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.

 

A consensus of international experts on definition, sampling, treatment, and prevention of peripheral extracorporeal membrane oxygenation cannula-site infection obtained by the Delphi method: the SAVECMO study

Intensive Care Medicine | Published: 08 January 2026

Background

Nosocomial infections are common in patients receiving extracorporeal membrane oxygenation (ECMO), with ECMO cannula-site infections (ECMO-CSI) being the most frequent infections directly related to the ECMO run. These infections can significantly impact patient outcomes. Currently, no adult guidelines exist for the prevention, diagnosis, and/or treatment of peripheral ECMO-CSI, resulting in heterogeneity in both clinical practice and research findings.

Methods

We conducted a Delphi study involving 39 international experts in ECMO management. The experts participated in four Delphi rounds to reach consensus on various aspects of ECMO-CSI complicating peripheral ECMO (central ECMO excluded), including definition, clinical suspicion, diagnostic methods, preventive measures, and treatment. Consensus was defined as ≥ 70% agreement among experts on each proposed item.

Results

The Delphi process established consensus on key aspects of ECMO-CSI. Experts agreed on clinical scenarios that warrant suspicion of ECMO-CSI, such as purulent discharge and local inflammatory signs. Standardized sampling techniques, including swabs and purulent drainage aspiration, were recommended, while others were rejected. Definitions were clarified, specifying that ECMO-CSI is defined by the isolation of a pathogen through local microbiological sampling and the presence of purulent discharge or local inflammatory signs. Among the preventive measures, the use of chlorhexidine-impregnated or semipermeable polyurethane dressings, unchanged for 7 days unless soiled or bleeding, was recommended, whereas systematic antibiotic prophylaxis, even for surgical ECMO, was not recommended.

Conclusion

This study presents an international expert consensus focusing on peripheral ECMO-CSI, providing a standardized framework to improve clinical management and facilitate future research. The consensus aims to enhance patient outcomes and support evidence-based guidelines in this complex field.

 

Quality Evaluation of Guidelines for the Diagnosis and Treatment of Liver Failure

 

by Wang, Xia; Zheng, Meng-Yao; He, Hai-Yu; Zhu, Hui-Ling; Zhao, Ya-Fang; Chen, Yu-Hang; Xu, Zhi-Yuan; Yang, Jin-Hui; Sun, Da-Li 

 

Critical Care Medicine:  June 04, 2024.

 

Objectives: 

This study aimed to systematically assess the methodological quality and key recommendations of the guidelines for the diagnosis and treatment of liver failure (LF), furnishing constructive insights for guideline developers and equipping clinicians with evidence-based information to facilitate informed decision-making.

Data Sources: 

Electronic databases and manual searches from January 2011 to August 2023.

Study Selection: 

Two reviewers independently screened titles and abstracts, then full texts for eligibility. Fourteen guidelines were included.

Data Extraction and Synthesis: 

Two reviewers extracted data and checked by two others. Methodological quality of the guidelines was appraised using the Appraisal of Guidelines for Research and Evaluation II tool. Of the 14 guidelines, only the guidelines established by the Society of Critical Care Medicine and the American College of Gastroenterology (2023) achieved an aggregate quality score exceeding 60%, thereby meriting clinical recommendations. It emerged that there remains ample room for enhancement in the quality of the guidelines, particularly within the domains of stakeholder engagement, rigor, and applicability. Furthermore, an in-depth scrutiny of common recommendations and supporting evidence drawn from the 10 adult LF guidelines unveiled several key issues: controversy exists in the recommendation, the absence of supporting evidence and confusing use of evidence for recommendations, and a preference in evidence selection.

Conclusions: 

There are high differences in methodological quality and recommendations among LF guidelines. Improving these existing problems and controversies will benefit existing clinical practice and will be an effective way for developers to upgrade the guidelines.

 

Right ventricle-specific therapies in acute respiratory distress syndrome: a scoping review

by Simran Ganeriwal, Gabriele Alves dos Anjos, Mary Schleicher, Maxwell A. Hockstein, Adriano R. Tonelli, Abhijit Duggal and Matthew T. Siuba 

Critical Care volume 27, Article number: 104 (2023) Published: 12 March 2023

Objective

To summarize knowledge and identify gaps in evidence regarding treatment of right ventricular dysfunction (RVD) in acute respiratory distress syndrome (ARDS).

Data sources

We conducted a comprehensive search of MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials.

Study selection

Studies were included if they reported effects of treatments on right ventricular function, whether or not the intent was to modify right ventricular function.

Data extraction

Data extraction was performed independently and in duplicate by two authors. Data items included the study design, patient population, type of intervention, comparison group, and RV-specific outcomes.

