Critical Care Bulletin: August 2026

 

Intracranial pressure physiology, monitoring and individualized management in the acute brain injured patient

Intensive Care Medicine: Published: 29 July 2026

Abstract

Acute brain injury (ABI), including traumatic brain injury, ischemic and hemorrhagic stroke, is associated with high morbidity and mortality, which is driven not only by the primary brain injury, but also by the development of secondary cerebral insults. Among these, raised intracranial pressure (ICP) plays a central pathophysiological role, acting both as a consequence and a driver of ongoing brain injury through mechanical deformation and cerebral ischemia. Although invasive intracranial pressure (ICP) monitoring has a longstanding and ongoing role in neurocritical care management, the interpretation and clinical use of ICP remain controversial. Traditional management strategies rely on fixed ICP thresholds (e.g., > 22 mmHg) to trigger a standardized stepwise escalation of therapy; however, growing clinical evidence indicates that tolerance to ICP elevation varies widely across patients, disease entities, and physiological contexts. This review summarizes the physiological determinants of ICP, including intracranial compliance, cerebrospinal fluid dynamics, cerebral blood volume, and systemic factors, and describes the mechanisms underlying intracranial hypertension. We discuss limitations of using fixed ICP thresholds and highlight emerging concepts, such as ICP burden, waveform morphology, cerebral autoregulation, and functional brain monitoring, as tools to individualize ICP interpretation. The role of invasive and noninvasive ICP monitoring (nICP) modalities is reviewed, emphasizing the complementary value of nICP in guiding decision-making when invasive monitoring is unavailable or contraindicated. Particular attention is given to the integration of ICP within multimodal neuromonitoring frameworks assessing cerebral perfusion, oxygenation, and metabolism. Finally, we explore future perspectives, including the potential of artificial intelligence–based approaches to analyse complex neuromonitoring data, predict secondary insults, and move toward actionable, patientspecific therapeutic strategies. Collectively, these advances support a shift from a uniform, threshold-driven approach toward individualized, physiology-informed management of intracranial hypertension.

 

STARDaki: a consensus-based STARD extension for standardized reporting of diagnostic accuracy in acute kidney injury

Intensive Care Medicine: Published: 28 July 2026

Introduction

Biomarkers have been identified to predict, diagnose and prognosticate acute kidney injury (AKI) but existing studies are heterogenous and contradictory.

Objective

To compare diagnostic performance of AKI biomarkers, evaluate the quality of AKI biomarker studies and to develop standards for reporting studies of diagnostic test accuracy (DTA) of AKI biomarkers.

Methods

A systematic literature review was conducted to identify studies focusing on the diagnostic performance of AKI biomarkers published before February 2025. Retrieved DTA studies were assessed for methodological quality and completeness using the QUADAS-2 and Standards for Reporting Diagnostic Accuracy (STARD) 2015 checklists. An international 17 member expert panel was convened to agree consensus standards for AKI biomarker studies (STARDaki) via a modified Delphi process.

Results

122 DTA studies for AKI biomarkers were identified, but 15 were insufficiently reported. Of the remaining 107 studies, only 19 reported on diagnosis of AKI within 48 h of sampling. Of these studies, only 16 were considered high-quality based on the QUADAS-2 criteria. The compliance level with the STARD checklist was too low to permit meta-analysis. The expert panel agreed criteria for patient selection, reference standards, and reporting of test–retest reliability to supplement the STARD guidance for AKI biomarker studies.

Conclusion

Most studies examining AKI biomarker performance fail to conform to the STARD standards for reporting, leading to poor diagnostic accuracy estimates and reduced clinical applicability and generalizability. An expert panel proposed STARDaki criteria to advance the development and clinical use of AKI biomarkers (www.stardaki.icu).

