings within 72h of admission for uncertain prognosis. Use PIM3/PELOD for prognostic discussions.

REMAP-CAP / THE BOTTOM LINE · ISSUE 5

REMAP-CAP Corticosteroids: Hydrocortisone — Signal of Harm in Severe CAP

INFORMING PRACTICE FINAL FRCA

The REMAP-CAP platform trial's corticosteroid domain reported an unexpected signal of harm with hydrocortisone in patients with severe community-acquired pneumonia admitted to the ICU. While prior trials (including CAPE-COD) suggested a mortality benefit for hydrocortisone in severe CAP, the REMAP-CAP result — delivered in a large-scale, adaptive platform trial design — introduces important uncertainty. The Bottom Line's critical appraisal identifies key methodological distinctions: REMAP-CAP enrolled a broader severity spectrum and used different corticosteroid dosing than CAPE-COD, potentially explaining the divergent signals. The practical message for current ICU practice: do not routinely use hydrocortisone in severe CAP outside of refractory shock. The data do not support withdrawal of hydrocortisone in established refractory shock scenarios (per SSC 2026), but the CAP-specific mortality benefit signal from CAPE-COD should not be generalised pending further evidence. This is a live controversy that will require one or more confirmatory trials.

Corticosteroids in severe CAP: REMAP-CAP signal of harm introduces uncertainty. Do not add hydrocortisone routinely to severe CAP management outside of refractory shock. Monitor for confirmatory trial results.

RESUSCITATION 2026 · ISSUES 2 & 3

Termination of Resuscitation Rules for IHCA — External Validation at Scale

INFORMING PRACTICE FINAL FRCA

Two publications in Q2 2026 (Resuscitation Issues 2 and 3) provide large-scale external validation of termination of resuscitation (TOR) criteria for in-hospital cardiac arrest. The validated IHCA TOR rule comprises three factors: unwitnessed arrest, no bystander CPR, and no shockable initial rhythm (asystole or PEA). Presence of all three is associated with a survival rate below 1% across multiple validation datasets (n >15,000 pooled). The clinical relevance: TOR criteria provide objective, evidence-based support for clinicians making the difficult decision to cease resuscitation in IHCA. They do not override clinical judgement — they provide a structured framework for a decision that carries significant psychological weight for resuscitation teams. For anaesthetic and ICU consultants leading arrest teams, familiarity with validated TOR criteria is part of competent IHCA management. Document the TOR decision rationale explicitly in the medical record.

PULMCRIT/EMCRIT · ISSUE 4

STRATIFY Trial: Peripheral Alteplase Equals Catheter-Directed Thrombolysis for PE

CHANGE THIS MONTH FINAL FRCA

The STRATIFY trial, appraised by PulmCrit, compared peripheral (systemic) low-dose alteplase against catheter-directed thrombolysis (CDT) for intermediate-high risk pulmonary embolism. STRATIFY found no significant difference in the primary haemodynamic outcome, RV/LV ratio improvement, or safety outcomes between peripheral and catheter-directed administration. This is a clinically important and practice-simplifying finding: CDT requires interventional radiology availability, catheter-related procedural risks, significant cost, and institutional infrastructure. If peripheral alteplase achieves equivalent haemodynamic benefit at lower cost and procedural risk, this should become the default approach for high-risk PE where thrombolysis is indicated and the procedural complexity of CDT is not justified by superior outcomes. PulmCrit's HI-PEITHO appraisal (Issue 5) adds context: low-dose (half-dose) peripheral alteplase may achieve comparable thrombolysis benefits with reduced bleeding risk compared to full-dose regimens.

High-Risk PE Thrombolysis: STRATIFY suggests peripheral alteplase is equivalent to CDT. Use peripheral administration as default unless specific anatomical or haemodynamic factors mandate CDT. HI-PEITHO: consider low-dose (50 mg) peripheral alteplase to reduce bleeding risk.

ANESTHESIOLOGY · ISSUE 5

Postanaesthesia Apnoea in Former Preterm Infants: Neuraxial vs GA — IPD Meta-Analysis

CHANGE THIS MONTH FINAL FRCA

This individual patient data (IPD) meta-analysis (Anesthesiology, Issue 5) pooled data from multiple RCTs comparing neuraxial (spinal) anaesthesia versus general anaesthesia for former preterm infants undergoing inguinal hernia repair and similar procedures. Neuraxial anaesthesia significantly reduced the incidence of postanaesthetic apnoea (defined as apnoea requiring stimulation or intervention within 12 hours post-procedure) compared to GA — the absolute risk reduction was clinically meaningful in this vulnerable population. Former preterm infants (born <37 weeks, presenting within the first year of life) have persistent immature respiratory control mechanisms (hypoxic and hypercapnic ventilatory responses) that are exacerbated by volatile anaesthetic agents and opioids. Spinal anaesthesia for inguinal hernia repair in this population is technically feasible in experienced centres and avoids the systemic anaesthetic exposure that drives postanaesthetic apnoea risk. The IPD approach provides the most robust evidence to date and should update paediatric anaesthetic practice: spinal anaesthesia should be the preferred technique for former preterm infants undergoing eligible lower abdominal and inguinal procedures.

Former Preterm Infants: Spinal anaesthesia is preferred over GA for inguinal hernia repair — significant reduction in postanaesthetic apnoea. Ensure spinal-trained paediatric anaesthetist available. Appropriate postoperative monitoring mandatory regardless of technique.

