FFICM SBA · Consultant-Level Revision High Yield · With Nuance ⚡ Updated 2025–2026

ICU Guidelines
Deep Dive

All guidance reviewed to latest available versions — including DAS 2025, GPICS V3 (January 2026), and Global ARDS Definition 2024. Pitched at ST6/imminent-consultant level for the Final FFICM SBA.

Sepsis ARDS/Vent AKI/RRT Cardiac Arrest DNC PADIS/Sedation Glycaemia Nutrition Fluids Transfusion TBI DKA/HHS PE SAH Liver Failure Endocarditis Organ Donation Tracheostomy VAP/HAP Obstetrics 🔴 DAS 2025 🟣 FICM / GPICS
Tier 1 — Essential Expect multiple questions per sitting
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Sepsis — Surviving Sepsis Campaign 2021 CURRENT
Hour-1 Bundle · Vasopressor Hierarchy · Steroids · Source Control · Biomarkers
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📖Sepsis-3 Definition (2016): Life-threatening organ dysfunction (SOFA ≥2 acute change) due to dysregulated host response to infection. Septic shock = sepsis + vasopressors to maintain MAP ≥65 + lactate >2 mmol/L despite adequate resuscitation. qSOFA (≥2/3: RR≥22, altered mentation, SBP≤100) = screening tool only, NOT diagnostic — do not use to define sepsis.
Hour-1 Bundle — All 5 Elements
  • Measure Lactate — re-measure within 2h if initial >2 mmol/L; lactate >4 mmol/L = high-risk regardless of BP
  • Blood cultures before antibiotics — 2 sets, 2 sites; do not delay antibiotics >45 min for cultures
  • Broad-spectrum antibiotics within 1 hour — anti-pseudomonal beta-lactam ± MRSA cover; de-escalate per cultures
  • 30 ml/kg IV crystalloid — for hypotension or lactate ≥4 mmol/L; reassess fluid responsiveness after each bolus (not a minimum to always give)
  • Noradrenaline if hypotensive during/after fluids — target MAP ≥65 mmHg; can start peripherally pending CVC
⚠️ Exam Trap — EGDT AbandonedARISE, ProCESS, PROMISE (2014–2015): EGDT (targeting ScvO₂ >70%, CVP 8–12, Hct ≥30%) showed NO mortality benefit vs usual care. CVP is a poor predictor of fluid responsiveness. EGDT is abandoned. Do NOT select CVP targets or ScvO₂ >70% as resuscitation endpoints.
⚠️ Exam Trap — CLASSIC Trial (2022)Restrictive IV fluid strategy (250 ml boluses only for severe hypoperfusion signs) vs standard in septic shock — no difference in 90-day mortality. MORE fluid ≠ BETTER outcomes. The 30 ml/kg bundle component is a ceiling to initiate, not a minimum to always deliver. Always reassess fluid responsiveness.
Vasopressor Hierarchy — With Trial Evidence
  • 1st: Noradrenaline — alpha-1 dominance, less tachycardia/arrhythmia than dopamine (De Backer 2010 RCT — dopamine no longer recommended)
  • 2nd: Vasopressin 0.01–0.03 u/min — VASST: reduces norad requirement; may reduce AKI progression in less severe shock; do NOT exceed 0.03–0.04 u/min (cardiac ischaemia risk)
  • 3rd: Adrenaline — if MAP not achieved despite norad + vasopressin
  • Dobutamine 2.5–20 mcg/kg/min — add if evidence of cardiac dysfunction (low CO, high lactate despite adequate MAP and filling)
  • Terlipressin: NOT recommended in septic shock (ATTRESS trial — no benefit, possible harm)
Corticosteroids — ADRENAL / APROCCHSS
💊Indication: noradrenaline (or adrenaline) >0.25 mcg/kg/min AND not achieving haemodynamic goals at 4 hours. Hydrocortisone 200 mg/day — 50 mg QDS IV or 200 mg continuous infusion. Do NOT use ACTH stimulation test to guide (CORTICUS, ADRENAL, APROCCHSS). Fludrocortisone 50 mcg OD enteral (per APROCCHSS) — reduces 90-day mortality in that trial; practice varies. SSC 2021 does not mandate fludrocortisone — know the nuance.
Source Control & Antibiotic Stewardship
  • Source control within 6–12 h where feasible (abscess drainage, anastomotic leak, infected device removal) — inadequate source control = treatment failure
  • Procalcitonin (PCT)-guided de-escalation — PRORATA trial: safe, reduces antibiotic duration; rising PCT suggests inadequate source control
  • Antifungals empirically: consider in high-risk (prolonged ICU, TPN, abdominal surgery, Candida colonisation, immunosuppression) — fluconazole first line; echinocandin (anidulafungin) if critically ill or azole-resistant risk
ARISE/ProCESS/PROMISE — EGDT abandoned De Backer 2010 — dopamine inferior, more arrhythmias VASST — vasopressin spares norad dose ADRENAL/APROCCHSS — hydrocortisone in refractory shock PRORATA — PCT-guided de-escalation safe CLASSIC 2022 — restrictive fluid non-inferior in septic shock
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ARDS & Mechanical Ventilation GLOBAL DEF 2024
Berlin 2012 · Global Definition 2024 · ARDSNet · Proning · HFOV · ECMO · Steroids
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⚡Global ARDS Definition 2024 (Matthay et al., AJRCCM Jan 2024): Expands Berlin 2012 to include: (1) Non-intubated ARDS — patients on HFNO ≥30 L/min or NIV/CPAP ≥5 cmH₂O; (2) SpO₂/FiO₂ ≤315 (if SpO₂ ≤97%) as alternative to P:F ratio; (3) Lung ultrasound as imaging modality; (4) Resource-limited category (no PEEP requirement). Berlin severity thresholds (mild/moderate/severe) unchanged for intubated patients. The global definition is NOT yet universally adopted — Berlin remains current clinical standard; both may appear in exam.
Berlin Definition (2012) — Intubated Patients
200–300Mild (P:F, mmHg)
100–200Moderate
<100Severe
≤315SpO₂/FiO₂ (global def, SpO₂ ≤97%)
ℹ️Berlin criteria ALL required: (1) onset ≤1 week of known insult; (2) bilateral opacities not fully explained by effusion/collapse/nodules; (3) respiratory failure not fully explained by cardiac failure/overload; (4) PEEP ≥5 cmH₂O. P:F ratio calculated on current PEEP setting.
Lung-Protective Ventilation — ARDSNet/ARMA Trial
6 ml/kgTidal volume (IBW)
<30Plateau pressure (cmH₂O)
<15Driving pressure (cmH₂O)
88–95%SpO₂ target
4.5–6.0PaCO₂ target (kPa)
IBW FormulaMales: 50 + 0.91 × (height cm − 152.4)   Females: 45.5 + 0.91 × (height cm − 152.4)
🔵 Driving Pressure — Independently PrognosticDriving pressure (Pplat − PEEP) independently associated with mortality even when Vt and Pplat are within targets (Amato 2015, NEJM). Target <15 cmH₂O. May need to reduce PEEP (not just Vt) if driving pressure elevated on high PEEP settings.
PEEP Strategy
  • ARDSNet low PEEP table: titrate PEEP to FiO₂ (e.g., FiO₂ 0.4 → PEEP 5; FiO₂ 0.8 → PEEP 14)
  • Higher PEEP: no mortality benefit in ALVEOLI, LOVS, ExPress trials; may improve oxygenation
  • ART Trial (2017) — HARM: staircase RM (40/40 RM + high PEEP) increased 28-day mortality. Aggressive sustained inflation RMs are harmful — do NOT use
Prone Positioning — PROSEVA Trial
✅Prone if P:F <150 on FiO₂ ≥0.6 + PEEP ≥5 cmH₂O for ≥16 hours/day. PROSEVA: 28-day mortality 16% vs 33% (NNT ~6). This is an absolute treatment, not just oxygenation rescue. Continue until sustained P:F >150 on FiO₂ ≤0.6 after ≥4h supine; minimum 4 sessions before abandoning. Apply in moderate-severe ARDS proactively.
NMB — ACURASYS vs ROSE
ACURASYS (2010)
  • 48h cisatracurium in P:F <150; reduced 90-day mortality & barotrauma; confounded by deep sedation in control arm
ROSE Trial (2019)
  • Early NMB vs light sedation control — NO mortality benefit. Control arm RASS 0 to −1 (key difference from ACURASYS)
⚠️Routine early NMB NOT recommended. Use NMB for: severe ventilator dyssynchrony unresponsive to sedation, refractory hypoxia (P:F <100 despite prone + optimised vent), ICP management. Always pair with adequate analgesia/sedation when using NMB.
HFOV — Contraindicated
🚫OSCILLATE (2013) stopped early — increased in-hospital mortality in HFOV arm. OSCAR neutral. HFOV is NOT recommended in adult ARDS. This is a harm-causing intervention.
VV-ECMO — CESAR & EOLIA
  • CESAR (2009): transfer to ECMO centre improved 6-month survival (63% vs 47%); limitation — control arm did not always receive optimised conventional ventilation
  • EOLIA (2018): VV-ECMO in P:F <80 — 60-day mortality 35% vs 46%, p=0.07 (NS primary endpoint); 28% crossover to ECMO in control; treatment effect likely real, underpowered
  • Current practice: consider VV-ECMO as rescue in refractory severe ARDS (P:F <80 despite prone, NMB, optimised vent) at ECMO-capable centre
Corticosteroids in ARDS — DEXA-ARDS
✅DEXA-ARDS (2020): Dexamethasone 20 mg/day × 5d then 10 mg × 5d in moderate-severe ARDS — reduced 60-day mortality (21% vs 36%) and increased ventilator-free days. Consider early dexamethasone in P:F <200. RECOVERY trial (dexamethasone 6 mg in COVID) — benefit only in those requiring O₂/ventilation, not in mild/no supplemental O₂ group.
