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.

 

 

 

Non-invasive intracranial pressure estimation in the intensive care unit: narrative review of methods and clinical applications

Intensive Care Medicine: Published: 27 April 2026

Abstract

Despite invasive methods are the gold standard for intracranial pressure (ICP) measurement, several non-invasive techniques (nICP) have been proposed as surrogate, although their use remains insufficiently recognized in clinical practice. These include transcranial Doppler blood flow velocity  assessment (arterial or venous), optic nerve sheath diameter (ONSD), automated pupillometry, measurement of skull expansion and compliance, brain imaging, double-depth ophthalmic artery blood flow velocity, and ultrasound time-of-flight. The main limitations of all indirect methods are calibration and zeroing, which constrain the absolute accuracy of non-invasive ICP monitoring. For transcranial Doppler-based methods, the 95% limits of agreement are approximately ± 7–15 mmHg, while for ONSD-based techniques they range from ± 7–10 mmHg. Improved predictive accuracy may be achieved by combining different modalities and applying advanced signal analysis techniques. Importantly, in patients with acute brain injury, nICP can complement invasive monitoring by guiding patient selection for urgent monitoring, facilitating brain assessment in moderate traumatic brain injury, and assisting management in patients with coagulopathy. In the general intensive care population, nICP may provide valuable information after cardiac arrest, liver failure, and sepsis. In the emergency department, early detection of intracranial hypertension helps prevent missing the “golden hour” of brain care. Finally, nICP is particularly relevant in low-resource settings, where intensive care facilities are limited.

 

Temperature control in acute brain injury

Intensive Care Medicine: Published 20 April 2026

Purpose

Temperature is a key determinant of cerebral vulnerability after acute brain injury and a physiological variable that can be continuously monitored and actively controlled in the intensive care unit. Its therapeutic role has evolved from hypothermia-centred strategies toward early recognition of fever and controlled normothermia. This review examines the physiological rationale, clinical evidence, and contemporary practice of temperature management in neurocritical care.

Methods

We synthesised evidence from major randomised trials, observational studies, and international consensus recommendations across traumatic brain injury, acute vascular brain injury, and post-cardiac arrest encephalopathy, together with current monitoring and implementation approaches.

Results

Fever is consistently associated with worse neurological outcomes. In traumatic brain injury, hypothermia reduces intracranial pressure but does not improve functional outcome when used prophylactically and is reserved for refractory intracranial hypertension. In acute vascular brain injury, neutral trials and feasibility constraints have shifted practice toward early detection and treatment of fever rather than hypothermia. In post-cardiac arrest care, contemporary guidelines recommend protocolised temperature control with selection and maintenance of a constant target between 32°C and 37.5°C and active prevention of fever, rather than mandatory hypothermia.

Conclusions

Temperature control is a fundamental component of care aimed at protecting the injured brain through continuous monitoring, early detection of fever, and prevention of temperature-related harm.

 

 

Low versus standard calorie and protein feeding and renal dysfunction in ventilated adults with shock: a NUTRIREA-3 post hoc analysis

Intensive Care Medicine: Published: 16 April 2026

Purpose

The optimal intake of artificial nutrition in critically ill patients remains unclear. While calorie and protein intakes affect glomerular function in patients with chronic kidney disease, their relation to renal function at the acute phase of intensive care is insufficiently documented. We aimed to study associations of a low-calorie and low-protein diet with renal outcomes in critically ill patients.

Methods

This post hoc analysis of the NUTRIREA-3 randomized-controlled trial included 3036 mechanically ventilated patients with shock. Calorie and protein intakes during the first 7 days were either low (6 kcal/kg and 0.2–0.4 g protein/kg/d) or standard (25 kcal/kg and 1.0–1.3 g protein/kg/d). The primary outcome was the incidence of acute kidney disease (AKD) during the ICU stay (up to ICU discharge or day 90 after inclusion, whichever occurred first).

Results

AKD during the ICU stay occurred in 669 (44.6%) low-group patients and 691 (46.1%) standard-group patients (hazard ratio, 0.97; 95% CI 0.88–1.07; P = 0.53). The highest urea level and the urea level at ICU discharge were significantly lower in the low group (P = 0.002). No differences were found for renal replacement therapy requirements or other renal outcomes. The results were similar in patients with early kidney dysfunction, severe organ failures, or end-stage chronic kidney disease.

Conclusion

In critically ill patients with shock, early low-calorie and low-protein nutrition for 7 days was not associated with worse renal outcomes or mortality compared to standard feeding, even in patients with preexisting renal dysfunction.

 

Implementation of a kidney protection strategy to prevent acute kidney injury after major surgery in high-risk patients identified by biomarkers: a systematic review and individual participant data meta-analysis of randomized controlled trials

Intensive Care Medicine: Published: 20 April 2026

Purpose

Acute kidney injury (AKI) is a common complication after major surgery and is associated with increased morbidity and mortality. Kidney protection strategies may help prevent moderate or severe AKI in high-risk patients. This study aims to assess the effect of the Kidney Disease: Improving Global Outcomes (KDIGO) kidney protection strategy for the prevention of AKI in patients after major surgery.

Methods

We conducted a systematic review and individual participant data (IPD) meta-analysis of randomized controlled trials (RCTs) comparing the kidney protection strategy recommended by international guidelines consisting of hemodynamic and fluid status optimization, avoidance of nephrotoxins or radiocontrast agents, regular monitoring of kidney function, and glycemic control to standard care in high-risk patients after major surgery with an enrichment strategy based on renal biomarkers. The primary outcome was moderate or severe AKI (KDIGO stage ≥ 2) within 72 h after surgery. MEDLINE via PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2000, to September 1, 2025. References of eligible trials and related reviews were hand-searched. Two reviewers independently assessed trial quality using the Cochrane Risk of Bias tool version 2.0. Certainty of the evidence was assessed using GRADE. IPD were pooled. Odds ratios (ORs) and mean difference with 95% confidence intervals (CIs) were computed with one-stage IPD meta-analysis. Heterogeneity was assessed by I² and Cochran’s Q.

Results

We identified four RCTs, two single-center trials and two multinational-multicenter trials. We pooled IPD from all four trials. The final cohort included 1,851 participants with 921 participants in the intervention group and 930 participants in the control group. Moderate or severe AKI occurred significantly less frequently in the intervention group (162/918 participants (17.7%)) compared to the control group (252/929 participants (27.1%)) (OR 0.55, 95% CI 0.44–0.70; p < 0.0001). There was no evidence of heterogeneity across studies (p = 0.7309, I² = 0.0%, τ² = 0). Secondary endpoints varied across trials and did not demonstrate major differences between groups. When measured, the intervention tended to result in fewer persistent AKI events and larger decreases in renal tubular stress biomarkers.

Conclusion

The implementation of a kidney protection strategy reduces the rates of moderate or severe AKI in biomarker-enriched high-risk patients after major surgery compared to standard of care, while the incremental clinical value of biomarker-guided selection itself remains uncertain.