We used Delphi methodology to provide guidance on gender equality and equity issues in professional life in intensive care, where information is evolving and no clear standard exists. A 12-member Steering Committee (7 women, 5 men) from 7 countries and 46 international panelists [(23 women, 21 men, 2 preferred not to disclose; median age 52 (33–75) years] from 32 countries (43

Background Core outcome measurement sets (COMS) enhance the consistency and comparability of outcome reporting in clinical research. However, their effectiveness depends on the selection of valid, reliable, and feasible measurement instruments. Core outcome sets (COS) and COMS have been developed for specific intensive care unit (ICU) patient subgroups. The aim of this study is to establish a standardised approach to outcome measurement and operationalisation for adults acutely admitted to the ICU who are participating in clinical trials and other clinical research.Methods This protocol describes the development of a COMS for adults acutely admitted to the ICU, the CoreMS-ICU, consisting of six core outcomes: survival, free of life support, free of delirium, out of hospital, health-related quality of life, and cognitive function. We will follow the Consensus-based Standards for the Selection of Health Measurement Instruments guideline and report according to the Core Outcome Set-STAndardised Protocol Items guideline. The development of the CoreMS-ICU will follow five predefined steps: (1) conceptual considerations for the six core outcomes; (2) systematic searches for outcome measurement instruments, including consideration of existing COMS; (3) quality assessment of relevant outcome measurement instruments; (4) consensus-based selection of outcome measurement instruments; and (5) recommendations and guidance on how to operationalise and report the measurement of the six core outcomes. We will involve research panels consisting of key stakeholders: patients, family members, healthcare professionals, and researchers in steps 1 and 4.Conclusions We aim to develop a COMS for adults acutely admitted to ICU patients to facilitate the consistent use of outcomes in trials and enhance the translation of research findings into clinical practice.

OBJECTIVES:RBC transfusions are common in the ICU. Recent studies suggest that a restrictive transfusion policy is noninferior or superior to a liberal policy. However, few studies focus on the influence of age in transfusion. In elderly ICU patients, reduced physiologic reserves may shift the perceived risk-benefit balance of transfusion, potentially leading to different transfusion practices. This study examines whether transfusion practices in ICU patients differ across patient age. DESIGN:This is a substudy of the International Point Prevalence Study of ICU Transfusion Practices (InPUT), a global, multicenter, prospective observational cohort study. SETTING:ICUs from 233 centers across 30 countries. Data were collected from March 2019 to October 2022 in prespecified weeks. PATIENTS:Adult ICU patients (≥ 18 yr) admitted during predefined study weeks. Patients were categorized by age (< 65, 65-75, 75-85, and > 85 yr). INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:A total of 3643 patients from 233 centers across 30 countries were included. Of these, 53% were younger than 65 years, 26% were 65-75 years, 17% were 75-85 years, and 4% were older than 85 years. RBC transfusion rates ranged from 23% to 26% across all age groups ( p = 0.91). Patients older than 85 years had higher stated hemoglobin thresholds (median, 10.0 g/dL) compared with younger patients (median, 8.0 g/dL; p < 0.001). "Age" and "improve general state" were more frequently cited as reasons for transfusion in patients older than 85 years. However, after adjustment, age was not associated with the probability of receiving an RBC transfusion. CONCLUSIONS:Different transfusion strategies are applied in patients older than 85 years old. These differences appear to be driven by age-related differences in physiology and diagnoses rather than motivated by older age itself.

BACKGROUND:The reasons and physiological triggers for blood transfusion in critically ill patients are not well characterized. Beyond hemoglobin levels, hemodynamic instability is frequently cited, but its role across clinical contexts remains unclear. AIMS:(1) To determine whether reasons and triggers for RBC transfusion differ across intensive care unit (ICU) days with varying transfusion intensity. (2) To describe reasons for non-RBC transfusions across these intensity groups. METHODS:This sub-study of the prospective International Point Prevalence Study of Intensive Care Unit Transfusion Practices (InPUT) classified ICU days by transfusion intensity: nonmajor (1 RBC unit), major (≥2 units), and massive (≥6 units in a single event, ≥10 per day, or Massive Transfusion Protocol activation). ICU days without transfusion for active bleeding were classified as no bleeding. RESULTS:Significant differences in the multivariate composition of reasons for RBC transfusion were observed across intensity groups on permutational analysis of variance (PERMANOVA). Hypotension was the most frequently cited physiological trigger in nonmajor (54%, n = 80/148) and major transfusions (68%, n = 196/288), but less frequent in massive transfusions (30%, n = 14/64). Tachycardia was the second most common trigger in nonmajor (37%, n = 80/148), major (40%, n = 116/288), and massive transfusions (22%, n = 19/64). CONCLUSION:RBC transfusions are administered for distinct, intensity-dependent combinations of reasons and triggers. Transfusion intensity and clinical context are therefore key factors in evaluating transfusion practices. Among bleeding critically ill patients, hypotension and tachycardia are the most frequently cited physiological triggers.