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AKI & RRT — KDIGO 2012 (Updated 2024)
KDIGO Staging · RRT Timing · CRRT Dose · Anticoagulation · What Doesn't Work
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StageCreatinineUrine Output
1×1.5–1.9 baseline (7 days) OR ≥26 µmol/L rise (48h)<0.5 ml/kg/hr for 6–12h
2×2.0–2.9 baseline<0.5 ml/kg/hr for ≥12h
3×3.0 baseline OR ≥354 µmol/L OR initiation of RRT<0.3 ml/kg/hr ≥24h OR anuria ≥12h
🔵 2024 KDIGO Update — BiomarkersKDIGO 2024 incorporates biomarkers for AKI risk stratification: TIMP-2 × IGFBP-7 (NephroCheck) ≥0.3 (ng/ml)²/1000 — identifies patients at high risk for AKI within 12h; can guide early intervention. NGAL (urinary/plasma) — less specific but established. Furosemide stress test: 1 mg/kg IV (naive) — urine output <200 ml in 2h = progression to Stage 3 likely. These are emerging risk stratification tools, not diagnostic criteria.
RRT Indications — AEIOU
🔴 Absolute / Urgent
  • Acidosis — refractory (pH <7.1)
  • Electrolytes — K⁺ >6.5 or ECG changes
  • Ingestion — dialysable toxins (Li, salicylates, methanol, ethylene glycol, metformin)
  • Overload — refractory pulmonary oedema
  • Uraemia — encephalopathy, pericarditis, neuropathy
🟠 Threshold-Based
  • Urea >30–35 mmol/L (rising)
  • Creatinine >500 µmol/L (context-dependent)
  • Oliguria <200 ml/12h unresponsive to optimisation
  • Stage 3 AKI + multi-organ failure
⚠️ Exam Trap — No Benefit to Early RRTSTARRT-AKI (2020) and AKIKI (2016): early RRT vs delayed — NO mortality benefit; early initiation associated with more adverse events (hypotension, hypophosphataemia). Do NOT start RRT on KDIGO staging alone without a clinical AEIOU indication.
CRRT — Mode, Dose, Anticoagulation
20–25CRRT effluent dose (ml/kg/hr)
25–30Prescribed dose to deliver 20–25
1.2–1.4IHD Kt/V per session
ℹ️ATN and RENAL trials: higher CRRT doses (35–45 ml/kg/hr) NOT superior to 20–25 ml/kg/hr. Prescribed dose ≠ delivered dose — downtime reduces delivery; prescribe 25–30 to achieve 20–25 ml/kg/hr delivered. CVVHDF has marginal advantage over CVVH/CVVHF for solute clearance.
  • Regional citrate anticoagulation (RCA) — preferred; anticoagulates circuit without systemic effect; prolongs filter life; monitor ionised Ca²⁺: circuit 0.25–0.35 mmol/L; systemic 1.0–1.2 mmol/L; contraindicated in severe liver failure (citrate accumulation — citrate toxicity: rising AG, rising total:ionised Ca²⁺ ratio)
  • Systemic UFH — alternative; APTT 45–65 sec; HIT risk
  • Argatroban — anticoagulant of choice in confirmed HIT requiring CRRT
What Does NOT Work (Abandoned Practices)
  • Low-dose dopamine ("renal dose"): DAG trial — no benefit; abandoned
  • NAC/NaHCO₃ for contrast nephropathy: PRESERVE trial — no benefit over IV saline
  • Furosemide: does NOT prevent or treat AKI — only treats fluid overload; forced diuresis is harmful
  • Routine furosemide stress test-guided RRT initiation: emerging but not standard of care
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Cardiac Arrest — Resus Council UK / ERC 2021 CURRENT
ALS · PARAMEDIC2 · TTM2 · COACT/TOMAHAWK · Neuroprognostication
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4H's
  • Hypoxia
  • Hypovolaemia
  • Hypo/Hyperkalaemia (metabolic)
  • Hypothermia
4T's
  • Tension pneumothorax
  • Tamponade
  • Toxins
  • Thromboembolism (PE/coronary)
1 mgAdrenaline (every 3–5 min)
300 mgAmiodarone (after 3rd shock)
150 mgAmiodarone (2nd dose)
⚠️ Exam Trap — Atropine RemovedAtropine was removed from the ALS algorithm in 2010. It is NOT recommended for cardiac arrest, PEA, or asystole. Do not select it as a cardiac arrest drug.
💊PARAMEDIC2 (2018): Adrenaline improves ROSC and 30-day survival (3.2% vs 2.4%) but NOT neurologically favourable survival (2.2% vs 1.9%, p=0.49). Adrenaline remains guideline-recommended but its benefit is predominantly physiological survival without quality-of-life benefit.
Post-ROSC Targets
94–98%SpO₂ — avoid hyperoxia
4.5–6.0PaCO₂ target (kPa)
≥65MAP (mmHg)
6–10Glucose (mmol/L)
  • 12-lead ECG immediately — STEMI → immediate PCI regardless of neurological status
  • No STEMI → COACT (2019) + TOMAHAWK (2021): immediate angiography does NOT improve 90-day survival vs delayed selective angiography in OHCA without STEMI. Do NOT routinely take to cathlab without STEMI.
Temperature Management — TTM2 (2021)
🌡️TTM2 (2021): Hypothermia 33°C vs targeted normothermia 37.5°C in comatose OHCA survivors — NO difference in 6-month mortality or neurological outcome (50% both arms). Active cooling to 33°C no longer routinely recommended. Current guidance: prevent fever — maintain temperature ≤37.7°C for ≥72h. Waveform EEG monitoring during normothermia to detect seizures.
Neuroprognostication — Multimodal, ≥72h Post-ROSC
🧠No single test sufficient. Multimodal approach required. Assess no earlier than 72h post-ROSC (or 72h post-rewarming). Must exclude confounders: residual sedation, hypothermia, metabolic disturbance.
TestPoor Prognosis IndicatorNotes
Pupils (Day 3)Bilaterally absent NPRQuantitative pupillometry (NPR <0.1) reduces subjectivity
SSEP (Day 3+)Bilateral absent cortical N20Lowest false positive rate — most robust single test
EEG (Day 2+)Burst suppression / flat / persistent seizuresReactive EEG = better prognosis; continuous monitoring preferred
NSE (48–72h)>60 µg/LHaemolysis causes false elevation — always check
CT Brain (≥24h)Diffuse anoxic injury (grey-white ratio <1.22)Early CT may underestimate injury
MRI (Day 2–7)Diffuse DWI restrictionMost sensitive imaging modality
🔵 Self-Fulfilling Prophecy WarningPremature withdrawal based on single pessimistic test risks self-fulfilling prophecy. Even with absent SSEP N20, 4–7% recover. Holistic decision with family. At least 2 concordant poor-prognosis tests required before considering withdrawal — never on one test alone.
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Death by Neurological Criteria — AoMRC 2008 UK ONLY
Preconditions · 7 Brainstem Tests · Apnoea Protocol · Spinal Reflexes · Confirmatory Tests
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🇬🇧UK uses "Death by Neurological Criteria" (DNC) — not "brain stem death" or "brain death" (philosophical ambiguity). Death is legally declared at the time of the first set of tests. Criteria differ from US (where confirmatory EEG/cerebral angiography may be required) — do NOT apply non-UK criteria in the exam.
Preconditions — ALL Must Be Met
  • Known irreversible structural brain injury consistent with DNC — aetiology must be established
  • Patient is deeply comatose + apnoeic + mechanically ventilated
  • All potentially reversible causes excluded
Exclusions to Eliminate Before Testing
  • Sedatives/opioids — allow ≥5 half-lives; check drug levels
  • Core temperature <34°C — warm before testing
  • Severe metabolic disturbance (Na, glucose, phosphate)
  • Neuromuscular blocking agents — confirm with train-of-four
  • Endocrine: hypothyroidism, Addisonian crisis
  • Reversible circulatory cause
7 Brainstem Reflex Tests
  • Pupils: no response to bright light (CN II, III) — need not be maximally dilated, just unreactive
  • Corneal reflex: no blink to light touch (CN V, VII)
  • Vestibulo-ocular (caloric): no eye movement to 50 ml ice-cold water each ear (CN VIII, III, VI) — observe 1 minute each side; canal must be unobstructed
  • Pain (cranial nerve territory): no motor response to deep supra-orbital pressure or jaw pressure — note: limb response is spinal and does NOT invalidate
  • Gag reflex: no response to posterior pharyngeal stimulation (CN IX, X)
  • Cough reflex: no cough on deep tracheal suction (CN X)
Apnoea Test — Exact Protocol
  • Pre-oxygenate FiO₂ 1.0 for ≥10 min; ensure PaO₂ >26.6 kPa (oxygen reserve)
  • Baseline PaCO₂ must be ≥5.3 kPa before disconnection (if low, briefly hypoventilate)
  • Disconnect ventilator; insufflate O₂ at carina (6 L/min) to prevent desaturation
  • Observe 5 minutes for spontaneous respiratory effort
  • Perform ABG: test confirms DNC if PaCO₂ ≥6.0 kPa AND pH <7.40 — demonstrates adequate hypercapnic drive was present; no respiratory response = DNC confirmed
  • Abandon if haemodynamic instability or SpO₂ falls — reconnect, reschedule
2Doctors required
≥5 yrsPost-full registration
2Separate test sets
1st setLegal time of death
🔵 Critical Distinctions — Exam Favourites (1) Spinal reflexes (Lazarus sign: limb flexion/extension, finger movements) CAN persist after DNC — they do NOT invalidate the diagnosis. They are spinally mediated. Warn families and staff.

