Here is edition 6 of the hottest critical care trials and papers 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 all the incredible curators in the FOAMed community — you know who you are!
BWGAF -Before We Go Any Further!
We wanted to highlight a rather special paper this week!
It may happen to be our own!
We challenge traditional pressure-centric teaching of cardiovascular physiology and put forward a clearer, more coherent framework for understanding blood flow in anaesthesia and critical care. We argue that the heart primarily supplies the energy for circulation, while vascular volume, elastance, compliance, impedance, and pulsatility determine what flow is possible. Key concepts like mean systemic pressure, right atrial pressure, preload, and venous return curves are reframed: pressures largely reflect the equilibrium state of the system rather than actively driving flow.
We highlight how we are over-reliant on static pressure targets (e.g., central venous pressure) and this has often led to physiological confusion and potentially harmful interventions that increase congestion without improving perfusion. Interventions in the critically ill should be guided by flow responsiveness, cardiac reserve, and dynamic assessment for better haemodynamic management in perioperative and critically ill patients. Our unified model reconciles longstanding debates and provides a practical foundation for contemporary shock management.
See also our Tweetorials on the facets of flow, pressure and volume in the cardiovascular system!
Jump Links!
Click the buttons, then the pics for the trial / paper / guideline to read more!
CARDIAC SURGERY BLEEDING META-ANALYSIS |
LIBERATE-D
iREHAB — Remote Rehabilitation in ICU Survivors
JAMA — Published May 18th 2026
Hot off the press — this is the paper of the month. The iRehab trial, a multicentre UK NHS RCT, evaluated whether a 6-week remote multicomponent rehabilitation programme (weekly video/telephone appointments, home exercise sessions, and online peer support) improved health-related quality of life in survivors of critical illness after hospital discharge, compared to standard care. With post-intensive care syndrome affecting the majority of ICU survivors, this is exactly the kind of pragmatic, patient-centred trial the field has needed. Co-chief investigator Prof Danny McAuley calls the results a platform to now deliver this care to those who benefit, while finding personalised treatments for those who don’t. Generating enormous buzz across #FOAMed and #ICUMedicine.
TOWAR — Prehospital Type O Whole Blood vs Components in Traumatic Haemorrhage
NEJM — Published May 18th 2026
The TOWAR trial — Type O Whole blood and Assessment of Age during prehospital Resuscitation — enrolled 1,020 severely bleeding trauma patients transferred by medical helicopter across multiple US centres, randomised 2:1 to whole blood or standard blood components. The result? No significant difference in 30-day mortality between the two arms, with roughly one in five patients dying in each group. As whole blood programmes expand globally, this result will temper some of the enthusiasm. Read alongside SWiFT (below) for the full picture on prehospital whole blood.
SWiFT — Prehospital Whole Blood in UK Major Trauma: Also Negative
NEJM — Published March 2026
A one-two punch on prehospital whole blood. The SWiFT trial ran across 10 UK air ambulance services and randomised 942 patients with major traumatic haemorrhage to whole blood (up to 2 units) or standard component therapy. The primary composite outcome — death or massive transfusion within 24 hours — occurred in 48.7% vs 47.7%. No meaningful difference. Two large RCTs, two negative results. The whole blood vs components debate in prehospital trauma care just got a lot more complicated.
SDD — Updated Bayesian Meta-Analysis: 99.2% Probability of Mortality Benefit
NEJM Evidence — Published April 2026
The eternal SDD debate roars back to life. This updated systematic review and Bayesian meta-analysis now incorporates 32 RCTs involving 27,687 patients. The pooled relative risk of hospital mortality for SDD versus usual care was 0.91, and there is a 99.2% posterior probability that SDD is associated with reduced in-hospital mortality. The accompanying NEJM editorial frames this starkly: SDD is the “elephant in the room” in critical care. Yet barely any ICUs outside the Netherlands practice it. Will this finally shift the needle on a 40-year controversy?
EDTA Central Line Lock — 4% Tetrasodium EDTA vs Usual Care
JAMA — Published May 18th 2026
Fresh from JAMA alongside iRehab and TOWAR. This RCT (Ornowska et al.) evaluated whether a locking solution containing 4% tetrasodium EDTA reduced central venous access device complications compared with usual care in ICU patients — targeting the composite of CVAD-associated bloodstream infection, catheter occlusion requiring alteplase, and catheter removal due to occlusion. A highly practical infection control question relevant to every ICU nurse and intensivist managing central lines daily. Results generating immediate discussion on #ICUnurse and #FOAMed.