Nosocomial infections or healthcare-acquired infections are a common cause of increased morbidity and mortality among hospitalized patients. Cancer patients are at an increased risk for these infections due to their immunosuppressed states. Considering these adverse effects on and the socioeconomic burden, efforts should be made to minimize the transmission of these infections and make the hospitals a safer environment. These infection rates can be significantly reduced by the implementing and improving compliance with the “care bundles.” This chapter will address the common nosocomial infections such as ventilator-associated pneumonia (VAP), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSI), including preventive strategies and care bundles for the same.

Background Tracheal intubation is a common yet high risk procedure in the critically ill with as many as half experiencing peri-intubation adverse outcomes. Research Question We aimed to evaluate the comparative effectiveness and safety of various sedative agents used for endotracheal intubation of the critically ill patient in the emergency department, intensive care unit, operating room, and pre-hospital setting. Study Design & Methods We conducted a network meta-analysis and systematic review of randomized controlled trials. We searched MEDLINE, EMBASE, PubMed, Cochrane, and trial registries from inception to December 10, 2025 for Randomized controlled trials (RCTs) comparing two or more sedative agents in critically ill adults or children undergoing endotracheal intubation. Outcomes of interest were hemodynamic instability during intubation, hypoxemia, cardiac arrest, mortality, intensive care unit and hospital length of stay, vasopressor use, adrenal insufficiency, and first-pass success. Reviewers screened, extracted data, and assessed risk of bias using the Cochrane RoB 2 tool independently and in duplicate. We performed frequentist random-effects model network meta-analysis and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rate certainty in estimates. Results We included 21 RCTs enrolling 6,031 patients across Intensive Care Unit, Emergency Department, Operating Room, and pre-hospital settings. Compared with etomidate, there is probably more hemodynamic instability during intubation with ketamine (RR 1.31, 95% CI 1.15-1.48; moderate certainty). Ketamine-propofol may decrease hemodynamic instability during intubation compared with etomidate (RR 0.44, 95% CI 0.27-0.72; low certainty) and ketamine (RR 0.34, 95% CI 0.21-0.56; low certainty). Compared with etomidate, ketamine may decrease the need for the initiation of post-intubation continuous infusion vasopressors (RR 0.80, 95% CI 0.50-1.28; low certainty). Etomidate caused increased adrenal suppression compared with other agents. Interpretation When considering sedation agents for endotracheal intubation of the critically ill, etomidate probably causes less hemodynamic instability during intubation when compared with ketamine. However, etomidate may increase the need for the initiation of post-intubation continuous infusion vasopressors when compared with ketamine and increases adrenal suppression. The clinical importance of these competing effects remains uncertain. Ketamine-propofol may decrease hemodynamic instability during intubation when compared with etomidate and ketamine though the available evidence is too limited and uncertain to support firm conclusions and further randomized trials are needed.

INTRODUCTION:More than 300 million major surgical procedures are carried out under general anaesthesia each year worldwide, and advanced airway management remains one of the leading daily challenges for clinicians. Data from large international prospective cohort studies on adverse events such as cardiovascular collapse, cardiac arrest and severe hypoxaemia during advanced airway management to facilitate anaesthesia are lacking. METHODS AND ANALYSIS:The International obServational sTudy on AiRway manaGement in operAting room and non-operaTing room anaEsthesia (STARGATE) study will be an international prospective observational cohort study describing the incidence of major adverse events associated with advanced airway management (tracheal intubation or supraglottic airway device placement) for general anaesthesia in the operating and non-operating room for surgery and medical procedures. The secondary aim will be to describe the practice of airway management in a large international cohort. Critically ill patients will be excluded from this study. Data on patients' characteristics, type of procedure and the adopted airway management strategy, post-procedure adverse events, operator characteristics and in-hospital mortality will be prospectively collected. The study aims to enrol 10 500 patients. ETHICS AND DISSEMINATION:The study has been approved by the Ethics Committee of the coordinating centre (Comitato Etico Interaziendale AOU San Luigi Gonzaga, N° 25/2023). Each of the participating centres will then seek approval of their local Ethics Committee before enrolment. Data will be disseminated to the scientific community by original articles submitted to international peer-reviewed journals. TRIAL REGISTRATION NUMBER:NCT05759299.