(2) Confirmatory tests (EEG, cerebral angiography, CT perfusion) are NOT required in the UK — unlike some countries. They may be used if brainstem tests cannot be completed (e.g., severe facial/petrous fractures).

(3) Neither doctor can be a member of the transplant team. At least one must be a consultant.

(4) A new DNACPR/ReSPECT form is NOT required — DNC documentation is specific and separate from resuscitation planning documents.
Tier 2 — High Yield Numbers, nuances and trial distinctions tested
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Sedation, Analgesia & Delirium — PADIS 2018 CURRENT
ABCDEF Bundle · Sedation Scales · Drug Choice · PICS · Propofol Infusion Syndrome
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💡ABCDEF Bundle: A=Assess/manage Analgesia, B=Both SAT+SBT daily, C=Choice of sedation/analgesia, D=Delirium screen/manage, E=Early mobility/Exercise, F=Family engagement. Bundle adherence associated with reduced mortality, delirium, and ICU stay.
ScaleRangeICU TargetNotes
RASS−5 to +4−2 to 00=alert; −5=unarousable; deep sedation (≤−3) associated with 180-day mortality
SAS1–72–34=calm/cooperative; 1=unarousable
CPOT0–8<2Pain scale for non-verbal; ≥3 = significant pain requiring treatment
BPS3–12<53 components × 1–4; validated in non-communicative patients
Sedation Agent Choice
  • Dexmedetomidine (alpha-2 agonist): preserves arousability; preferred for agitated delirium and weaning; less delirium vs midazolam (MENDS trial) and lorazepam; not for deep sedation; bradycardia/hypotension side effects
  • Propofol: flexible, titratable; risk of Propofol Infusion Syndrome (PRIS) at doses >4 mg/kg/hr for >48h — lactic acidosis, rhabdomyolysis, renal failure, new RBBB/Brugada-like ST changes, cardiac failure; treat by stopping propofol immediately; ECG monitoring recommended on high doses
  • Benzodiazepines: increased delirium, prolonged ventilation (MENDS, SLEAP trials) — avoid in general ICU; reserve for alcohol withdrawal (CIWA protocol), status epilepticus, specific anxiety disorders
  • Ketamine: NMDA antagonist; bronchodilator; opioid-sparing; procedural sedation; emerging evidence as analgesic adjunct reducing opioid consumption; may increase secretions
⚠️ Deep Sedation — Independently HarmfulDeep sedation (RASS −3 to −5) in first 48h is independently associated with 180-day mortality (SPICE trials). RASS ≤−3 appropriate ONLY for: refractory ICP, severe ARDS requiring NMB/prone, status epilepticus, procedural necessity. Do not default to deep sedation.
Delirium — Screening, Prevention, Treatment
  • CAM-ICU: 4 features — (1) Acute onset/fluctuation, (2) Inattention, (3) Altered consciousness (RASS ≠ 0), (4) Disorganised thinking; CAM-ICU+ = features 1+2 + either 3 or 4
  • ICDSC: 8-item; ≥4 = delirium; 1–3 = subsyndromal delirium (also has prognostic significance)
  • Haloperidol: HOPE-ICU + MIND-USA — no reduction in delirium duration. May use for symptom control (distress/agitation) but does NOT treat underlying delirium
  • Non-pharmacological: reorientation, day/night cycle, early mobilisation, hearing aids/glasses, dehydration prevention — primary prevention strategy
Post-Intensive Care Syndrome (PICS)
🔮PICS = cognitive impairment + PTSD/anxiety/depression (up to 50% of survivors) + ICUAW. ICUAW in 25–60% of prolonged ICU admissions; risk: NMB, deep sedation, hyperglycaemia, inactivity. GPICS V3 (2026) recommends ICU follow-up clinic for all level 3 patients; rehabilitation pathway from ICU through hospital and beyond. The exam increasingly tests PICS awareness and prevention strategies (light sedation, mobilisation, family involvement).
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Glycaemic Control — NICE-SUGAR Trial
Leuven Trials · Current Target · Hypoglycaemia Harm
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6–10Current target (mmol/L)
4.5–6.0AVOID — tight control (HARM)
7.8–10Pragmatic target some centres
<4.0Hypoglycaemia — independently harmful
TrialPopulationTargetResult
Leuven I (2001)Surgical ICU, single centre, Ghent4.4–6.1 mmol/LReduced ICU mortality — sparked enthusiasm; not reproducible
Leuven II (2006)Medical ICU4.4–6.1 mmol/LNo overall mortality benefit in intention-to-treat
NICE-SUGAR (2009)Multi-centre, n=61044.5–6.0 vs 8–10 mmol/LTight control: 90-day mortality 27.5% vs 24.9% (p=0.02) — HARM
⚠️ Exam TrapNICE-SUGAR: harm driven by severe hypoglycaemia (6.8% vs 0.5%). Leuven I results likely due to nutrition differences (TPN control arm). Never select 4.5–6 mmol/L as a glucose target. Current evidence: 6–10 mmol/L with IV insulin infusion protocol.
  • Check glucose hourly when titrating insulin infusion
  • Treat hypoglycaemia (<4 mmol/L): 50 ml 50% glucose or 150–200 ml 10% glucose IV
  • In T2DM or ACS: accept 8–12 mmol/L to reduce hypoglycaemia risk
  • SC insulin is NOT appropriate for tight glycaemic control in ICU — use IV infusion
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Nutrition — ESPEN ICU 2019
Early EN · EPaNIC · CALORIES · Refeeding Syndrome · EFFORT Trial
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<48 hrsStart enteral nutrition
20–25Acute phase kcal/kg/day
1.3 g/kgProtein target /day
Day 7+Start supplemental PN only
⚠️EPaNIC (2011): Early PN (day 1) vs late PN (day 8) — late PN: more patients discharged alive, fewer infections, shorter ventilation. Early PN is harmful. Do not start PN in first week unless EN completely contraindicated.
ℹ️CALORIES trial (UK, 2014): Early PN vs early EN — NO significant mortality difference (33.1% vs 34.2%). EN remains first-line for gut integrity, lower cost, central line avoidance — but the mortality benefit of EN over PN in a pragmatic UK ICU setting is not proven.
  • Protein: 1.3 g/kg/day; EFFORT trial: high protein (>2.2 g/kg/day) no benefit; possible harm in AKI and ventilated subgroups — do NOT overdo protein
  • Glutamine: REDOXS trial — increased 6-month mortality in MOF. IV glutamine contraindicated in renal/hepatic failure. Not recommended in critically ill
  • Antioxidants (Vit C, selenium): CITRIS-ALI — no benefit. Not recommended routinely
  • Omega-3: OMEGA trial — negative. Not recommended
  • Indirect calorimetry = gold standard for caloric targets; predictive equations inaccurate in ICU
Refeeding Syndrome — NICE NG22
🚨At-risk: BMI <16, weight loss >15% in 3–6 months, minimal intake >10 days, pre-feeding low K⁺/Mg²⁺/PO₄³⁻. Refeeding causes intracellular electrolyte shift — hypophosphataemia is the hallmark (respiratory failure, cardiac arrhythmias, haemolysis, encephalopathy).
  • Replace phosphate, potassium, magnesium before starting nutrition
  • Thiamine 200–300 mg IV BEFORE first glucose load (prevents Wernicke's/Korsakoff's)
  • Start at 10 kcal/kg/day, increase slowly — no more than 50% increase per day over 4–7 days
  • Monitor K⁺, Mg²⁺, PO₄³⁻ daily for first week
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Fluid Resuscitation — SMART / CLASSIC / SAFE
Fluid Choice · SOSD Phases · Fluid Responsiveness Assessment · Colloids
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✅SMART (2018): Balanced crystalloids (PlasmaLyte/LRS) vs 0.9% NaCl — balanced crystalloids reduced MAKE30 (composite of death, RRT, creatinine doubling), especially in sepsis. Use balanced crystalloids as default resuscitation fluid.
FluidUseAvoid / Notes
Hartmann's / LRSDefault resuscitation; 1st lineAvoid in TBI (slightly hypotonic — use 0.9% NaCl); pH 6.5 but metabolised to bicarbonate
PlasmaLytePreferred balanced; more physiological pH/compositionHigher cost than LRS
0.9% NaClTBI, hypochloraemic alkalosis, drug dilutionLarge volume → hyperchloraemic acidosis + AKI (SMART, SPLIT)
4.5% AlbuminSBP prophylaxis in cirrhosis; large volume paracentesis (>5L) — 8g/L removedSAFE trial: no benefit vs saline in general sepsis; ALBIOS — no benefit in septic shock
HES/StarchesNoneCONTRAINDICATED in sepsis/critically ill: CHEST + 6S — increased AKI, RRT, mortality
GelatinsLimited; not recommended in sepsisRisk of anaphylaxis, coagulopathy; no outcome data
SOSD Phases of Fluid Therapy
ResuscitationEmergency perfusion restoration
OptimisationFluid-responsive preload optimisation
StabilisationMaintenance; minimise positive balance
De-escalationActive negative balance / diuresis / UF
Fluid Responsiveness Assessment
  • PLR (Passive Leg Raise) + CO measurement: gold standard dynamic test; raise legs 45° for 1 min (autotransfusion ~300 ml); CO increase ≥10–15% = fluid responsive; reversible, no fluid given, valid in AF and spontaneous breathing
  • PPV (Pulse Pressure Variation) >13%: fluid responsive — ONLY valid in: (1) controlled ventilation, (2) sinus rhythm, (3) no spontaneous breaths, (4) Vt ≥8 ml/kg IBW, (5) no severe RV failure or raised intra-abdominal pressure
  • End-expiratory occlusion test: hold ventilation at end-expiration 15s; CO increase ≥5% = responsive; useful in spontaneously breathing patients
  • CVP: poor predictor of fluid responsiveness — abandoned as resuscitation endpoint (multiple trials)
🔵 SPLIT vs SMART — Apparent ConflictSPLIT trial (2015, NZ): no difference in AKI between PlasmaLyte and 0.9% NaCl. SMART (2018, larger, 15,800 patients): balanced crystalloids reduced MAKE30. The discrepancy is likely due to SMART's larger size and more septic patients. Current recommendation: balanced crystalloids preferred. SPLIT does not negate SMART.