 

Prone positioning in ARDS

Intensive Care Medicine: Published: 20 July 2026

Abstract

Over the past five decades, prone positioning has evolved from single case reports to an evidence-based intervention. Initially used as a rescue therapy, it is now recognized as an integral component of lung-protective mechanical ventilation strategies, applied early in intubated patients with acute respiratory distress syndrome (ARDS) with a PaO₂/F_IO₂ ratio < 150 mmHg. The COVID-19 pandemic further expanded its use to non-intubated patients, the so-called awake prone position (APP), with promising results. APP requires confirmation in non-COVID patients and in a more routine ICU practice. Improved oxygenation is a consistent and well-recognized effect of prone positioning in both intubated and non-intubated patients with ARDS. Beyond its effects on gas exchange, prone positioning mitigates ventilator-induced lung injury by reducing lung stress and strain and may also confer favorable hemodynamic effects. This article reviews the physiologic rationale for prone positioning, evidence from randomized controlled trials, current guideline recommendations, practical aspects of implementation, and ongoing questions in both intubated and non-intubated patients.

 

Persistent tissue hypoperfusion improves risk stratification beyond vasopressor dose in refractory septic shock: a secondary analysis of the ANDROMEDA-SHOCK-2 trial

Intensive Care Medicine: Published: 15 July 2026

Purpose

A recent Delphi consensus highlighted elements for defining refractory septic shock. We assessed whether integrating persistent tissue hypoperfusion with vasopressor dose after protocolized resuscitation improves mortality risk stratification compared with vasopressor dose alone.

Methods

We performed an exploratory secondary analysis of the ANDROMEDA-SHOCK-2 trial. After 6 h of hemodynamic resuscitation, refractoriness was operationalized as a norepinephrine equivalent dose (NEE) > 0.5 µg/kg/min plus an abnormal capillary refill time (> 3 s) and non-decreasing lactate (two-hypoperfusion criteria). A complementary analysis included NEE > 0.5 µg/kg/min combined with either of the tissue perfusion criteria. The primary outcome was 28-day mortality.

Results

Among 1363 patients with complete data, 188 (13.8%) had NEE > 0.5 µg/kg/min at 6-h, with 47.9% mortality. Fifty-three patients (3.9%) were classified as refractory septic shock under the two-hypoperfusion criteria and 124 (9.1%) under the ≥ 1-hypoperfusion criterion. Mortality was 73.6% (39/53) among patients meeting two-hypoperfusion criteria, compared with 23.7% (310/1310) among those classified as non-refractory according to these criteria. (aHR, 4.68; 95% CI 3.31–6.64;p < 0.001). Under ≥ 1-hypoperfusion criterion, mortality was 55.0% (68/124), compared with 22.7% (281/1239) among those classified as non-refractory under this approach (aHR, 2.62; 95% CI 1.90–3.46;p < 0.001). Refractory patients under either approach required had fewer life-support free days. Compared with NEE > 0.5 µg/kg/min alone, the two-hypoperfusion construct yielded superior prognostic enrichment for 28-day mortality (LR + , 8.12; 95% CI 4.70–14.03 vs. 2.71; 95% CI 2.10–3.50;p < 0.001).

Conclusion

In early septic shock, combining persistent tissue hypoperfusion with vasopressor dose improves risk stratification beyond vasopressor dose alone and identifies a subgroup with markedly increased mortality. These hypothesis-generating findings require validation in future studies.

 

Key principles for rehabilitation of critically ill patients with obesity

Intensive Care Medicine: Published: 17 July 2026

Purpose

Patients with obesity who are admitted to an ICU bring specific challenges for rehabilitation during and after critical illness. This narrative review explores impact of differences in body compositions and pathophysiology on outcomes to summarise interprofessional, patient-centred rehabilitation strategies across the trajectory of recovery.

Methods

The interprofessional expert panel reviewed major trials and guidelines, integrating their clinical expertise with the current evidence.

Results

Three distinct phenotypes potentially influence outcomes for survivors. Whilst patients with preserved muscle mass may have a survival advantage, the phenotypes characterised by ectopic visceral fat or sarcopenia are frequently complicated by multimorbidity and polypharmacy, likely increasing the risk of adverse effects such as suboptimal sedation, prolonged ventilation and immobilisation, malnutrition, and impaired recovery. Targeted respiratory interventions, including secretion-clearance techniques and appropriate patient positioning to prevent atelectasis, reduce the work of breathing. Optimisation of communication and swallowing function is an essential component for facilitating safe oral intake and promoting active patient participation in rehabilitation. Concurrently, targeted nutrition strategies combined with early, targeted, progressive mobilisation might mitigate ICU acquired weakness and support functional recovery. The availability of appropriate weight‑based equipment is fundamental to ensuring safe mobilisation for both patients and healthcare professionals.

