CCN Weekly · 19–25 Sep 2026
Dr Jonny Wilkinson – FOAMed, papers, POCUS and the bits that actually change the ward round.
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Papers
POCUS
FOAMed
Fluids / HD
Podcasts
Meetings
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Editor’s opener
Week ending 25 September 2026. Pulse-dose steroids got a proper kicking from Josh Farkas, Scott Weingart reminded us that waiting for “the line service” is not a plan when the potassium is 7.8, and ESICM put its shock-monitoring guideline back in front of the microphone. Add a fresh ICM letter on why people actually die from meningitis on ICU, and a couple of peri-op papers that punch above their weight on the ICU step-down ward.
CCN pick of the papers
CSF diversion after aSAH: stop treating every drain as equal
Klug and colleagues put the CSF-diversion menu in one place. Lumbar drainage is the only strategy with RCT-grade signal for fewer delayed infarcts and better function. EVD still wins when the ventricles are blocked or the patient is obtunded. Bedside translation: do not default to EVD “because neuro ICU”. Match the drain to the problem.
Source: Critical Care · Critical Care Reviews Paper of the Day, 25 Sep 2026 · CCR listing
EURECA: why they die is not always the brain
Grospeaud, Sonneville and the EURECA group split neurologic versus systemic death in severe meningitis and encephalitis. That split matters. If the brain is the failing organ you manage ICP, source and withdrawal conversations differently than if the problem is refractory shock or extra-CNS organ failure. Read it before the next family meeting on a meningococcal or HSV case.
Source: Intensive Care Medicine, published 23 Sep 2026
A bag before induction will not save the MAP
Eichinger et al. randomised 504 higher-risk adults to a pre-op crystalloid bolus or usual care. Time-weighted MAP under 65 mmHg after induction did not budge. If you still “fill them up so they do not drop”, this is your weekly reminder that vasomotor tone, not a litre of Hartmann’s in the anaesthetic room, is the usual culprit.
Source: Anesthesiology (RCT; featured on Waveform this week)
GLP-1 agonists before surgery: the observational signal is not “stop them all”
Choi and colleagues compared pre-op GLP-1 RA use against other glucose-lowering classes in a large EHR cohort from before the 2023 hold-the-drug guidance. Mortality and some infective outcomes looked better, not worse, versus metformin and DPP-4 inhibitors, with no excess aspiration versus comparator classes. This does not license a full stomach. It does argue against treating every semaglutide sticker as an automatic cancellation.
Source: Anesthesiology / PubMed · featured on Waveform this week
Sepsis is not one disease. Stop analysing it as if it were.
Antcliffe, McAuley, Silversides and co walk through subphenotypes and theragnostics. Re-analyses of old trials keep showing opposite treatment effects hiding inside the same syndrome label. If your unit is still running “sepsis = this bundle for everyone”, this is the paper to put on the journal club table. CCR made it Paper of the Day on 20 Sep.
Source: Intensive Care Medicine · CCR, 20 Sep 2026 · open access via PMC
Bonus context, not a new drop: SODa-BIC is now in print
The NEJM print version of SODa-BIC landed mid-month: bicarbonate versus placebo in acidotic, vasopressor-dependent adults. No dent in 30-day MAKE. pH goes up. Patients do not. Keep bicarb for the physiology you can name, not as a default drip.
Source: NEJM / PubMed · TBL summary: The Bottom Line. Print date sits on the edge of the seven-day window, so this is context only.
Best #POCUS
PLAX is your first look for type A. Use the length you have.
Stephen Alerhand’s pearl this week: parasternal long axis sees the first 3–5 cm of the ascending aorta, which is the longest continuous TTE run you get at the bedside. Not a rule-out study. A rule-in study. If the flap is there, you have already changed the next phone call.
Source: @EchoBridgeMD on X, 24 Sep 2026
Arrest, probe on, diagnosis on the screen
Luis Morgado posted a three-clip sequence of a cause of arrest picked up on POCUS during CPR. This is the use-case that still justifies the machine living next to the airway trolley rather than in a cupboard. Watch the clips, then ask your own team who holds the probe when the next crash bleep goes.