A recent Delphi consensus highlighted elements for defining refractory septic shock. We assessed whether integrating persistent tissue hypoperfusion with vasopressor dose after protocolized resuscitation improves mortality risk stratification compared with vasopressor dose alone. We performed an exploratory secondary analysis of the ANDROMEDA-SHOCK-2 trial. After 6 h of hemodynamic resuscitation, refractoriness was operationalized as a norepinephrine equivalent dose (NEE) > 0.5 µg/kg/min plus an abnormal capillary refill time (> 3 s) and non-decreasing lactate (two-hypoperfusion criteria). A complementary analysis included NEE > 0.5 µg/kg/min combined with either of the tissue perfusion criteria. The primary outcome was 28-day mortality. Among 1363 patients with complete data, 188 (13.8

BACKGROUND:We compared the efficacy of chlorhexidine-impregnated central lines (CLs) with plain CLs in preventing central line-associated bloodstream infections (CLABSIs) in critically ill patients. METHODS:The study was conducted from April 2023 to August 2024 in 8 hospitals across India, Malaysia, Papua New Guinea, Colombia, Egypt, and Turkey. Data were collected prospectively using the INICC Surveillance Online System. Cases and controls were recruited simultaneously. Data were analyzed using t tests, χ² tests, and Fisher exact tests when indicated. Relative risks (RR) and their corresponding 95% confidence intervals (CI) were calculated. RESULTS:A total of 6,672 patients were included. Patients with impregnated CLs had 4,721 CL-days, while those with plain CLs had 18,822 CL-days. The CLABSI rate in patients with impregnated CLs was 1.48 per 1,000 CL-days, compared to 4.78 per 1,000 CL-days in those with plain CLs (RR=0.31, 95%CI=0.14-0.67, P=.003). A subgroup analysis excluding patients with hemodialysis but using central venous catheters (CVCs) showed 1.72 CLABSIs per 1,000 CL-days in patients with impregnated CVCs compared to 5.84 per 1,000 CL-days in those with plain CVCs (RR=0.29, 95%CI=0.12-0.68, P=.004). CONCLUSIONS:This study highlights the significant benefits of impregnated CLs over plain CLs in reducing CLABSI rates, achieving a 69% decrease in incidence.

INTRODUCTION:Postoperative pulmonary complications (PPCs) represent a significant cause of postoperative morbidity and even mortality. However, there is a lack of consensus regarding this composite endpoint, the definition of the individual components, classification and optimal outcome measures. This study aims to refine the PPCs composite framework by evaluating its construct validity, assessing the necessity and risks of a composite measure and exploring the feasibility of differentiating severity categories. METHODS:A Delphi consensus process will be conducted, engaging an international multidisciplinary group of 30-40 panellists, including clinicians, researchers, patients, public representatives and health economists. Through iterative rounds, the study will seek agreement on the individual components of the PPCs composite. Additionally, consensus will establish a framework for a composite outcome measure based on a standardised severity classification, appropriate timeframes and weighted grading of PPCs. ANALYSIS:Consensus, defined by ≥75% concurrence in multiple choice questions or on Likert-scale statements, will be evaluated from round 2 onwards. Delphi rounds will be continued until all statements have reached stability of responses evaluated by χ2 tests or the Kruskal-Wallis test. ETHICS AND DISSEMINATION:The study will be conducted in strict compliance with the principles of the Declaration of Helsinki and will adhere to ACCORD guidance for reporting. Ethics approval has been obtained for this study from the University of Wolverhampton, UK (SOABE/202425/staff/3). Informed consent will be obtained from all panellists before the commencement of the Delphi process. The results of the study will be published in a peer-reviewed journal with the authorship assigned in accordance with ICMJE requirements. TRIAL REGISTRATION NUMBER:NCT06916598 (clinicaltrials.gov).

