Top Hot Critical Care Trials, Papers & Guidelines!
Here is edition 5 of the hottest critical care trials and papers. These papers are generating buzz across sites like Critical Care Reviews, EMCrit/PulmCrit, REBEL EM, LITFL, The Bottom Line, and many others. A huge thank you, as always, to the incredible curators in the FOAMed community — you know who you are!
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Click the buttons, then the pics for the trial / paper / guideline to read more!
SURVIVING SEPSIS CAMPAIGN GUIDELINES 2026
The landmark 2026 update to the Surviving Sepsis Campaign guidelines — 129 statements, 46 entirely new. The 69-person panel represented 23 countries. This is the most important sepsis document of the year and is dominating #FOAMcc and #CritCare discussions globally.
Key talking points:
- Procalcitonin to guide stopping (not starting) antibiotics
- A nuanced approach to non-invasive vs invasive blood pressure monitoring in shock
- A continued recommendation against polymyxin B haemoperfusion and IV vitamin D for sepsis.
TIGRIS — Polymyxin B Haemoadsorption in Endotoxic Septic Shock
Multicentre, open-label, Bayesian, phase 3 RCT testing polymyxin B haemoadsorption in sepsis and associated MOF. The 28-day Bayesian primary analysis was favourable for safety and efficacy, and there may have been a 90-day mortality signal for improvement.
However, the SSC 2026 guidelines still recommend against routine use — open-label design, small sample, and sensitivity to prior selection temper enthusiasm. Splitting opinion on #FOAMcc: Bayesian believers vs frequentist sceptics.
PRONTO — Procalcitonin + NEWS2 for Sepsis in the ED
This multicentre, phase 3 RCT across England and Wales evaluated whether combining procalcitonin testing with NEWS2 improved sepsis identification and antibiotic initiation in the ED compared to NEWS2 alone. A pragmatic, real-world UK trial directly relevant to emergency and critical care practice everywhere. Widely discussed on #FOAMed and #EmergencyMedicine — does adding a biomarker actually change what we do?
PHIND — Bedside Identification of ARDS Subphenotypes
A landmark step toward precision medicine in ARDS. This prospective, multicentre UK NHS cohort study prospectively identified the well-described hyperinflammatory and hypoinflammatory ARDS subphenotypes in real time at the bedside. The two groups showed significantly different 60-day mortality. The companion editorial calls this a genuine stride toward subphenotype-guided therapy, where different patients might need fundamentally different management. Major buzz in ARDS and #CritCare circles.
R2D2-ICU — Restrictive vs Liberal Physical Restraint in the ICU
A genuinely important and underappreciated topic. This French multicentre RCT compared a restrictive approach to physical restraints (only in severe agitation, RASS ≥+3) versus systematic restraint use in mechanically ventilated ICU patients. The results, presented at ISICEM Brussels, challenge routine restraint practice in many units globally. Important for all ICU nurses and intensivists to know about, patient dignity and delirium outcomes both in the frame.
INSPIRE — Anakinra for Pneumonia to Prevent Organ Dysfunction
Precision immunotherapy for pneumonia – this double-blind, placebo-controlled phase IIa RCT used a presepsin-guided strategy to identify patients with IL-1 activation and treated them with subcutaneous anakinra (IL-1 receptor antagonist) for 10 days. The primary endpoint (progression to organ dysfunction by day 7 or death by day 90), was significantly reduced in the anakinra group. Small but potentially practice-changing in the direction of travel. Generating considerable discussion on #MedEd and #CritCare.
REMAP-CAP — Hydrocortisone for Severe Non-COVID CAP: Futile?
This eagerly awaited result from the REMAP-CAP corticosteroid domain stopped early for futility — a fixed 7-day course of hydrocortisone showed no significant mortality benefit in ICU patients with severe non-COVID community-acquired pneumonia. This directly contradicts the CAPE-COD trial (which showed benefit) and has reignited passionate debate about corticosteroids in CAP. The Bottom Line, PulmCCM, and St Emlyn’s have all covered this extensively. Do steroids work in CAP or not? The jury is truly still out.
BETAMETHASONE-CAP — Corticosteroids for Mycoplasma Pneumoniae CAP
Hot off the press. This Swedish multicentre RCT found that adjunctive betamethasone hastened resolution of hypoxaemia in hospitalised adults with Mycoplasma pneumoniae community-acquired pneumonia. A timely finding given the ongoing CAP steroid debate above. Caveats: open-label, only 70 patients, and unclear applicability to other pathogens. Read alongside REMAP-CAP for the full picture.
BUFFERED CRYSTALLOIDS vs SALINE — Updated Cochrane Review 2026
The 2026 Cochrane update on buffered solutions versus 0.9% saline for resuscitation in critically ill adults and children lands as the balanced-vs-saline debate rumbles on in every ICU worldwide. With SMART, PLUS, BaSICS, and PLUS all in the mix, this synthesis matters. A must-read for anyone still debating their default fluid — and it will inevitably reignite Twitter/X arguments. Watch the #FOAMcc feed.