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Blood Products — TRICC / TRISS / BSH
Restrictive Thresholds · Massive Haemorrhage · ROTEM · Reversal Agents · MINT 2023
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PopulationThreshold (g/L)Trial
General ICU (stable)70TRICC
Septic shock70TRISS — 70 = 90 g/L in septic shock
Cardiac disease / post-cardiac surgery80TRICS III
ACS / acute MI80MINT (2023) — see below
GI bleeding70–80Villanueva 2013, TRIGGER
⚠️ MINT Trial (2023) — Recent UpdateMINT trial in ACS patients: restrictive threshold (Hb 80 g/L) was non-inferior overall; however the pre-specified ACS subgroup had a signal favouring liberal strategy. Standard answer for ACS: transfuse if Hb <80 g/L. Know that debate continues in this subgroup.
Massive Haemorrhage Protocol (MHP) — BSH
  • Activate MHP early — call blood bank; do NOT wait for labs
  • Target ratio: 1:1:1 — FFP : Platelets : pRBC
  • Tranexamic Acid (TXA): give within 3 hours of injury/haemorrhage — CRASH-2 (trauma), WOMAN (PPH), CRASH-3 (mild-moderate TBI); 1g IV over 10 min then 1g over 8h; TXA >3h may be harmful
  • Calcium — 10% calcium gluconate 10 ml per 4 units pRBC; citrate chelation causes hypocalcaemia impairing coagulation and cardiac function
  • Fibrinogen: target >1.5–2.0 g/L — fibrinogen concentrate (4g) or cryoprecipitate
  • Platelets: target >50 ×10⁹/L; >100 ×10⁹/L if TBI/multiple trauma
  • "Lethal triad": hypothermia + acidosis + coagulopathy — treat all three simultaneously
ROTEM/TEG — Viscoelastic Haemostatic Assays
  • ITACTIC trial: VHA-guided resuscitation reduces total blood product use vs standard lab-guided
  • FIBTEM MCF <12 mm → fibrinogen concentrate/cryoprecipitate
  • EXTEM MCF <50 mm + normal FIBTEM → platelets
  • EXTEM CT prolonged + EXTEM/INTEM ratio >1.5 → FFP
  • LI60 <85% (hyperfibrinolysis) → TXA
DrugReversal AgentNotes
WarfarinPCC (4-factor) + Vit K 10mg IVPCC faster/less volume than FFP; FFP inferior for urgent reversal
DabigatranIdarucizumab (Praxbind) 5g IVSpecific; dialysable
Rivaroxaban/ApixabanAndexanet alfa (Ondexxya) or PCC 50 units/kgAndexanet licensed; PCC pragmatic alternative
UFHProtamine 1mg per 100 units UFH (max 50mg)Partial reversal of LMWH only
🪖
Traumatic Brain Injury — BTF 4th Edition 2016 CURRENT
ICP/CPP Targets · Osmotherapy · Decompression · Contraindications · Seizure Prophylaxis
▼
>22ICP treat above (mmHg)
60–70CPP target (mmHg)
MAP − ICPCPP formula
ℹ️Age-based SBP targets (BTF 4th Ed): ≥50 mmHg age 15–49 and >70 years; ≥60 mmHg age 50–69. Autoregulation impaired in severe TBI — CPP becomes pressure-passive; PRx monitoring can identify CPP-optimal targets.
TierInterventionNotes
0 (always)HOB 30°, neutral neck, normothermia, normoglycaemia, avoid hypotension/hypoxiaNon-negotiable baselines regardless of ICP
1 (first line)Sedation/analgesia, CSF drainage (EVD), mild hyperventilation (PaCO₂ 4.5–5.0 kPa)Hyperventilation: temporary bridge only — vasoconstriction causes ischaemia risk if prolonged
2 (second line)Osmotherapy (mannitol or HTS), NMBMonitor osmolality (mannitol <320); Na target 145–155 (HTS)
3 (rescue)Decompressive craniectomy, barbiturate coma, hypothermiaThird-tier carries significant risk; quality of life discussion required
🔵 Mannitol vs HTS DistinctionMannitol 0.25–1 g/kg: osmolar diuresis; avoid if hypovolaemic; monitor osmolality gap (<10); max serum osmolality 320 mosmol/kg. Hypertonic saline (3%): Na target 145–155 mmol/L; no diuresis; preferred if haemodynamically unstable or when mannitol contraindicated. 23.4% HTS (30 ml) — rapid bolus for impending herniation/uncal herniation.
Contraindicated Interventions in TBI
  • Steroids (methylprednisolone): MRC CRASH trial — increased 14-day and 6-month mortality. Absolutely contraindicated
  • Therapeutic hypothermia for ICP: EUROTHERM3235 — hypothermia 32–35°C for ICP control increased unfavourable outcomes vs standard care. Do NOT use
  • Prophylactic hyperventilation: PaCO₂ <4.0 kPa — cerebral ischaemia; use only as temporary bridge
  • Hypotonic fluids (Hartmann's): worsen cerebral oedema — use 0.9% NaCl in TBI
Decompressive Craniectomy Trials
DECRA (2011)
  • Bifrontal DC for ICP >20 (>15 min); reduced ICP/ICU stay; worse neurological outcomes (unfavourable GOS); criticised: low threshold, surgical technique differences
RESCUEicp (2016)
  • DC for ICP >25 after full medical management; reduced mortality (27% vs 49%); more survivors in vegetative state (8.5% vs 2.1%); quality-of-life discussion essential
Anticonvulsant Prophylaxis
  • Recommended for 7 days only — reduces early post-traumatic seizures, not late epilepsy; do NOT continue beyond day 7
  • Levetiracetam preferred over phenytoin — fewer drug interactions; non-inferior for status epilepticus (ESETT trial)
Tier 3 — Know the Key Points & Distinctions Nuanced questions appear regularly
💉
DKA & HHS — JBDS 2023 CURRENT
FRIII · Euglycaemic DKA · SGLT-2i · HHS Distinction
▼
>11Glucose (mmol/L)
<7.3pH
<15Bicarbonate (mmol/L)
>3.0Blood ketones (mmol/L)
FRIII — JBDS 2023Fixed Rate Insulin Infusion = 0.1 units/kg/hr (actual body weight, max 15 units/hr)
  • DO NOT give IV insulin bolus — risk of precipitous hypoglycaemia and hypokalaemia
  • Continue long-acting insulin (Lantus/Levemir) at usual dose throughout — prevents rebound ketosis on stopping FRIII
  • Add 10% glucose 125 ml/hr when BG falls to <14 mmol/L — allows continued FRIII to clear ketones
  • Add potassium 40 mmol/L to fluids if K⁺ <5.5 mmol/L (confirm urine output first)
  • Sodium bicarbonate: NOT indicated in DKA regardless of pH — paradoxical CSF acidosis, worsens hypokalaemia, no outcome benefit. Never select in SBA
Resolution Criteria
>7.3pH
>15Bicarbonate (mmol/L)
<0.6Blood ketones (mmol/L)
Euglycaemic DKA — Increasingly Examined
🔮Euglycaemic DKA = glucose <11 mmol/L despite ketosis + acidosis. Key cause: SGLT-2 inhibitors (empagliflozin, dapagliflozin, canagliflozin) — now widespread in T2DM and heart failure with reduced EF. Also: fasting/low-carb diet, pregnancy, partial insulin use. Treat identically to standard DKA with FRIII; add 10% glucose earlier (from outset) to maintain BG 8–12 mmol/L while continuing insulin to clear ketones. Can occur in T2DM, not just T1DM.
FeatureDKAHHS
Glucose>11 mmol/L>30 mmol/L
OsmolalityVariable>320 mosmol/kg
Ketones>3 mmol/L (strongly positive)Absent/minimal (<3)
AcidosisYes (pH <7.3)No (pH >7.3)
Insulin infusion0.1 units/kg/hr0.05 units/kg/hr (only if ketones >1.0)
Fluid replacement0.9% NaCl; replace over hours0.9% NaCl; reduce osmolality 3–8 mosmol/kg/hr; over 24–72h
VTE riskModerateVery high — LMWH mandatory throughout
🫀
Pulmonary Embolism — ESC 2019 / 2024 Update
Risk Stratification · PESI · Thrombolysis · YEARS · Duration
▼
Risk CategoryCriteriaManagement
High RiskSBP <90 mmHg / drop ≥40 mmHg for >15 min / vasopressors requiredImmediate systemic thrombolysis (alteplase 100 mg/2h); if fails/CI → surgical embolectomy or catheter-directed
Int-HighPESI III–IV or sPESI ≥1 + RV dysfunction (echo/CT) + elevated troponinLMWH/UFH; HDU/ICU monitoring; rescue thrombolysis if deterioration
Int-LowPESI III–IV or sPESI ≥1 — but only RV dysfunction OR troponin (not both)Anticoagulation; hospitalisation
Low RiskPESI I–II or sPESI 0DOAC; early discharge/outpatient treatment
🚨Systemic thrombolysis — Alteplase 100 mg over 2h. Absolute CI: haemorrhagic stroke ever, ischaemic stroke <3 months, CNS tumour, active internal bleeding, major surgery <3 weeks, significant head trauma <3 months. In cardiac arrest secondary to PE: 50 mg IV bolus (modified regimen).