The paediatric airway differs from the adult airway both anatomically and physiologically. These guidelines are recommended for use in unanticipated difficult airways in children aged 1-12 years. If the initial intubation attempt fails, the anaesthesia team should "Call for help" (Code D) and prioritise providing oxygen to maintain peripheral oxygen saturation (SpO2) above 95%. While awaiting help, the anaesthesia team may re-attempt tracheal intubation, this time by a more experienced operator, after reoptimising position and considering alternate airway devices. The anaesthesiologist may opt for a 2nd generation supraglottic airway (SGA) device as a rescue device or continue the anaesthetic using a face mask (FM). Maintaining oxygenation throughout the period is essential. The current guidelines introduce a circular design for the algorithm, allowing device interchangeability. If satisfactory oxygenation is achieved with either a 2nd generation SGA device or FM, the decision to continue anaesthesia or wake the child will depend on the urgency of the procedure and the comfort of the anaesthesiologist. If satisfactory ventilation cannot be maintained with a 2nd generation SGA device or FM or following a failed tracheal intubation, declare "complete ventilation failure" and prepare for an emergency surgical airway. The options for emergency surgical airway depend on the availability of trained surgical help and the age of the child. Post-resuscitation care should address the various steps taken to return the child to normalcy and to discharge. This should include giving an "Airway Alert Card" to the parents to avoid similar life-threatening situations in future.

BACKGROUND:Clinical practice guidelines recommend use of buffered crystalloid solutions in critically ill patients but do not distinguish between solutions based on different buffering anions, that is, acetate- versus lactate-buffered solutions. We therefore surveyed relevant physicians about their preferences and attitudes toward each solution. METHODS:We conducted an international online survey of anesthesiologists (within perioperative care) and intensive care unit (ICU) physicians. The survey comprised 13 questions on respondents' attitudes and preferences regarding the use of acetate- and/or lactate-buffered crystalloid solutions, including their opinions on a potential clinical trial comparing these solutions and the clinical importance of such a trial. RESULTS:A total of 1321 respondents participated, with a response rate of 34%, ranging from 14% to 96% across 18 countries. Most surveyed physicians reported using buffered crystalloid solutions "very often" (76%) or "often" (16%). Availability of acetate- and lactate-buffered solutions varied, as 35% of respondents reported having both types available, 35% reported having only acetate-, and 24% reported having only lactate-buffered solutions available. Most respondents (87%) would support a randomized trial in adult emergency surgical patients and ICU patients comparing an acetate- versus lactate-buffered crystalloid solution. The median rating of the clinical importance of this question was 5 (interquartile range 4-6) on a scale from 1 to 9. CONCLUSIONS:In this international survey, the reported use of buffered crystalloid solutions was high. Availability of the different solutions varied widely. The support for a potential randomized trial was high, with the clinical importance rated important but not critical by most respondents.

OBJECTIVE:This European Society of Intensive Care Medicine (ESICM) guideline provides evidence-based recommendations on the volume of early resuscitation fluid for adult critically ill patients. METHODS:An international panel of experts developed the guideline, focusing on fluid resuscitation volume in adult critically ill patients with circulatory failure. Using the PICO format, questions were formulated, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was applied to assess evidence and formulate recommendations. RESULTS:In adults with sepsis or septic shock, the guideline suggests administering up to 30 ml/kg of intravenous crystalloids in the initial phase, with adjustments based on clinical context and frequent reassessments (very low certainty of evidence). We suggest using an individualized approach in the optimization phase (very low certainty of evidence). No recommendation could be made for or against restrictive or liberal fluid strategies in the optimization phase (moderate certainty of no effect). For hemorrhagic shock, a restrictive fluid strategy is suggested after blunt trauma (moderate certainty) and penetrating trauma (low certainty), with fluid administration for non-traumatic hemorrhagic shock guided by hemodynamic and biochemical parameters (ungraded best practice). For circulatory failure due to left-sided cardiogenic shock, fluid resuscitation as the primary treatment is not recommended. Fluids should be administered cautiously for cardiac tamponade until definitive treatment and guided by surrogate markers of right heart congestion in acute pulmonary embolism (ungraded best practice). No recommendation could be made for circulatory failure associated with acute respiratory distress syndrome. CONCLUSIONS:The panel made four conditional recommendations and four ungraded best practice statements. No recommendations were made for two questions. Knowledge gaps were identified, and suggestions for future research were provided.