SCCM GUIDELINES — Caring for Older Adults in the ICU 2026
Brand new SCCM guidelines addressing the unique needs of patients aged 65 and over in critical care — a rapidly growing ICU population. Five key clinical questions tackled, centred around the “4Ms” framework: What Matters, Medications, Mentation, and Mobility. Emphasises geriatric models of care, hearing and cognitive assessments, delirium prevention, and goals of care conversations. Essential reading as our ICU population ages. Discussed on #ICUMedicine and #MedEd.
REFRACTORY SEPTIC SHOCK — SCCM/ESICM Delphi Consensus Definition
A joint SCCM and ESICM Delphi consensus formally defines refractory septic shock for the first time. A clinical entity everyone recognises but no one has agreed on. Without a standardised definition, trial design and clinical protocols are virtually impossible. This is the essential first step toward better evidence and better care in the sickest septic patients. Pair with Episode 4’s refractory shock review for context.
ICP TREATMENT THRESHOLDS IN PAEDIATRIC TBI
What intracranial pressure threshold should we be treating in children with traumatic brain injury? This study (Agrawal et al.) interrogates the evidence behind the thresholds embedded in paediatric TBI guidelines, where adult data has long dominated. Critically important for any unit managing children with severe head injury — and a reminder that children are not small adults. Generating discussion in #ICUMedicine and neurocritical care communities.
ACID-BASE STATUS DURING VA-ECMO IN CARDIOGENIC SHOCK
Acid-base derangements during venoarterial ECMO are common but poorly characterised. This study (Dahiya et al.) examines the patterns and clinical significance of acid-base status in VA-ECMO-supported cardiogenic shock patients. As ECMO use expands globally, understanding its metabolic consequences is increasingly important. A niche but important paper getting traction in the cardiogenic shock and ECMO #FOAMcc community.
CHLORHEXIDINE BATHING IN ICU — Updated Meta-Analysis
Does daily 2% chlorhexidine bathing reduce mortality and ICU length of stay compared to soap and water? This updated systematic review and meta-analysis (Souza Júnior et al.) gives us the most comprehensive answer yet. A practical infection control question affecting every ICU nurse and intensivist daily. Watch the #ICUnurse feed for reactions.
STARRT-AKI PHOSPHATE POST HOC — Hypophosphatemia and Ventilator-Free Days
This post hoc analysis of the landmark STARRT-AKI trial asks whether hypophosphatemia during kidney replacement therapy impacts ventilator-free days. Electrolyte management during CRRT is often under-appreciated yet clinically impactful — phosphate depletion during CRRT is common and the downstream respiratory consequences matter. Interesting nephrocritical care data generating discussion on #ICUMedicine.
LEVOSIMENDAN PK DURING ECMO — Drug Sequestration in Cardiogenic Shock
Levosimendan is increasingly used in cardiogenic shock but its pharmacokinetics during ECMO support are unpredictable. This paper (Tebib et al.) highlights key challenges including drug sequestration in the ECMO circuit and metabolite formation — raising the question of whether standard dosing achieves therapeutic levels during ECMO support. Clinically important for anyone using levosimendan in their cardiogenic shock protocol alongside VA-ECMO.
HFNC vs HELMET CPAP IN ACUTE HYPOXAEMIC RESPIRATORY FAILURE
The ongoing debate between high-flow nasal oxygen and helmet CPAP in acute hypoxaemic respiratory failure continues with new data (Coppola et al.). Which modality reduces intubation rates and improves outcomes — and in which patients? As non-invasive respiratory support options multiply, knowing which tool to reach for first matters. A hot topic in #FOAMed respiratory circles and directly relevant to ED and ICU practice.
HOST-DIRECTED PRECISION PHARMACOTHERAPY IN SEPTIC SHOCK
Moving beyond antibiotics — this framework paper (Cheng et al.) proposes a precision pharmacotherapy approach targeting the host response in septic shock, rather than just the pathogen. Covers immune checkpoint inhibitors, cytokine-targeted therapies, and emerging strategies. As the microbiome, genomics, and endotyping enter mainstream critical care thinking, this provides a useful conceptual map for where the field is heading. Thought-provoking #FOAMcc and #MedEd reading.
PREHOSPITAL ECPR IN REFRACTORY OUT-OF-HOSPITAL CARDIAC ARREST
Prehospital extracorporeal cardiopulmonary resuscitation (ECPR) for refractory out-of-hospital cardiac arrest is gaining momentum globally, but who is truly eligible, and are retrospective eligibility studies misleading us? The paper above reports findings, but interestingly, a reply from Hung et al. challenges how we should assess and report ECPR eligibility, with important implications for service design. A rapidly evolving area generating significant #ResuscitationMed and #FOAMed discussion.
Quick Hits from the Trenches:
- Huge X/social media buzz around SSC 2026 guidelines — especially the procalcitonin and vasopressor monitoring recommendations
- PHIND driving excited discussion about precision medicine finally arriving in ARDS
- TIGRIS splitting opinion — Bayesian believers vs sceptics on #FOAMcc
- REMAP-CAP CAP steroid futility result has reignited the hydrocortisone-in-pneumonia debate
- R2D2-ICU quietly challenging restraint culture in ICUs worldwide
- The Cochrane fluids review predictably reigniting the great balanced crystalloid debate
Stay tuned for Episode 6!
JW and Team x