YEARS Algorithm (Diagnostic)
  • 3 criteria: (1) signs of DVT, (2) haemoptysis, (3) PE most likely diagnosis
  • 0 criteria: exclude if D-dimer <1000 ng/ml; ≥1 criteria: exclude if D-dimer <500 ng/ml; otherwise: CTPA
  • Reduces CTPA rate by ~14% vs standard Wells + D-dimer
  • Age-adjusted D-dimer: (age × 10 µg/L if age >50) — increases specificity for PE exclusion in elderly
  • DOACs preferred for stable PE — rivaroxaban 15 mg BD × 21d then 20 mg OD; apixaban 10 mg BD × 7d then 5 mg BD
  • Antiphospholipid syndrome: DOAC inferior to warfarin — use LMWH bridge to warfarin
  • Cancer-associated VTE: DOAC or LMWH (CARAVAGGIO, SELECT-D); LMWH remains option for GI tumours due to DOAC bleeding risk
  • Duration: provoked (surgical) = 3 months; provoked (non-surgical transient) = 3–6 months; unprovoked = indefinite extended therapy after weighing bleeding risk
💥
Subarachnoid Haemorrhage — NICE NG228 (2022)
Grading · Nimodipine · DCI vs Vasospasm · SIADH vs CSW
▼
WFNS Grade
  • I: GCS 15
  • II: GCS 13–14, no motor deficit
  • III: GCS 13–14 + motor deficit
  • IV: GCS 7–12
  • V: GCS 3–6
Modified Fisher (CT — vasospasm risk)
  • 1: No SAH, no IVH
  • 2: Thin SAH, no IVH
  • 3: Thin SAH + IVH
  • 4: Thick SAH ± IVH (highest risk)
60 mgNimodipine oral (q4h)
21 daysNimodipine duration
4–14DCI risk window (days)
<24 hrsSecure aneurysm (coiling preferred)
🔵 Vasospasm vs DCI — Critical DistinctionVasospasm = radiological (TCD MCA velocity >120 cm/s; CT angiography). DCI (Delayed Cerebral Ischaemia) = clinical — new neurological deficit or infarct not otherwise explained (days 4–14). Not all vasospasm causes DCI; DCI can occur without vasospasm. Treat DCI (new focal deficit), not asymptomatic vasospasm.
⚠️ SIADH vs Cerebral Salt Wasting — Critical DistinctionBoth cause hyponatraemia with high urine sodium. SIADH = euvolaemic/hypervolaemic → fluid restrict. CSW = hypovolaemic (negative sodium balance) → IV sodium replacement + fluids. Fluid restriction in CSW is DANGEROUS — worsens hypovolaemia and DCI risk. In SAH, CSW is probably more common. Assess volume status carefully — not by CVP alone.
  • Nimodipine reduces DCI risk — give to ALL aSAH patients regardless of severity
  • Induced hypertension ONLY after aneurysm secured — target SBP 160–200 mmHg for symptomatic vasospasm
  • Maintain euvolaemia (not hypervolaemia) — triple-H therapy no longer recommended
  • Cardiac complications: neurogenic stunned myocardium; ECG changes (QTc prolongation, T-wave inversion, ST changes) — not ischaemia; troponin may rise; echo shows wall motion abnormalities
  • Phenytoin associated with worse outcomes in SAH — use levetiracetam for seizure prophylaxis
🏥
Acute Liver Failure — EASL / King's College Criteria
KCC · NAC · Cerebral Oedema · Coagulopathy Nuance
▼
Paracetamol ALF — KCC
  • pH <7.25 post-resuscitation (regardless of encephalopathy)
  • OR all 3: INR >6.5 + creatinine >300 µmol/L + Grade III–IV encephalopathy
  • Lactate >3.5 mmol/L at 4h or >3.0 mmol/L at 12h post-resuscitation (additional criterion)
Non-Paracetamol ALF — KCC
  • INR >6.5 (PT >100s) regardless of encephalopathy
  • OR 3 of 5: age <10 or >40; aetiology (seroneg hepatitis, halothane); jaundice→encephalopathy >7d; INR >3.5; bilirubin >300 µmol/L
  • N-Acetylcysteine (NAC): paracetamol ALF — effective within 24h; continue even if late presentation; also give in non-paracetamol ALF (ALFSG trial 2009 — improved transplant-free survival in Grade I–II encephalopathy 40% vs 27%)
  • Do NOT correct INR unless active bleeding or invasive procedure — INR reflects synthetic function, not actual bleeding risk; ROTEM more useful; VitK is reasonable (if deficient)
  • Cerebral oedema (Grade III–IV): ICP monitoring; mannitol 20%; hypertonic saline Na target 145–155; avoid benzodiazepines; short-acting sedation
  • Hypoglycaemia: common (impaired gluconeogenesis); monitor hourly; 10–50% glucose infusion
  • Any KCC-positive patient: discuss with liver transplant centre urgently
🦠
Infective Endocarditis — ESC 2023 CURRENT
Duke Criteria · Surgical Indications · Endocarditis Team · Regimens
▼
Major Criteria
  • Blood cultures: typical organism ×2 or persistent bacteraemia
  • Echo: vegetation, abscess, new partial dehiscence of prosthetic valve, new regurgitation
  • Positive FDG-PET/CT or SPECT-CT (prosthetic valve — added in ESC 2023)
Minor Criteria
  • Predisposing condition / IV drug use
  • Fever >38°C
  • Vascular phenomena (septic emboli, Janeway lesions)
  • Immunological phenomena (Osler nodes, Roth spots, RF)
  • Positive blood culture not meeting major criteria
🔪Urgent surgery for: (1) Heart failure — severe AR/MR/valve obstruction causing pulmonary oedema/cardiogenic shock; (2) Uncontrolled infection — abscess, fistula, heart block, persistent bacteraemia >7d, increasing vegetation on antibiotics; (3) Embolism prevention — vegetation >10mm with prior embolism, >15mm mobile, >30mm isolated. Surgical timing: emergency (24h), urgent (days), elective (weeks).
🔵 Endocarditis Team — ESC 2023 Key Addition"Endocarditis team" concept enshrined in ESC 2023: cardiologist + cardiac surgeon + ID/microbiology specialist + neurologist (if embolic events) — multidisciplinary management at IE-referral centre. This is directly examinable. Mortality reduced when managed at specialist centres with endocarditis team.
  • Streptococcal NVE: Amoxicillin/Penicillin G × 4 weeks ± gentamicin (2 weeks only — nephrotoxicity risk)
  • Staphylococcal NVE: Flucloxacillin 12g/day × 4–6 weeks; MRSA → vancomycin ± rifampicin
  • Staphylococcal PVE: Flucloxacillin + rifampicin + gentamicin × 6 weeks (gentamicin first 2 weeks only)
  • Enterococcal: Ampicillin + ceftriaxone × 6 weeks (equal to ampicillin + gentamicin; less nephrotoxicity)
💗
Organ Donation — NHSBT / NICE NG135 CURRENT
DBD · DCD Maastricht · Opt-Out 2020 · NRP · Hormonal Resuscitation
▼
Maastricht Cat.DescriptionUK Use
IDead on arrivalRare
IIUnsuccessful resuscitation (uncontrolled DCD)Specialist centres
IIIPlanned withdrawal of life-sustaining treatment (controlled DCD)Most common UK DCD
IVCardiac arrest in a brain-dead patientOccasional
VUnexpected cardiac arrest in ICUEmerging
⚖️Opt-out legislation: Organ Donation (Deemed Consent) Act 2019 — England; deemed consent for adults resident in England >12 months who have not opted out. Does NOT override family objection in practice. Human Tissue Act 2004 — governs consent, storage and use of human tissue. Elective ventilation solely for organ donation: NOT legal without prior consent (unlike anaesthesia for surgery).
60–80DBD MAP target (mmHg)
4–10CVP (mmHg)
<155Na target (mmol/L)
>80Hb target (g/L)
🔮Normothermic Regional Perfusion (NRP) in DCD: ECMO-based technique after cardiac arrest in Cat III DCD — restores normothermic oxygenated perfusion to abdominal organs before retrieval (arch vessels clamped to prevent brain reperfusion). Significantly improves DCD liver graft function and reduces primary non-function. Standard practice at most UK DCD centres now. Know this concept.
  • Hormonal resuscitation (DBD haemodynamic instability): T3 4µg bolus then 3µg/hr; vasopressin 0.5–4 u/hr; methylprednisolone 15 mg/kg IV; insulin infusion (glucose 4–8 mmol/L)
  • SNOD (Specialist Nurse in Organ Donation) — involve early; family approach must be separated from withdrawal decision discussion
🌬️
Tracheostomy — TRACMAN / NTSP / DAS Emergency
TRACMAN · PDT Techniques · Emergency Airway · Decannulation · Speaking Valves
▼
⚠️TRACMAN (2013): Early (day 1–4) vs late (>day 10) tracheostomy — NO difference in 30-day mortality, ICU stay, sedation use, or VAP. Do NOT rush to tracheostomy. Consider if ventilation anticipated >10–14 days.
NTSP Emergency Algorithm — Maturity Matters
🚨Immature stoma (<7 days): Do NOT attempt blind tracheostomy reintubation — false passage risk. Attempt oral intubation first; if fails → surgical airway (eFONA). Mature stoma (≥7 days): Attempt tracheostomy tube reinsert (same size or one smaller); if fails → oral intubation; if fails → eFONA. Mandatory bedside equipment: dilators, spare tube (same + smaller), suction, syringe, ETT.