Conclusion

Interprofessional collaboration is central to optimising outcomes and should extend beyond the ICU to structured post-ICU follow-up to address persistent, worsening, or newly emerging health impairments. Early rehabilitation in critically ill patients with obesity should integrate physiological, logistical, and psychosocial considerations to support equitable and functional recovery.

 

 

 

Antiseizure medication dosing and monitoring in the intensive care unit: a practical narrative review

Intensive Care Medicine: Published: 15 July 2026

Abstract

Purpose

Antiseizure medications (ASMs) are commonly used in the intensive care unit (ICU) and often exhibit pharmacokinetics that differ substantially from those in healthy volunteers or in the outpatient setting. Organ dysfunction, polypharmacy, exogenous devices, and greater severity of illness all influence ASM pharmacokinetics, dosing decisions, and monitoring parameters. It is essential for critical care clinicians to familiarize themselves with the pharmacokinetics, dosing considerations, effects of exogenous devices, and therapeutic drug monitoring (TDM)—all covered in this narrative review—to incorporate in their approach to ASMs in the critical care setting.

Methods

We identified relevant literature from MEDLINE from inception to March 2026 related to ASMs in the ICU. Data on pharmacokinetics, dosing in the ICU, the effect of renal replacement therapy, extracorporeal membrane oxygenation (ECMO), and plasmapheresis (PLEX) on ASM exposure, and the role of TDM in the ICU were collected and summarized.

Results

Considerations for 15 ASMs (brivaracetam, cannabidiol, carbamazepine, cenobamate, clobazam, lacosamide, lamotrigine, levetiracetam, oxcarbazepine, perampanel, phenobarbital, phenytoin, topiramate, valproate, and zonisamide) were included in the review. Dosing considerations for TDM, including indications and target reference ranges, and specific settings such as organ dysfunction, illness severity, renal replacement therapy, ECMO, and PLEX are discussed.

Conclusion

The use of ASMs in the ICU require a distinct approach from outpatient settings. Severity of illness, organ dysfunction and replacement devices, and frequent drug–drug interactions warrant tailored agent selection, dosing, and monitoring.

 

 

 

High-flow nasal cannula oxygen during breaks from noninvasive ventilation after extubation: an observational study

Intensive Care Medicine: Published: 13 July 2026

Abstract

Purpose

Clinical practice guidelines recommend prophylactic noninvasive ventilation (NIV) after extubation in high-risk patients. The effects of high-flow nasal cannula (HFNC) oxygen during breaks from NIV after extubation have been poorly explored. Our objective was to assess whether HFNC rather than standard oxygen during breaks from NIV may prevent extubation failure.

Methods

Observational study based on two multicenter clinical trials including patients at high-risk of extubation failure (> 65 years or with underlying cardiac or respiratory disease). We included the 1077 patients who received prophylactic NIV after extubation, alternating with HFNC (NIV/HFNC) or standard oxygen (NIV/O₂). The primary outcome was the proportion of patients who failed extubation (reintubation or death within the seven days following extubation). We used G-computation to estimate the causal effect of HFNC on the risk of extubation failure, while accounting for confounding factors.

Results

After extubation, 655 patients (61%) received NIV/HFNC while 422 (39%) received NIV/O₂. The extubation failure rate at day 7 was significantly lower with NIV/HFNC than with NIV/O₂ (13.7% vs. 18.5%; difference, − 4.7% [95% CI, − 9.4% to – 0.3%]; p = 0.036). Using G-computation, NIV/HFNC was not more effective than NIV/O₂ in reducing the risk of extubation failure, with an estimated adjusted difference of − 3.9% [95% CI, − 8.7% to 0.9%]. Reintubation rates were significantly lower with NIV/HFNC than with NIV/O₂ at 48h, but did not significantly differ beyond 48h.

Conclusions

Although the adjusted analysis did not confirm the favorable unadjusted findings, HFNC during breaks from NIV might decrease the risk of extubation failure, and warrants future clinical trials.