Source: @DrCriticalCare on X, 23 Sep 2026
VExUS with Koratala and Argaiz, on the CHEST Pulse feed
If your unit still treats IVC diameter as a volume oracle, sit with this conversation. Congestion is RAP plus venous compliance plus the organ you actually care about. Portal and femoral veins still work when TR wrecks the hepatic S wave. That is the teaching Waveform flagged this week.
Source: CHEST Pulse podcast · companion teaching: VExUS in TR, NephroPOCUS
Echo-MAD starts 28 September. Enrol.
A UK-facing study asking the only POCUS question that matters: how often does the scan change what you do, not how pretty the clip is. Sign-up is open. If you FUSIC or run an echo rota, this is your chance to put real-world practice on paper.
Source: @Marleyite on X · echomadstudy@gmail.com
Best #FOAMed
Pulse-dose steroid for non-CNS disease is a habit, not an evidence base
Farkas hoovered up the RCTs. CNS indications can justify the gram-a-day ritual because methylpred does not cross the blood-brain barrier well. Outside the skull, sixteen trials against ordinary steroid doses are a graveyard of negative results, with extra fungal and cardiac harm attached. If you are still writing “methylpred 1 g for three days” for AE-ILD or vasculitis without a trial protocol, read this before the next prescription.
Source: PulmCrit, 23 Sep 2026 · thread: @PulmCrit
EMCrit 434: put the dialysis catheter in yourself
Weingart’s point is blunt. If the indication is emergency RRT, toxic clearance or exchange, waiting for another team is a delay dressed up as governance. 12 Fr is the workhorse. 15–16 cm right IJ, 24 cm femoral. Own the kit, own the complication profile, own the clock.
Source: EMCrit 434, 21 Sep 2026
A2B: dex and clonidine do not beat propofol off the ventilator
REBEL’s appraisal of A2B is the sedation piece of the week. Neither dexmedetomidine nor clonidine shortened time to successful extubation versus propofol. Both bought more severe bradycardia. Dex had more serious adverse events. Propofol remains the default primary sedative unless you have a specific reason to switch.
Source: REBEL EM, 21 Sep 2026
LITFL adult intubation checklist
A clean, current adult emergency intubation checklist: prep, pause, plan B, post-intubation care. Pin it to the airway trolley. The version you last laminated in 2019 is not this version.
Source: LITFL, 20 Sep 2026
Spit, scratch, splash, stick: do you actually need PEP?
Four everyday ED and ICU exposures walked through with the only three questions that matter. Was the fluid capable of transmitting HIV? Did it reach a susceptible site? If both are yes, how fast can you start PEP? Spit in the eye is not a stick. A hollow-bore through a glove is. Start treatment, then chase the source serology.
Source: LITFL Microbial Mystery, 23 Sep 2026
DFTB: preterm enteral feeding without the folklore
Which milk, when to start, how fast to climb, when to stop. Trophic feeds early, UAC is not a veto, slow the climb if NEC risk is high. Useful even if you only cover the odd 29-weeker on the adult unit waiting for a neonatal transfer.
Source: Don’t Forget the Bubbles, updated 21 Sep 2026
Fluids / haemodynamics watch
ESICM shock guidelines, explained by one of the authors
Antonio Messina walks the 2025 ESICM circulatory shock and haemodynamic monitoring guideline. Serial tissue perfusion. Dynamic fluid-responsiveness tests. Targeted fluid, not liberal bags. Echo first to name the shock. Arterial line and cardiac output when the first moves fail. This is the haemodynamic document of the year. The podcast is the practical cut.
Source: ESICM Talk, 23 Sep 2026 · guideline: ICM 2025
Pre-induction crystalloid bolus: another negative
Covered above in the paper picks. It belongs here too. Giving volume to treat a vasodilation problem is still the most popular wrong move in the anaesthetic room and the resus bay.