  • PDT: Ciaglia Blue Rhino (single-step, guidewire, bronchoscope-guided) most common in UK
  • PDT contraindications: INR >1.5, Plt <50, FiO₂ >0.6, high PEEP, neck anatomy issues, <10 years age, emergency
  • Always bronchoscope-guided PDT — reduces posterior wall injury and malposition
  • Decannulation requires: GCS ≥8, cuff deflation tolerated ≥24h, secretions manageable, not ventilator-dependent, passes cough/swallow assessment
  • Passy-Muir speaking valve: one-way; inhalation via trache, exhalation via larynx; cuff MUST be fully deflated — otherwise obstruction; benefits: speech, swallow, secretion management
🦠
VAP / HAP — IDSA 2016 / ESICM
Prevention Bundle · SDD Controversy · Short-Course Antibiotics · CPIS Diagnosis
▼
  • HOB 30–45°; daily sedation hold; oral chlorhexidine 0.12–0.2%; subglottic secretion drainage tubes; closed suction systems; avoid unnecessary reintubation
  • Short-course antibiotics: 7 days — non-inferior to 14 days; exception: Pseudomonas/Acinetobacter may need longer (8–14 days) due to relapse risk
  • PCT-guided de-escalation — safe, reduces antibiotic days (PRORATA)
  • BAL (≥10⁴ CFU/ml) — most accurate diagnosis; reduces antibiotics vs non-invasive methods
🔵 SDD/SOD Controversy — Know Both SidesSDD (selective digestive decontamination): oral + enteral non-absorbable antibiotics + short systemic cephalosporin; multiple European trials showed VAP reduction and mortality benefit (de Jonge 2003, ICHE 2009). SuDDICU trial (2022, Australia/NZ): SDD — NO 90-day mortality benefit in a setting with higher baseline antibiotic resistance than European studies. Conclusion: SDD effective in low-resistance environments; may select for MDR organisms in high-resistance settings. Not universally adopted in UK — ongoing debate.
🤱
Obstetric Critical Care — MBRRACE / RCOG Guidelines
MgSO₄ Protocol · Magnesium Toxicity · PPH Uterotonics · Perimortem CS
▼
📊MBRRACE-UK — maternal mortality audit; leading causes of death: cardiovascular disease (1st), thromboembolism, neurological, sepsis. Systemic trends: indirect causes overtaking direct causes; mental health deaths; Black women at higher risk (5× white women). These inequality issues are increasingly examined.
MgSO₄ — Magpie Trial Protocol Loading: 4g IV over 5–15 min   Maintenance: 1g/hr IV for ≥24h post-delivery or last seizure   Recurrent seizure: 2–4g IV bolus
🚨Magnesium toxicity: Therapeutic range 2–3.5 mmol/L. Loss of patellar reflexes ~3.5–5 mmol/L → stop infusion. Respiratory arrest ~6–7.5 mmol/L. Cardiac arrest >15 mmol/L. Antidote: 10% calcium gluconate 10 ml IV — keep at bedside at all times. Monitor urine output ≥25 ml/hr; reduce dose in renal impairment.
  • Antihypertensives — severe PET (SBP ≥160 mmHg): Labetalol IV (20 mg bolus to 300 mg total; or 20–160 mg/hr infusion) 1st line; Hydralazine 5 mg IV boluses 2nd line; Oral nifedipine MR — effective; do not combine with MgSO₄ (hypotension/neuromuscular block)
  • ACEi and ARBs: CONTRAINDICATED in pregnancy
  • TXA (WOMAN trial): give within 3 hours of PPH; reduces death from PPH by 31%
  • PPH uterotonics: Oxytocin → Ergometrine (avoid in hypertension) → Carboprost (avoid in asthma) → Misoprostol PR/SL
🔵 Perimortem Caesarean SectionCardiac arrest in pregnancy ≥20 weeks: standard ALS + deliver within 5 minutes of arrest onset at the bedside (not in theatre). Aortocaval compression by gravid uterus significantly impairs CPR effectiveness and venous return. Delivery may also aid maternal resuscitation by relieving this compression.
Difficult Airway Society (DAS) Airway guidelines — high exam yield for ICM
😤
DAS 2025 — Unanticipated Difficult Tracheal Intubation NEW 2025
Plan A→D · Physiologically Difficult Airway · First-Pass Success · eFONA · Human Factors
▼
⚡DAS 2025 Guidelines (Ahmad et al., BJA December 2025) supersede the DAS 2015 guidelines. 65 recommendations from 3-year systematic review (1,241 papers, 3-round Delphi process). Core algorithm (Plan A→D) is maintained but substantially updated. This is now the definitive UK airway guideline.
Core Algorithm — Plan A → B → C → D
DAS 2025 Linear Algorithm — Progress rapidly if failure occurs
A
Tracheal Intubation
Maximise first-attempt success: correct patient positioning (ear-to-sternal notch for obese/high-risk), optimal pre-oxygenation, video laryngoscopy as primary tool, bougie/stylet use, appropriate blade size. Limit to 3 attempts maximum (including attempt by most experienced person available). Maintain oxygenation between attempts. Declare "failed intubation" at 3 attempts. Confirm placement with waveform capnography — mandatory.
B
Supraglottic Airway Device (SAD) Ventilation
2nd generation SAD preferred (i-gel, ProSeal LMA, Supreme LMA) — provide better seal, allow gastric tube passage. Maximum 3 attempts. If SAD successful and ventilation adequate: consider "wake up" if feasible; if proceeding under SAD, evaluate whether intubation through SAD is appropriate (Aintree technique). 2025 update: SAD can also be used as conduit for intubation via bronchoscope.
C
Face Mask Ventilation
2-person technique if needed (4-handed). Oral ± nasal airway adjuncts. If face mask ventilation is successful: wake patient up if possible. Assess ability to wait for further senior help vs proceed to Plan D.
D
Emergency Front of Neck Access (eFONA) — CICO
"Can't Intubate, Can't Oxygenate": scalpel-bougie-tube technique preferred in adults. Horizontal stab incision through skin → cricothyroid membrane → bougie (or finger dilate) → 6.0 cuffed ETT or Portex tracheostomy tube. Do NOT use needle cricothyroidotomy in adults — high failure rate, inadequate ventilation, kinking. Jet ventilation only if purpose-built device available. Confirm with capnography.
Key 2025 Updates vs 2015
  • Video laryngoscopy — universal use expected as primary Plan A tool; recommended as default where available (not "if video laryngoscope available" — it should be available); improves glottic view but does NOT guarantee success; tube delivery may be harder on VL without bougie
  • Physiologically difficult airway — new concept in 2025: patient with abnormal physiology (haemodynamic instability, severe hypoxia, high aspiration risk, metabolic acidosis) requiring modified approach regardless of anatomical difficulty; pre-oxygenation and haemodynamic optimisation before intubation
  • Pre-oxygenation — HFNO 60 L/min FiO₂ 1.0 for 3–5 min (apnoeic oxygenation throughout); NIV/CPAP for patients with de-saturating or respiratory failure; 25° head-up position; ear-to-sternal notch (ramp position) for obesity
  • First-pass success — maximising first-attempt intubation success is prioritised (not just managing failure); bougie/stylet use routine with VL; muscle relaxation (rocuronium 1.2 mg/kg) optimises laryngoscopy conditions
  • Human factors — team briefing, role assignment, cognitive aids (difficult airway trolley checklist), simulation training, clear communication and escalation; 2025 guidelines emphasise systems and people as much as devices
  • POCUS in airway — pre-tracheal ultrasound to identify cricothyroid membrane (especially in obesity/anatomically difficult), confirm tracheal tube position (ring-down artefact), confirm bilateral lung sliding post-intubation
  • Documentation & follow-up — mandatory: document what happened, what device worked, why failure occurred if applicable, plan for extubation/future airway. Patient letter recommended. Alert bracelet/system where appropriate.
Physiologically Difficult Airway — New 2025 Concept
🔴Patients with: (1) Haemodynamic instability — RSI may cause cardiovascular collapse; give push-dose vasopressors (metaraminol 0.5–1 mg, phenylephrine 100 mcg, or dilute adrenaline) and fluid pre-load; ketamine preferred induction agent; (2) Severe hypoxia — pre-oxygenate aggressively with HFNO ± NIV; accept lower SpO₂ threshold to act vs waiting for perfect conditions; (3) Obesity/high aspiration risk — head-up position, modified RSI with cricoid pressure, consider awake intubation; (4) Metabolic acidosis — post-intubation respiratory acidosis can be fatal; maintain high RR post-intubation; avoid apnoeic periods
RSI in ICU Context (DAS 2025)
  • Induction agents: Ketamine 1–2 mg/kg — preferred in haemodynamic instability (sympathomimetic); bronchodilator; preserves airway reflexes. Propofol 0.5–1.5 mg/kg — use cautiously in cardiovascular instability. Thiopentone 3–5 mg/kg — rapid offset; cardiovascular depression
  • Muscle relaxant: Rocuronium 1.2 mg/kg — preferred for RSI (sugammadex 16 mg/kg available for reversal); Suxamethonium 1.5 mg/kg — when rocuronium not available or specific indication; avoid in hyperkalaemia, burns, crush injury, neuromuscular disease
  • Sugammadex — must be immediately available if rocuronium used for RSI; 16 mg/kg IV for immediate reversal of 1.2 mg/kg rocuronium
  • Post-intubation: anticipate and prevent hypotension (vasopressors at bedside before starting); start sedation infusion before induction
👁️
DAS 2019 — Awake Tracheal Intubation (ATI) CURRENT
Indications · AFOI vs Awake VL · Topicalisation · Sedation Options
▼
💡ATI preserves spontaneous ventilation and airway reflexes when predicted or confirmed difficult airway makes general anaesthesia/RSI unsafe. The key indication: when you cannot predict ability to oxygenate after induction. DAS 2019: ATI should be considered whenever predictors of difficult airway management are present.