 

60 years of ARDS and the evolution of extracorporeal lung support – from ECMO to ECCO2R

 

Intensive Care Medicine  Published: 07 July 2026

 

Abstract

Extracorporeal life support (ECLS), including venovenous extracorporeal membrane oxygenation (VV-ECMO) and extracorporeal carbon dioxide removal (ECCO₂R), is an established treatment for selected patients with acute respiratory distress syndrome (ARDS). In this review, on the 60th anniversary of ARDS, we review the evolution of ECLS as a support strategy in ARDS, the evidence surrounding its efficacy, factors associated with prognosis, management of patients on ECLS, associated complications, and long-term outcomes among survivors. We also highlight existing areas of uncertainty, and ongoing clinical research that will define the next decade and beyond of ECLS for ARDS.

 

 

Lung- and diaphragm-protective mechanical ventilation in acute respiratory distress syndrome

Intensive Care Medicine  Published: 07 July 2026

Abstract

Lung-protective ventilation is the current standard for mechanical ventilation of patients with acute respiratory distress syndrome (ARDS). Traditionally, this approach has focused on the controlled phase of mechanical ventilation, but emerging data suggest that how patients are managed during assisted ventilation may also impact clinical outcomes. Experimental and observational clinical data indicate that excessive respiratory effort may further damage already injured lungs and may also lead to diaphragm myotrauma. Conversely, insufficient effort and prolonged passive ventilation are associated with diaphragm atrophy and dysfunction. Recent non-invasive techniques to monitor respiratory drive and effort at the bedside have facilitated the development of a new strategy to protect both the lungs and the diaphragm. The lung- and diaphragm-protective (LDP) ventilation framework highlights the need to better integrate ventilation and sedation strategies to facilitate timely and safe spontaneous breathing. This new paradigm has driven the development of emerging supportive and therapeutic modalities, such as diaphragm neurostimulation and partial neuromuscular blockade. Clinical trials are needed to evaluate the impact of LDP strategies on patient-centered outcomes, using designs that account for the possibility of heterogeneity of treatment effect in the ARDS population. In this review, we summarize the physiological background for the LDP framework, as well as the current clinical evidence evaluating this strategy.

 

Prehospital airway and ventilatory management: a collaborative and narrative review

Intensive Care Medicine Published: 02 July 2026

Purpose

Prehospital airway and ventilatory management is a frequent, high-stakes and technically demanding component of emergency care. Environmental constraints, limited resources, and variable provider experience make it particularly challenging, and prehospital care systems differ substantially across countries, from paramedic-based to physician-led models, contributing to heterogeneity in clinical practices and patient outcomes. In this narrative review, we discuss evidence-based best practice, including indications, timing, physiological optimization, procedural conduct, and post-intubation management of prehospital tracheal intubation or non-invasive ventilation and high-flow nasal oxygen.

Methods

Tracheal intubation remains the definitive airway management strategy when performed for appropriate indications by adequately trained providers. Indications span major trauma, traumatic brain injury, out-of-hospital cardiac arrest, and comatose patients, though its role in comatose poisoned patients is increasingly questioned. Physiology optimization before intubation is a critical and frequently underappreciated determinant of outcome, encompassing preoxygenation with non-invasive positive pressure ventilation, bag-valve-mask ventilation between induction and laryngoscopy, and careful sedative selection to limit peri-intubation hemodynamic compromise.

Results

When intubation fails, a structured escalation strategy including videolaryngoscopy, supraglottic airway devices, and emergency front-of-neck access must be rehearsed and immediately available. In out-of-hospital cardiac arrest, supraglottic airways represent a valid primary alternative with equivalent neurological survival and faster placement. Non-invasive ventilation (primarily CPAP and BiPAP) has a well-established role in acute cardiogenic pulmonary edema and COPD exacerbations, reducing intubation rates and mortality. High-flow nasal oxygen is an emerging modality with strong in-hospital evidence, but prehospital data remain extremely limited and logistical constraints restrict its routine use. Non-invasive support must never delay intubation when clinical deterioration demands it.

Conclusion

Specific contexts require tailored adaptations: altitude physiology in helicopter transport, obesity-specific positioning, cervical spine precautions in neurological injury, comfort-focused strategies in palliative patients, and proactive stabilization before prolonged transport. Evidence gaps remain, particularly regarding prehospital high-flow nasal oxygen.