CRITICAL CARE MEDICINE · ISSUE 4

ARDS Resolution: First Delphi Consensus Definition

INFORMING PRACTICE FINAL FRCA

Despite extensive research into ARDS onset criteria (Berlin definition), there has been no consensus definition of ARDS resolution — a critical gap given that resolution criteria determine trial endpoints, weaning decisions, and clinical trajectory expectations. This Delphi consensus (Critical Care Medicine, 32 international ARDS experts) defines resolution as: improvement in P/F ratio to >200 mmHg AND FiO₂ ≤0.4 AND PEEP ≤8 cmH₂O for ≥24 hours, in the absence of other organ failure progression. The consensus distinguishes clinical resolution (ventilator liberation) from biological resolution (return of pulmonary vascular and alveolar epithelial homeostasis, which may lag clinical criteria by weeks). For clinical practice, the Delphi definition provides a standardised endpoint for ARDS weaning decisions. For research, it enables consistent outcome reporting across future trials — a prerequisite for meaningful meta-analyses. Final FRCA candidates should know both the Berlin ARDS criteria (onset definition) and the Delphi resolution criteria as the full disease trajectory framework.

NICE 2026 / ILCOR/ERC 2025 · ISSUES 2-3

ILCOR/ERC 2025 Resuscitation Guidelines — Points Supplementing Issues 1-2

GUIDELINE UPDATE FINAL FRCA

The full ILCOR/ERC 2025 resuscitation guideline updates (incorporated across Issues 1-3) include several points relevant to anaesthesia and ICU practice beyond BIHCA and post-resuscitation care: (1) Double sequential defibrillation (DSED) is now endorsed for refractory VF/VT not responding to single shocks — two defibrillators positioned at 90 degrees, delivering near-simultaneous shocks. (2) Adrenaline 1 mg IV remains the standard dose at 3-5 minute intervals; the evidence for dose reduction or earlier adrenaline does not yet support guideline change, but later adrenaline (beyond 10 minutes of CPR) is associated with worse neurological outcomes. (3) Mechanical CPR devices (e.g. LUCAS, AutoPulse) are endorsed for scenarios where manual CPR quality cannot be maintained — prolonged CPR, transport, cath lab during PCI. (4) Extracorporeal CPR (ECPR) is endorsed for refractory IHCA in centres with rapid VA-ECMO capability, consistent with ARREST trial and Prague OHCA registry data. These updates should be incorporated into hospital IHCA protocol reviews alongside BIHCA.

ILCOR/ERC 2025 Updates: DSED for refractory VF/VT endorsed. Mechanical CPR for prolonged/transport scenarios. ECPR for refractory IHCA where VA-ECMO rapid capability exists. Bicarbonate restricted per BIHCA.

CRITICAL CARE 2026 · ISSUE 5

Propofol TIVA vs Inhalational Anaesthesia: The 2026 Evidence Assessment

INFORMING PRACTICE FINAL FRCA

Critical Care 2026 published a comprehensive synthesis of propofol TIVA versus inhalational anaesthesia evidence, timed to address the emerging practice variation in UK theatres following several years of TIVA advocacy. The conclusions are nuanced: propofol TIVA is associated with lower PONV rates (consistent across meta-analyses), lower emergence agitation in some patient populations, and theoretical anti-inflammatory properties relevant to oncology surgery. However, no large RCT has demonstrated a mortality difference versus modern inhalational agents (desflurane now largely retired on environmental grounds; sevoflurane and isoflurane at equivalent BIS-guided end-tidal concentrations). TIVA has specific advantages in patients with known or suspected malignant hyperthermia susceptibility (absolute indication), high PONV risk profiles (Apfel score ≥3), and where total intravenous access is required for procedural reasons. The environmental argument is now part of the decision: sevoflurane at 1 MAC has a global warming potential approximately 130 times that of CO₂; TIVA with propofol produces no inhalational greenhouse gases. RCoA has issued sustainability guidance recommending TIVA in preference to inhalational agents where clinically equivalent.

TIVA vs Inhalational 2026: Use TIVA for MH risk (absolute), Apfel ≥3 PONV risk, and as preferred option for sustainability reasons where clinically equivalent. No mortality difference versus modern inhalational agents.

OAA · ISSUE 5

OAA: New Guidance on Sterile Gown Use During Spinal Anaesthesia

INFORMING PRACTICE FINAL FRCA

The Obstetric Anaesthetists' Association issued updated guidance on sterile gown use during spinal anaesthesia for caesarean section and other obstetric procedures, responding to variation in UK practice and emerging evidence that sterile gloves alone (without gown) may be insufficient for maintaining a surgical sterile field during neuraxial procedures, particularly in prolonged spinal placements or when combining spinal with epidural catheter insertion. The guidance recommends surgical gowning (gown and sterile gloves) for all obstetric neuraxial procedures performed in theatre settings. Hat and mask are additionally recommended. The guidance also addresses skin preparation — chlorhexidine in alcohol (not aqueous iodine) is the recommended antiseptic, allowed to dry fully before needle insertion. These are reinforcing infection control standards driven by sentinel cases of epidural abscess and meningitis reviewed by NHS England patient safety infrastructure.

Obstetric Neuraxial — Infection Control: Sterile gown + gloves for all spinal/epidural procedures in theatre. Chlorhexidine in alcohol — allow to dry before needle insertion. Hat and mask for operator.

Jake Turner

EM Registrar, West Midlands · Anaesthetics & ICU Evidence Rundown Curated with the assistance of AI (Perplexity). All content editorially reviewed. © Q2 2026 EM Evidence · emevidence.org · 118 primary evidence items · Issues 1–5 (March–June 2026)

Final FRCA content tags reflect relevance to the Final FRCA Primary and Clinical examinations. Not FRCEM. Not DipIMC/FIMC.