Indications for ATI
  • Predicted difficult DL/VL (limited mouth opening, neck immobility, distorted airway anatomy)
  • Predicted difficult face mask ventilation AND difficult laryngoscopy simultaneously
  • Obese patients with predicted difficult airway who cannot tolerate supine position
  • Cervical spine instability (rheumatoid arthritis, ankylosing spondylitis, post-trauma) — DAS/AoA/BSOA/ICS/NACCS 2024 guidelines specifically address this
  • Known difficult airway from previous anaesthetic alert
  • Airway obstruction requiring assessment before securing
ATI Protocol — Key Steps
  • Antisialogogue: glycopyrrolate 200 mcg IV 20–30 min before procedure — reduces secretions, improves topicalisation quality
  • Supplemental O₂: HFNO or nasal cannula throughout — must be administered during ATI
  • Topicalisation: lidocaine — maximum dose 9 mg/kg lean body weight; techniques: nebulised (4% lidocaine), "spray-as-you-go" through bronchoscope, Krause forceps for superior laryngeal nerve block, transtracheal injection (4 ml 4% lidocaine); test topicalisation before advancing scope
  • Sedation (optional, cautious): Dexmedetomidine TCI or IV infusion (most evidence, preserves ventilatory drive); Remifentanil TCI Ce 1–2 ng/ml; Midazolam titrated (risk of over-sedation); avoid deep sedation — defeats purpose of ATI
  • AFOI (awake fibreoptic intubation): gold standard — passes scope nasally or orally, visualises vocal cords, rail-roads ETT
  • Awake VL: increasingly used — easier to teach; less secretion-sensitive; good for anticipated difficult laryngoscopy
  • Confirm tracheal placement with capnography before inducing anaesthesia
⚠️ Exam Trap — Failed ATIIf ATI fails: do NOT immediately proceed to Plan A RSI. Consider: (1) further topicalisation optimisation; (2) calling for senior help; (3) awake surgical airway under LA if immediate airway threat; (4) only proceed to RSI if airway is adequate for rescue.
🏥
DAS 2017 — Critically Ill Adults + DAS 2012 Extubation Guidelines
ICU vs Theatre Context · Modified RSI · Pre-Oxygenation · Extubation Risk Stratification
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⚠️Critically ill patients differ from theatre patients: reduced physiological reserve, unstable haemodynamics, high aspiration risk, limited pre-oxygenation time, altered drug pharmacokinetics, reduced team experience with difficult airways, unfamiliar environments. The DAS 2017 guidelines (Higgs et al., Anaesthesia) address all hospital locations outside theatre.
Pre-Intubation Optimisation (DAS 2017/2025)
  • Position: ramped/25° head-up — improves FRC, reduces aspiration risk, improves glottic view; ear-to-sternal notch in obese
  • Pre-oxygenation: HFNO 60 L/min FiO₂ 1.0 for ≥3–5 min; NIV/BiPAP in de-saturating patients; target SpO₂ >95% before intubation; continue HFNO during intubation attempt (apnoeic oxygenation)
  • Haemodynamic preparation: vasopressors at bedside; fluid bolus if hypovolaemic; avoid propofol as sole induction in haemodynamic instability
  • Team briefing: declare difficulty grade, which plan to use, role assignment (laryngoscopist, assistant, drug-giver, capnography), "what is the plan if this fails?"
Modified RSI vs Standard RSI
ElementClassic RSIModified RSI (ICU/Critically Ill)
BMV before intubationAvoided (aspiration risk)Used if SpO₂ falling — oxygenation priority over aspiration risk
Cricoid pressureRoutinely applied (Sellick's manoeuvre)Applied; may be released if impeding laryngoscopy; evidence for benefit limited
Opioid pre-doseNot usedFentanyl 1–2 mcg/kg to blunt intubation response; ketamine analgesic adjunct
Induction agentThiopentone 5 mg/kgKetamine (haemodynamic instability); propofol (lower dose 0.5–1.5 mg/kg)
DAS 2012 Extubation Guidelines — Risk Stratification
DAS Extubation: 4-Step Process
S1
Plan Extubation — Is it safe?
Assess: extubation risk factors (anticipated difficult re-intubation, predicted upper airway problem, general risk factors — obesity, obstructive sleep apnoea, supine procedure); optimise reversible factors first
S2
Prepare for Extubation
Low-risk: standard extubation. At-risk: choose technique — awake extubation (preferred in at-risk), remifentanil TCI (smooth emergence), airway exchange catheter (AEC — Cook), consider extubation to NIV/HFNO if respiratory risk
S3
Perform Extubation
Awake: patient responsive, following commands, protective airway reflexes present. Asleep: only if low-risk and no anticipated difficult re-intubation. Suction; deflate cuff; remove tube; apply O₂ immediately
S4
Post-Extubation Care
HDU/ICU-level monitoring; HFNO or NIV rescue if SpO₂ deteriorates; low threshold for re-intubation (plan and equipment at bedside); avoid "trial and error" re-intubation attempts; predict and prevent laryngospasm (heliox if upper airway obstruction)
💡Airway Exchange Catheter (AEC/Cook): hollow, semi-rigid catheter left in trachea post-extubation; allows O₂ insufflation or re-intubation railroading; patient tolerates with some discomfort; used when re-intubation predicted to be difficult if patient deteriorates; remove after 1–2 hours once extubation success confirmed.
🔵 Cuff Leak Test in ICUBefore extubation in prolonged intubated ICU patients: deflate cuff, occlude ETT — hear/feel air leak around tube. Absence of leak = laryngeal oedema/subglottic swelling; consider dexamethasone (0.1 mg/kg IV, 4 doses 6-hourly before planned extubation) — reduces post-extubation stridor and failed extubation (ADAGIO trial).
FICM / ICS — Guidelines & Standards UK-specific governance and service delivery
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GPICS V3 — Guidelines for the Provision of ICU Services NEW 2026
Levels of Care · Staffing · Governance · Follow-Up · Patient/Family Involvement
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⚡GPICS V3 (January 2026) published by FICM/ICS — the definitive reference for planning, commissioning and delivering adult ICU services in the UK. Supersedes V2.1 (2022). Key changes: terminology updated (standards → minimum standards; recommendations → recommendations for a quality service); patient/family co-production embedded in guidelines development; new chapters on sustainability, equality/diversity/inclusion (EDI), and pandemic preparedness.
Levels of Critical Care
LevelDefinitionNurse:Patient ratio
Level 1Enhanced care — at risk of deterioration; single organ support not requiring ICUVariable (not defined in GPICS as standard ICU)
Level 2HDU — detailed monitoring and intervention; single (non-respiratory) organ support; post-operative1:2 minimum
Level 3ICU — advanced respiratory support (IPPV) OR ≥2 organ support1:1 minimum for IPPV
🔵 GPICS V3 — Minimum Standards (Key Exam Points) "Minimum standards" (previously "standards") are defined as must-do requirements — all UK ICUs expected to meet them or record on a risk register if unmet.

Key minimum standards include:
— ICU must have a designated consultant intensivist responsible for each patient
— Consultant-led ward rounds at least twice daily for level 3 patients
— Consultant direct presence on the unit for ≥16h/day; available 24h
— 1:1 nursing for all IPPV patients (level 3); 1:2 for level 2
— Pharmacist with critical care training on each ward round
— Physiotherapy available 7 days a week
— Microbiologist/ID physician available for antimicrobial advice 24h
— Access to renal support (RRT) 24h
— Echocardiography available 24h
— Critical Care Outreach (CCO) team — 24h availability recommended
CRITCON Levels (ICS 2023 Update)
CRITCON 0Normal ICU function
CRITCON 1Local pressure — increased demand
CRITCON 2Network pressure — regional escalation
CRITCON 3National pressure — exceptional measures
ICU Follow-Up & PICS Care Pathway
  • GPICS V3 recommends ICU follow-up clinics for all level 3 patients as a recommendation for quality service
  • Minimum: formal assessment at hospital discharge + 2–3 month post-ICU clinic
  • PICS domains: cognitive, psychological (PTSD, anxiety, depression), physical (ICUAW, functional impairment)
  • ICU diaries — written by staff and families; reduces PTSD incidence in survivors (Garrouste-Orgeas trial)
  • Rehabilitation needs assessment tool (RNT) — used at discharge from ICU and beyond
  • NICE NG236 (2022) — rehabilitation after critical illness: structured programme from ICU through community
Governance Requirements (GPICS V3)
  • ICUs must participate in a national audit programme — ICNARC (Intensive Care National Audit and Research Centre) in England/Wales; SICSAG in Scotland
  • Multidisciplinary clinical governance meetings including mortality and morbidity analysis — minimum requirement
  • Participation in mortality review programme (structured judgement review or equivalent)
  • Healthcare-associated infection surveillance programme
  • Documentation of pre-admission consultation, agreed ceilings of therapy, and time-limited treatment trials
  • GPICS V3 is used as the benchmark by CQC (Care Quality Commission) for inspection and peer review
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FICM End of Life Care 2019 / ESICM 2024
Withholding · Withdrawal · MCA · Best Interests · ReSPECT · Futility
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📖FICM/FPM "Care at the End of Life" (2019) + NICE NG31 (2015) — Care of the Dying Adult. ESICM published updated end-of-life and palliative care guidelines (2024) — largely consistent with UK framework but with differences in legal/cultural context. Know UK-specific framework.