Critical Care Bulletin: May 2026

 

Effects of out-of-bed armchair positioning on oxygenation in spontaneously breathing ICU patients receiving respiratory support: a randomized controlled trial

Intensive Care Medicine: Published: 18 May 2026

Purpose

Comparing the effects of an out-of-bed armchair position versus an in-bed semi-recumbent position on oxygenation in spontaneously breathing intensive care unit (ICU) patients, receiving respiratory support is a common practice with limited supported evidence.

Methods

A single-center randomized controlled trial in spontaneously breathing adult ICU patients receiving invasive pressure support ventilation, high-flow nasal oxygen, or non-invasive ventilation. Patients were assigned to armchair or semi-recumbent in-bed positioning for 3 h. Arterial blood gasses were obtained immediately before and after positioning. PaO₂/FiO₂ (P/F) changes were analyzed with a linear mixed-effects model including group, time, and their interaction, adjusted for stratification variables.

Results

284 patients were randomized (146 and 138 in the armchair and bed groups, respectively). Baseline P/F ratios did not differ between groups. A significant interaction between group and time was observed (p = 0.002). In the armchair group, the P/F ratio increased by 13 mm Hg (95% CI 1–24), whereas it decreased by 13 mm Hg (95% CI − 25 to − 1) in the bed group. The post-positioning marginal mean P/F ratio was higher in the armchair group (241 mm Hg, 95% CI 214–268) than in the bed group (206 mm Hg, 95% CI 179–233; p = 0.004). No serious adverse events occurred. Minor adverse events were more frequent in the armchair group but had minimal impact on positioning duration.

Conclusion

In spontaneously breathing ICU patients receiving respiratory support, out-of-bed armchair positioning was associated with higher oxygenation after 3 h than remaining in a semi-recumbent position, with no serious adverse events observed.

 

 

The FICUS cluster randomized controlled trial of a family support intervention in adult intensive care units: mental health and family functioning outcomes

Intensive Care Medicine: Published 18 May 2026

Purpose

To examine the effect of a multicomponent, nurse-led, interprofessional family support intervention on family functioning and mental health in adult intensive care units (ICUs).

Methods

A cluster-randomized controlled trial in 16 Swiss ICUs compared an intervention—a family care pathway with specially trained ICU family nurses engaging and liaising with families, giving psychoeducational and relationship-focused care, and providing structured, interprofessional communication—to usual care. Family members of patients with an expected ICU stay of ≥ 48 h and a high risk of death, serious impairment, or prolonged mechanical ventilation participated. Outcomes included family functioning, resilience, life satisfaction, quality of life, distress, anxiety, depression, and posttraumatic stress, assessed at patient ICU admission, discharge, 3-, 6-, and 12 months post-ICU, and analyzed by linear mixed effects models.

Results

Almost half (43%) of the invited family members participated (885; May 2022 to January 2024). Follow-ups were completed on time by 736 (83.2%), 665 (75.1%), 643 (71.6%), and 593 (67.0%), respectively. Between 609 and 613 were included in the analysis. Family member characteristics were comparable at baseline, yet patient mechanical ventilation (60.3 vs. 49.5%) and ICU death (19.9 vs. 13.2%) were higher in the intervention than the control arm. There was no significant difference between the study arms for any of the outcomes. Type of relationship, prior ICU experience, and patient mechanical ventilation were associated with some of the outcomes. Mental health systematically improved post-ICU.

Conclusion

No evidence of a significant improvement in family functioning or mental health was found within the first year after ICU treatment. Due to limitations, the results of our study have to be interpreted cautiously and in a hypothesis-generating manner.

 

 

Reproducible clinical archetypes in acute respiratory failure: a multi-cohort trajectory analysis

Intensive Care Medicine: Published 17 May 2026

Purpose

Acute hypoxemic respiratory failure (AHRF) is common and biologically heterogeneous. Static phenotyping at a single time point does not capture illness evolution and risks stage-mixing; reproducible clinical course archetypes may address this. We aimed to identify, externally validate, and predict trajectory classes (TCs) of persistent AHRF.