Source: Anesthesiology RCT
VExUS is not dead just because the tricuspid leaks
Hepatic S-reversal in severe TR is not a reason to bin the exam. Portal pulsatility and femoral stasis still track decongestion when you take litres off. Waveform put this teaching back in the This Week pile on 23 Sep for a reason.
Source: NephroPOCUS · via Waveform This Week
Podcasts
EMCrit 434 – Temporary haemodialysis catheters
New episode, 21 Sep. Procedural, opinionated, immediately usable. If your unit still treats non-tunneled HD lines as a renal-registrar-only skill, this is the push.
Source: emcrit.org
ESICM Talk – 2025 shock and monitoring guidelines
Dropped 23 Sep. Messina on CRT, perfusion, fluid-responsiveness and when to escalate from echo to CO monitoring. Pair it with the paper and you have a teaching session.
Source: esicm.org
Critical Care Commute Season 6, live from CRUS WEST
Brindley and Byker opened the new season from CRUS WEST 2026 with a scrap about whether POCUS is a therapy or a fire alarm. The right question. An oximeter never cut mortality in an RCT either. We still use it.
Source: @CriticalCommute, 23 Sep 2026
No new ICSCast, ICU Dropouts or Block It Like It’s Hot episode landed in the last seven days. Last Block It was 6 Sep. Last ICSCast was late August.
Meetings / dates
LACTIC 2026, Leeds – 24–25 September
Happening now at the Queens Hotel. Cardiogenic shock, HCID, empyema, CT chest, vascular access, CVVHDF, BIS. If you are in Yorkshire this weekend, this is the room.
Source: FICM / LACTIC · booking: Clockwork Medical
ESICM: Refractory septic shock definition 2026 – 29 Sep, 16:00 CEST
Flavia Machado, Marc Leone, Daniel De Backer, chaired by Messina. What “refractory” means now, and what you do when the first stack fails. World Heart Day timing is not an accident.
Source: ESICM
ICS Inside Intensive Care: infection controversies – 30 Sep, 16:00 BST
Clinical metagenomics, SDD, and immunomodulation in sepsis. Shankar-Hari on the last of those. This is the UK infection argument of the autumn.
Source: Intensive Care Society
Organ Donation Week – 21–27 September
Jack Parry-Jones for FICM: refer early, do the brain-stem tests when they are possible, keep the physiology in range so the tests can actually happen. The four UK CMOs already said this in February. Do it.
Source: FICM, 24 Sep 2026
ESICM World Pharmacists Day webinar – 25 Sep, 14:00 CEST
Antimicrobials on ECMO and agitation kit in TBI. If you missed the live slot today, grab the replay when it lands.
Source: ESICM
From Waveform
Standouts from icuwaveform.grok.me this week. Go there for the live feed. These are the five that earned a second look.
Paper of the Day: Klug on CSF diversion after aSAH
CCR’s 25 Sep pick, sitting at the top of Waveform. Personalised drain strategy rather than unit habit. Full write-up in the paper picks above.
Source: Waveform · Critical Care paper
This Week: PulmCrit pulse-dose myth-bust
Waveform surfaced it on 23 Sep the same day it published. Highest educational yield FOAMed item of the week.
Source: Waveform This Week
This Week: 2025 ESICM shock and monitoring guideline
Not a 2026 rewrite. It is the document people are actually talking about again this week because the NEXT podcast dropped. Echo first. Fluids second. Monitor the ones who do not respond.
This Week: EURECA on cause of death in CNS infection
ICM scientific letter, 23 Sep. Neurologic versus systemic death is a useful split for the next meningitis death review.
Weekly news collated!
Close. That is the week. Pulse-dose scepticism, drains that match the anatomy, shock monitoring that starts with a probe rather than a bag, and a reminder that someone in the room should be able to put in a 12 Fr line at 03:00.
CCN crew. Read it, argue with it, send the good stuff on!
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