Protein Dose and Muscle Protein Synthesis in Critical Illness — RCT
American Journal of Respiratory and Critical Care Medicine — 2026
Does giving more protein actually increase muscle protein synthesis in critically ill patients? This RCT (Summers et al.) directly measures muscle protein synthesis rates and finds that increasing protein dose beyond a threshold does not further augment synthesis. A potentially practice-changing finding for ICU nutritionists and intensivists alike — particularly relevant given the trend toward high-protein feeding in critical illness. Challenging a key assumption underpinning current feeding guidelines and generating considerable #FOAMed debate.
TTM2 — 2-Year Long-Term Outcomes After Cardiac Arrest
JAMA Neurology — 2026
The 2-year follow-up data from the landmark TTM2 trial (targeted hypothermia vs targeted normothermia after out-of-hospital cardiac arrest) is in. This follow-up of the randomised cohort examines long-term neurological and functional outcomes and recovery trajectories, going well beyond the 6-month data previously reported. How do patients who survive to hospital discharge fare over 2 years? As post-cardiac arrest care evolves, understanding long-term survivorship is crucial. Essential reading for anyone involved in post-resuscitation care and #FOAMcc.
SuDDICU-International — Full Trial Results: Still No Significant Mortality Benefit
NEJM — Updated April 2026
The full international data from the SuDDICU trial — now including the Canadian sites alongside the previously reported Australian data — is the trial that prompted the updated meta-analysis above. Across 9,280 patients, SDD did not significantly reduce in-hospital mortality (27.9% vs 29.5%, OR 0.94, 95% CI 0.84–1.05). The individual trial is negative; the 32-trial Bayesian meta-analysis is overwhelmingly positive. Read both together and decide for yourself. This is exactly the kind of evidence tension that defines modern critical care.
PRIME-AIR — Perioperative Lung Expansion Bundle After Open Abdominal Surgery: Negative
Lancet Respiratory Medicine — 2025/2026
This phase 3 multicentre RCT across 17 US academic hospitals tested a comprehensive perioperative lung expansion bundle — preoperative education, individualised intraoperative PEEP, optimised neuromuscular blockade reversal, and postoperative incentive spirometry and early mobilisation — against usual care in patients at moderate-to-high risk of postoperative pulmonary complications undergoing major open abdominal surgery. The result? No significant reduction in PPC severity by day 7. Important for anaesthetists, intensivists, and perioperative teams, and prompting reappraisal of lung protection strategies.
Driving Pressure in ARDS — Updated Meta-Analysis of RCTs
Intensive Care Medicine — April 2026
This meta-analysis (Agrafiotis et al.) pools the RCT evidence on driving pressure-limiting ventilation strategies in patients with ARDS. Driving pressure has been a dominant concept in ARDS ventilation since the landmark 2015 Amato observational study — but does actively targeting it as an intervention improve outcomes? This synthesis provides the clearest RCT-level answer yet. A must-read for anyone managing ventilated ARDS patients and directly relevant to everyday ICU practice.
Cardiorenal Syndrome Type 2 — RRT vs Conservative Management: RCT
ESC Heart Failure — Published May 2026
This RCT (Schleef et al.) directly tackles one of the most contentious questions in cardiorenal medicine: should patients with type 2 severe cardiorenal syndrome receive renal replacement therapy or conservative management? RRT in this population is common but evidence-poor. A genuinely difficult clinical dilemma where objective data has long been lacking. Generating discussion across #ICUMedicine and the cardiology-critical care interface.
Blood Pressure Targets After Endovascular Thrombectomy — Meta-Analysis
Journal of the American Heart Association — April 2026
What blood pressure target should we be aiming for in patients after successful endovascular thrombectomy for acute ischaemic stroke? This meta-analysis (Hashmi et al.) of RCTs comparing intensive versus standard blood pressure control post-thrombectomy provides important evidence for a clinically ubiquitous but protocol-variable decision. Neurocritical care and stroke teams are paying close attention — directly relevant to any unit managing post-thrombectomy patients.
Surviving Sepsis Campaign — Paediatric International Guidelines 2026
Intensive Care Medicine — Published March 2026
Alongside the adult SSC 2026 guidelines from Episode 5 comes the long-awaited 2026 paediatric update. A comprehensive revision of evidence-based recommendations for the management of sepsis and septic shock in children — covering recognition, fluid resuscitation, vasopressors, antimicrobials, and adjunctive therapies in neonates, infants, and children. Essential for any critical care unit managing paediatric patients and for paediatric intensivists globally.