Methods

We analyzed MIMIC-IV (derivation; n = 3938) and two external validation cohorts (UK/Netherlands; n = 6480) comprising adults with PaO₂/FiO₂ < 300 mmHg and PEEP ≥ 5 cmH₂O for ≥ 72 h. Daily mean PaO₂/FiO₂ to day 14 and time to ICU discharge/death were jointly modelled using a competing-risk latent class mixed model. Early TC prediction used a 12-variable XGBoost model. We explored prevalence of ARDS and hyperinflammatory subphenotypes between TCs.

Results

A four-class model provided optimal fit: (TC1) early recovery (0.3% 14-day mortality); (TC2) stable persistence (8% 14-day mortality); (TC3) biphasic improvement–deterioration (17% 14-day mortality); and (TC4) rapid decline (100% 14-day mortality). These archetypes generalized to external cohorts with high assignment certainty. TCs demonstrated distinct patterns in other clinical biomarker trajectories. TC4 was enriched for the hyperinflammatory subphenotype (41–53%), while TC2 was most common in patients with ARDS (50%). Early TC prediction models achieved mean AUCs ≥ 0.78 (0.70–0.86) by day 3 in external validation.

Conclusions

Four reproducible oxygenation archetypes capture the 14-day course of persistent respiratory failure. By providing early prognostic value distinct from static baseline severity, these trajectories have the potential to guide therapeutic strategies, reduce patient heterogeneity in trials, and direct biological phenotyping.

 

 

Airway management in critically ill patients with obesity

Intensive Care Medicine: Published: 13 May 2026

Abstract

Obesity is a global health challenge. An increasing number of patients with obesity are admitted to an intensive care unit. Airway management in these patients represents a unique challenge due to significant anatomical and physiological alterations. Increased adipose tissue in the face, cheeks, pharynx, hypopharynx, and neck narrows the upper airway, renders soft tissues more collapsible, and complicates airway management. In addition, the functional residual capacity is reduced, resulting in markedly shortened safe apnea time, contributing to severe hypoxemia during intubation. Non-invasive ventilation is effective in mitigating this risk and should be applied from pre-induction to laryngoscopy. Peri-intubation physiological optimization should include assessment of preload and cardiac contractility, with careful consideration of right ventricular strain. The transition from negative to positive intrathoracic pressure should be closely monitored, with cautious titration of positive end-expiratory pressure. Recognition of these anatomical and physiological challenges may prompt clinicians to consider awake intubation in selected patients. When rapid sequence induction is performed, both ketamine and etomidate are appropriate options; the choice between them should be guided by the clinical context, patient characteristics, local practice patterns and availability. Videolaryngoscopy increases the incidence of successful intubation on the first attempt and should be adopted routinely in the population with obesity. Several questions remain unanswered, including the safety and efficacy of pre-emptive vasopressor use to prevent post-intubation cardiovascular collapse and the optimal dosing of hypnotic agents to achieve ideal intubation conditions, while minimizing adverse events.

 

Standard of care for rehabilitation in critical illness

Intensive Care Medicine: Published: 30 April 2026

Background

Rehabilitation is recognised as a cornerstone of intensive care, essential for optimising functional recovery and reducing long-term disability. Contemporary ICU populations, characterised by advanced age, multimorbidity, and prolonged stays, are at heightened risk of muscle wasting, immobility, frailty, cognitive decline, and functional dependence. Mitigation of these sequelae requires careful interprofessional collaboration for person-centred rehabilitation across the care continuum.

Content

This review synthesises evidence from randomised controlled trials, meta-analyses, and clinical practice guidelines on rehabilitation during and after intensive care. Best practice within the ICU begins with early awakening and mobilisation with evidence demonstrating that physical rehabilitation is safe, with low adverse-event rates. Furthermore, multiprofessional strategies that span across ICU, ward, and community are required to address complex problems including physical, cognitive, and psychological sequelae of critical illness.

Future directions

Research priorities include detailed reporting of intervention dose (timing, intensity, duration) for both usual care and rehabilitation provided within clinical trials, and development of intervention implementation strategies that enhance uptake and fidelity in routine practice.

Conclusion

Rehabilitation is integral to contemporary ICU care, spanning the trajectory of recovery into the community. Within the ICU, it requires interprofessional, experienced healthcare personnel to assess clinical status for safe rehabilitation and to identify an individual’s anticipated recovery trajectory. Standardised intervention reporting and implementation-focussed research are essential to advance evidence and improve outcomes for critically ill patients.