Key Ethical and Legal Framework (UK)
  • Mental Capacity Act 2005 (MCA): 5 principles — (1) capacity assumed unless proven otherwise; (2) all practicable steps to support decision-making; (3) unwise decisions ≠ lack capacity; (4) best interests; (5) least restrictive option. Capacity is decision-specific and time-specific
  • Best interests decision: when patient lacks capacity — involve family/carers, previous expressed wishes, LPA for health/welfare, advance decision to refuse treatment (ADRT). Best interests = not only medical interests but values, beliefs, quality of life
  • Lasting Power of Attorney (LPA) for Health and Welfare: valid only when patient lacks capacity; LPA can refuse life-sustaining treatment only if specifically stated; cannot demand treatment
  • Advance Decision to Refuse Treatment (ADRT): legally binding if valid, applicable, in writing with witness for life-sustaining treatment; cannot compel treatment
ReSPECT Form (Recommended Summary Plan for Emergency Care)
📋ReSPECT replaces DNACPR in many UK settings — broader tool capturing patient priorities, goals of care, and care in emergency situations. Sections include: clinical summary, personal priorities, and clinically appropriate emergency care (including CPR decision). A ReSPECT form is NOT the same as a DNACPR form — it encompasses more than just resuscitation. It is not legally binding but is a clinical decision tool.
Withholding vs Withdrawing — Key Distinctions
Withholding
  • Not starting a treatment (e.g., not intubating, not starting RRT)
  • Most common form of treatment limitation
  • Ethically equivalent to withdrawal (UK law/ethics)
  • No requirement for patient consent to withhold futile treatment
Withdrawal
  • Stopping an existing treatment (e.g., stopping vasopressors, extubation)
  • Less common; often requires greater documentation and family communication
  • Ethically and legally equivalent to withholding in UK
  • Clinician cannot be compelled to continue treatment deemed futile
  • Doctrine of Double Effect: an action intended to relieve suffering (e.g., opioids for dyspnoea) is permissible even if it may hasten death — intention is key. This is legally accepted in UK law
  • Futility: UK courts have upheld clinicians' right to withhold/withdraw treatment deemed futile even against family wishes — but families must be fully involved in discussions and given time to understand. Seek ethics committee input if dispute
  • Palliative care team involvement — FICM recommends early integration of palliative care for patients with poor prognosis or complex symptom management needs; not just for the dying
Symptom Management at End of Life (ICU)
  • Comfort measures: analgesia (morphine/alfentanil infusion), anxiolytics (midazolam), antisecretory agents (glycopyrrolate), anti-emetics
  • Ventilator withdrawal: typically 2-stage — reduce FiO₂ and PEEP first, then CPAP, then extubate (or leave breathing on CPAP if this is comfortable)
  • Routine monitoring (arterial lines, CVP, invasive monitoring) — discontinue unless required for comfort management
  • Document clearly the goals of care and symptom targets; regular multidisciplinary family meetings
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FICM/ICS/AAGBI — Transfer of Critically Ill Adults
Minimum Standards · Team Composition · Monitoring · Handover · Acceptability Criteria
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🚗FICM/ICS/AAGBI Guidelines for Transfer of Critically Ill Adults — covers both intra-hospital (between clinical areas) and inter-hospital (primary and secondary transfers). All critically ill transfers carry risk; transfers should only occur when the benefits outweigh risks.
Team Composition (Level 3 / ICU Transfer)
  • Minimum 2 suitably trained personnel: one doctor (ST4+ or equivalent ICU/anaesthesia experience, or ACP) + one nurse or paramedic with critical care training
  • Transfer doctor must have: airway management skills, ICU drug knowledge, emergency management skills, familiarity with transport equipment
  • Accompanying nurse — ICU-trained, familiar with transport environment
  • For complex patients: consider consultant-led transfer team
Minimum Monitoring During Transfer
ECGContinuous
SpO₂Continuous
ETCO₂Mandatory (IPPV)
IBPInvasive BP if arterial line
TempActive warming
⚠️ETCO₂ is mandatory during transfer if patient is intubated/ventilated — confirms tube position, detects disconnection/obstruction. Non-negotiable. Do not transfer intubated patients without waveform capnography.
Pre-Transfer Stabilisation — Minimum Standards
  • Airway secured and confirmed (ETT, cuffed trache) — do NOT transfer with unsecured airway if avoidable
  • Adequate IV access (minimum 2 large-bore peripheral or one CVC/IO)
  • Haemodynamic stability achieved or attempt made — document if transferred with ongoing instability
  • Adequate O₂ supply calculated (consider FiO₂, ventilator dead space, journey time × 2 as safety margin)
  • Drug infusions checked and adequate for journey + contingency
  • Full documentation: current status, monitoring trends, drug infusions, transfer letter, radiological images
ATMIST / SBAR Handover
ATMIST
  • Age/sex
  • Time of incident/admission
  • Mechanism of injury/diagnosis
  • Injuries/conditions found
  • Signs (vital signs, clinical status)
  • Treatment given
SBAR
  • Situation — who/what
  • Background — context
  • Assessment — clinical findings
  • Recommendation — what do you need?
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FICM — Clinical Frailty Scale & POCUS in ICU
CFS in ICU Admission · FICM POCUS Guidance · Ultrasound Applications
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Clinical Frailty Scale (CFS) in ICU
👴CFS — validated tool for frailty assessment; increasingly embedded in ICU triage and end-of-life decision-making. GPICS V3 recommends frailty assessment for all ICU admissions.
1–3Not frail — independent, active
4Vulnerable — not dependent
5–6Mildly/moderately frail — some dependence
7–9Severely frail → terminal illness
  • CFS should be based on pre-morbid status (2 weeks before acute illness onset) — NOT current acute functional status
  • CFS ≥5 associated with significantly worse ICU outcomes; CFS ≥7 — very high 1-year mortality
  • CFS alone should NOT determine ICU admission decisions — it is one factor in holistic assessment
  • COVID-19 used CFS ≥7 as indicator for critical care triage during pandemic — CFS emerged as nationally significant tool during this period
  • CFS in acute illness: assess based on baseline, not acute presentation; frailty is not synonymous with age
FICM POCUS Guidance — ICU Applications
🔊FICM and FAMUS (Faculty of Acute Medicine Ultrasound) have published joint guidance on point-of-care ultrasound in critical care. GPICS V3 recommends POCUS availability 24h.
Cardiac POCUS
  • LV/RV function (qualitative)
  • Pericardial effusion/tamponade
  • Volume status (IVC collapsibility — limited in IPPV)
  • Valve pathology (gross)
  • Post-cardiac arrest guidance
Lung POCUS
  • Pneumothorax (absent lung sliding)
  • Pleural effusion (quantification)
  • Consolidation (hepatisation)
  • Pulmonary oedema (B-lines)
  • ARDS diagnosis (global def 2024)
Other Applications
  • Vascular access guidance (CVC, arterial)
  • Airway — cricothyroid membrane identification
  • Thoracentesis / paracentesis guidance
  • Bladder volume assessment
  • FAST exam in trauma
🔵 POCUS Limitations — Exam Favourites IVC collapsibility as fluid responsiveness marker: ONLY valid in mechanically ventilated, non-spontaneously breathing, sinus rhythm patients. IVC collapse >50% (spontaneous breathing) or IVC distensibility >18% (mechanically ventilated) suggests fluid responsiveness. Completely invalid in spontaneously breathing patients or those with raised intra-abdominal pressure. TTE windows limited by body habitus, drains, dressings — TOE (trans-oesophageal echo) may be required for adequate cardiac assessment.
📌 Final FFICM SBA Strategy — Consultant-Level Approach
Complete Trial Reference — 2025 Status
ARISE/ProCESS/PROMISE — EGDT abandoned NICE-SUGAR — tight glycaemia harmful ART — aggressive RM harmful OSCILLATE — HFOV harmful ROSE — routine NMB no benefit TRACMAN — no early tracheostomy benefit STARRT-AKI/AKIKI — no early RRT benefit EPaNIC — early PN harmful REDOXS — glutamine in MOF harmful PRESERVE — no NAC/NaHCO₃ for contrast nephropathy MRC CRASH — steroids in TBI harmful EUROTHERM3235 — hypothermia for ICP harmful COACT/TOMAHAWK — no urgent angio without STEMI TTM2 — 33°C no better than normothermia De Backer 2010 — dopamine inferior to noradrenaline SuDDICU — SDD no mortality benefit (high-resistance settings) EFFORT — high-dose protein no benefit; possible harm PROSEVA — prone 16h in P:F <150 reduces mortality ARDSNet/ARMA — 6 ml/kg reduces mortality Magpie — MgSO₄ prevents eclampsia DEXA-ARDS — dexamethasone reduces 60-day ARDS mortality CRASH-2 — TXA within 3h reduces traumatic haemorrhage mortality WOMAN — TXA within 3h reduces PPH death ALFSG (Lee 2009) — NAC improves transplant-free survival in early ALF SMART — balanced crystalloids reduce MAKE30 vs 0.9% NaCl ITACTIC — VHA-guided resus reduces blood product use EOLIA — VV-ECMO trend to benefit in severe ARDS (p=0.07) CESAR — transfer to ECMO centre improves outcome CALORIES — EN not superior to PN in pragmatic UK trial CLASSIC 2022 — restrictive fluid non-inferior in septic shock VASST — vasopressin spares noradrenaline dose DECRA — early DC worse neurological outcomes in TBI RESCUEicp — DC reduces mortality but more vegetative survivors PARAMEDIC2 — adrenaline improves ROSC not neurological outcome MINT 2023 — transfusion threshold nuance in ACS ADAGIO — dexamethasone reduces post-extubation stridor/failure ACURASYS — NMB benefit in ARDS (confounded by sedation)