Data synthesis

Of 1,430 studies screened, 51 studies reporting on 1,526 patients were included. By frequency, the included studies examined the following interventions: ventilator settings (29.4%), inhaled medications (33.3%), extracorporeal life support (13.7%), intravenous or oral medications (13.7%), and prone positioning (9.8%). The majority of the studies were non-randomized experimental studies (53%), with the next most common being case reports (16%). Only 5.9% of studies were RCTs. In total, 27% of studies were conducted with the goal of modifying RV function.

Conclusions

Given the prevalence of RVD in ARDS and its association with mortality, the dearth of research on this topic is concerning. This review highlights the need for prospective trials aimed at treating RV dysfunction in ARDS.

 

Intensive care doctors and nurses personal preferences for Intensive Care, as compared to the general population: a discrete choice experiment

 by Matthew H. Anstey, Imogen A. Mitchell, Charlie Corke, Lauren Murray, Marion Mitchell, Andrew Udy, Vineet Sarode, Nhi Nguyen, Oliver Flower, Kwok M. Ho, Edward Litton, Bradley Wibrow and Richard Norman 

 Critical Care volume 25, Article number: 287 (2021) Published: 10 August 2021

 Background

To test the hypothesis that Intensive Care Unit (ICU) doctors and nurses differ in their personal preferences for treatment from the general population, and whether doctors and nurses make different choices when thinking about themselves, as compared to when they are treating a patient.

Methods

Cross sectional, observational study conducted in 13 ICUs in Australia in 2017 using a discrete choice experiment survey. Respondents completed a series of choice sets, based on hypothetical situations which varied in the severity or likelihood of: death, cognitive impairment, need for prolonged treatment, need for assistance with care or requiring residential care.

Results

A total of 980 ICU staff (233 doctors and 747 nurses) participated in the study. ICU staff place the highest value on avoiding ending up in a dependent state. The ICU staff were more likely to choose to discontinue therapy when the prognosis was worse, compared with the general population. There was consensus between ICU staff personal views and the treatment pathway likely to be followed in 69% of the choices considered by nurses and 70% of those faced by doctors. In 27% (1614/5945 responses) of the nurses and 23% of the doctors (435/1870 responses), they felt that aggressive treatment would be continued for the hypothetical patient but they would not want that for themselves.

Conclusion

The likelihood of returning to independence (or not requiring care assistance) was reported as the most important factor for ICU staff (and the general population) in deciding whether to receive ongoing treatments. Goals of care discussions should focus on this, over likelihood of survival.

 

Lopinavir-ritonavir and hydroxychloroquine for critically ill patients with COVID-19: REMAP-CAP randomized controlled trial

 

Lopinavir-ritonavir and hydroxychloroquine for critically ill patients with COVID-19: REMAP-CAP randomized controlled trial

By: Yaseen M. Arabi, Anthony C. Gordon, the REMAP-CAP Investigators

 

Intensive Care Medicine volume 47, pages867–886  Published: 12 July 2021

 

Purpose

To study the efficacy of lopinavir-ritonavir and hydroxychloroquine in critically ill patients with coronavirus disease 2019 (COVID-19).

Methods

Critically ill adults with COVID-19 were randomized to receive lopinavir-ritonavir, hydroxychloroquine, combination therapy of lopinavir-ritonavir and hydroxychloroquine or no antiviral therapy (control). The primary endpoint was an ordinal scale of organ support-free days. Analyses used a Bayesian cumulative logistic model and expressed treatment effects as an adjusted odds ratio (OR) where an OR > 1 is favorable.

Results

We randomized 694 patients to receive lopinavir-ritonavir (n = 255), hydroxychloroquine (n = 50), combination therapy (n = 27) or control (n = 362). The median organ support-free days among patients in lopinavir-ritonavir, hydroxychloroquine, and combination therapy groups was 4 (– 1 to 15), 0 (– 1 to 9) and—1 (– 1 to 7), respectively, compared to 6 (– 1 to 16) in the control group with in-hospital mortality of 88/249 (35%), 17/49 (35%), 13/26 (50%), respectively, compared to 106/353 (30%) in the control group. The three interventions decreased organ support-free days compared to control (OR [95% credible interval]: 0.73 [0.55, 0.99], 0.57 [0.35, 0.83] 0.41 [0.24, 0.72]), yielding posterior probabilities that reached the threshold futility (≥ 99.0%), and high probabilities of harm (98.0%, 99.9% and > 99.9%, respectively). The three interventions reduced hospital survival compared with control (OR [95% CrI]: 0.65 [0.45, 0.95], 0.56 [0.30, 0.89], and 0.36 [0.17, 0.73]), yielding high probabilities of harm (98.5% and 99.4% and 99.8%, respectively).

Conclusion

Among critically ill patients with COVID-19, lopinavir-ritonavir, hydroxychloroquine, or combination therapy worsened outcomes compared to no antiviral therapy.