BALTIC Trial — Extended Barrier Precautions vs Hand Hygiene in Neonatal ICU Sepsis
JAMA Network Open — May 2026
This cluster-randomised trial (Faust et al.) compares extended barrier precautions against hand hygiene alone for prevention of neonatal sepsis in intensive care patients. Healthcare-associated infections in neonatal ICU remain a major cause of morbidity and mortality worldwide, and this is one of the few high-quality RCTs addressing infection prevention in this vulnerable population. Practice-relevant for all neonatal ICU teams and infection control specialists.
CHG Dressings in Paediatric ICU — Prevention of CLABSI
Paediatric Critical Care Medicine — 2026
This RCT (Portero-Prados et al.) evaluates the effectiveness of chlorhexidine gluconate-impregnated dressings in preventing central line-associated bloodstream infection in a paediatric ICU. CLABSI remains one of the most important preventable complications in any ICU — and evidence in children specifically is more limited than in adults. A practical, implementable intervention examined with high-quality trial methodology.
Automated Oxygen Titration in Infant Bronchiolitis — Multicentre RCT
Archives of Disease in Childhood — Published May 2026
Automated oxygen flow titration versus manual titration in infants with bronchiolitis: does the robot do it better? This multicentre RCT (Cros et al.) tests automated closed-loop oxygen delivery in a notoriously resource-intensive but common paediatric condition. Hypoxaemia management in bronchiolitis can tie up significant nursing time — if automation is safe and effective, the implications for ward and HDU care are significant. Discussed widely in #FOAMed and paediatric critical care circles.
FIRST-ABC Step Down — HFNO vs CPAP After Extubation in Children
Critical Care Reviews Livestream / Journal — 2026
This eagerly awaited paediatric trial from Padmanabhan Ramnarayan and Alvin Richards-Belle compares high-flow nasal oxygen with continuous positive airway pressure in recently extubated children — the “step down” phase of respiratory support. Post-extubation respiratory failure is one of the most important avoidable complications in PICU, and the optimal non-invasive support strategy remains debated. Generating significant discussion in paediatric critical care communities and featured at a Critical Care Reviews Livestream event.
Prehospital ECPR — Should Retrospective Eligibility Studies Guide Service Design?
Scandinavian Journal of Trauma, Resuscitation & Emergency Medicine — 2026
This paper (Hung et al.) challenges how we assess ECPR eligibility retrospectively — a methodology used to justify and design prehospital ECPR services worldwide. The argument: patients deemed eligible retrospectively may not reflect true real-time eligibility, introducing systematic optimism into service planning. An important methodological critique for a rapidly expanding intervention with enormous resource implications. Generating debate in #ResuscitationMed and #FOAMed communities.
Movements During General Anaesthesia and Psychologically Traumatic Awareness — The Efference Copy Network
Anesthesia & Analgesia — May 2026
A fascinating and important review for anyone working in anaesthesia or critical care. Drawing on NAP5 data — the largest ever study into accidental awareness during general anaesthesia (AAGA) — this paper explains why AAGA is virtually confined to cases where neuromuscular blockade is used (1 in 8,000 vs 1 in 136,000 without NMB), and why the inability to move is so psychologically devastating. The authors invoke the “Efference Copy Network” to explain the neurological basis of this distress: paralysis, not pain, was the dominant source of trauma for patients, with feelings of entombment and subsequent PTSD. A thought-provoking read that should inform how we discuss NMB and awareness risk with patients preoperatively, and how we support survivors.
LIBERATE-D — Conservative Dialysis Strategy in AKI Requiring Dialysis
JAMA — 2026
This RCT evaluates a conservative approach to dialysis in patients with AKI requiring renal replacement therapy. The conservative strategy was associated with improved kidney recovery and reduced long-term dialysis dependence — a clinically vital outcome given the high rates of dialysis dependence seen in AKI survivors. Important for nephrologists, intensivists, and anyone involved in the decision of when and how aggressively to initiate and continue RRT in critically ill patients. Generating significant discussion on #ICUMedicine.
Quick Hits from the Trenches
- iRehab generating real excitement about the future of post-ICU survivorship — finally a practical, scalable intervention for PICS
- TOWAR + SWiFT double negative results cooling enthusiasm for prehospital whole blood programmes; expect fierce debate at upcoming trauma conferences
- SDD Bayesian meta (99.2% probability of benefit) vs negative SuDDICU trial creating major #FOAMcc tension — the elephant in the room just got bigger
- Protein dose RCT challenging assumptions behind high-protein ICU feeding protocols
- Strong paediatric representation this month: FIRST-ABC Step Down, BALTIC, automated oxygen, and CHG dressings all merit attention
Stay tuned for Episode 7!
JW and Team x
