This Week in Critical Care — May 14, 2026

Welcome to This Week in Critical Care. This week we're covering 10 notable papers spanning airway management, neurocritical care, critical care pharmacology, and the ethics and humanism of our practice. Let's dive in.

Airway Management and Procedures We begin with a topic central to our practice: airway management and procedural support. A review in *Intensive Care Medicine* provides guidance on airway management in critically ill patients with obesity [9]. The authors highlight the unique anatomical and physiological challenges, including narrowed upper airways and a reduced functional residual capacity that shortens safe apnea time. They recommend routine use of videolaryngoscopy to increase first-pass success and applying non-invasive ventilation from pre-induction through laryngoscopy to mitigate the risk of severe hypoxemia. While awake intubation may be appropriate for select patients, if rapid sequence induction is chosen, the choice between ketamine and etomidate should be guided by the clinical context.

This brings us to a major network meta-analysis in *Critical Care* that directly compares induction agents for emergency intubation [10]. In over 4,600 patients across nine trials, investigators found that etomidate and ketamine probably result in similar short-term mortality. However, the data also show that ketamine probably increases the risk of cardiovascular collapse, post-induction hypotension, and the need for vasopressors compared to etomidate. There was little to no difference in first-pass success or cardiac arrest. This provides moderate-certainty evidence suggesting a trade-off: while mortality may be equivalent, clinicians should anticipate and prepare for more hemodynamic instability when choosing ketamine. The evidence for propofol in this setting remains very uncertain.

Rounding out our procedural theme, a randomized controlled trial in *Annals of Intensive Care* examined the use of high-flow nasal oxygen during bronchoscopy in patients with acute respiratory failure [2]. Compared to standard oxygen therapy, using high-flow via a single-prong cannula interface significantly reduced the primary outcome of respiratory support escalation within 24 hours. This occurred in only 15% of the high-flow group versus nearly 34% of the standard oxygen group. Furthermore, the rate of intubation within 24 hours was significantly lower with high-flow, at 7.5% compared to 20%.

Neurocritical Care Next, we turn to neurocritical care, with two papers offering new insights into assessment and monitoring. A prospective cohort study in *Critical Care* investigated the prevalence and meaning of movements in comatose adults at risk of death by neurologic criteria [3]. The study found that spinal-mediated movements and movements of unclear origin are common, occurring in 27% and 12% of patients, respectively. The critical finding is that these movements were not associated with the presence of cerebral blood flow on CT angiography or brain perfusion on CT perfusion scans. This holds true even in the subgroup of patients who met clinical criteria for death by neurologic criteria. The clinical implication is clear: these movements are not indicative of brain viability and should not confound the clinical determination of brain death.

Shifting from clinical observation to technological innovation, a paper in *Science Translational Medicine* introduces a platform for near real-time monitoring of cerebrospinal fluid [8]. The device, called NeuroSense, integrates with standard external ventricular drainage systems. It uses electrochemical biosensors to continuously measure key biomarkers like glucose and lactate, along with pH and CSF flow rate. By providing this data at the bedside in near real-time, the platform aims to enable much earlier detection of trends indicating infection or drain malfunction, which currently rely on intermittent sampling and delayed lab results.

Pharmacology and Support Systems Our third theme focuses on optimizing drug delivery and supportive therapies. First, a randomized pharmacokinetic trial in *Critical Care* assessed the intrapulmonary penetration of two key antibiotics for nosocomial pneumonia: ceftolozane/tazobactam and ceftazidime/avibactam, when given by continuous infusion [6]. The study measured concentrations in the epithelial lining fluid of critically ill patients. The key takeaway is that standard dosing regimens for both drug combinations achieved exposures consistent with pharmacodynamic targets for susceptible isolates. This provides reassurance for current continuous infusion strategies, though the authors note that interindividual variability and the risk of overexposure support the consideration of therapeutic drug monitoring.

Also in *Critical Care*, an international Delphi consensus study provides much-needed guidance on managing metabolic complications of regional citrate anticoagulation for continuous renal replacement therapy, or CRRT [7]. The panel of 29 experts reached consensus on 22 statements, confirming that citrate anticoagulation is feasible even in high-risk patients with liver dysfunction or severe shock, provided there is close monitoring. They outline a stepwise approach to prevent and manage citrate accumulation, centered on reducing citrate delivery. This expert consensus provides a practical framework for safely using the guideline-recommended form of anticoagulation in complex patient populations where data has been limited.

Ethics and the Human Side of the ICU Moving beyond pathophysiology, two papers this week address the profound ethical and human dimensions of our work. A study in *Critical Care Medicine* examined the impact of financial strain on the caregivers of ICU patients in the United States [4]. The findings are stark: nearly 64% of caregivers reported difficulty paying for the patient's medical care. This financial strain was significantly associated with worse psychological outcomes for the caregiver, including more severe symptoms of posttraumatic stress, anxiety, and depression. It was also linked to greater decisional regret and higher levels of medical mistrust. This work quantifies a significant, often hidden, burden on families that directly impacts their well-being and their perception of the care being provided.

In a similar vein, a narrative review in *Critical Care* tackles the complex ethical challenges of organ donation after extracorporeal cardiopulmonary resuscitation, or ECPR [5]. As ECPR use grows, so does the scenario where a patient survives the initial arrest but suffers devastating neurological injury, raising the possibility of organ donation. The authors propose a structured ethical model to navigate this transition. Core principles include a strict separation between the resuscitation and donation decision-making teams, transparent prognostication, and the early integration of ethics consultation. This framework aims to preserve patient-centered care and public trust as we integrate these life-saving therapies.

A Framework for the Future Finally, we look at a new tool designed to help us navigate the future of technology in the ICU. Published in *Annals of Intensive Care*, a multinational panel developed and validated the IMPACT framework for evaluating generative artificial intelligence in critical care [1]. The authors note that existing metrics for AI tools often just assess textual similarity, failing to capture crucial elements like clinical accuracy, the quality of reasoning, or a sense of urgency. The IMPACT framework, developed through a rigorous consensus process with 58 experts, provides a validated, six-domain tool with 21 sub-items specifically designed to assess GenAI for clinical decision support in our environment. This provides a much-needed standardized approach for evaluating these emerging technologies responsibly.

Editor's Pick If you only have time for one paper this week, make it the network meta-analysis on induction agents for emergency intubation in *Critical Care* [10]. It provides the most comprehensive evidence to date on a daily clinical question, highlighting that while mortality may be similar between etomidate and ketamine, the increased risk of hemodynamic instability with ketamine is a crucial consideration for patient safety.

Clinical Bottom Line Here are the key takeaways from this week in Critical Care. First: When choosing an intubation agent, be aware that while etomidate and ketamine likely have similar mortality, ketamine probably causes more hemodynamic instability. Plan accordingly. Second: For patients with acute respiratory failure undergoing bronchoscopy, using high-flow nasal oxygen via a single-prong cannula reduces the need for subsequent respiratory support escalation compared to standard oxygen. Third: Spinal-mediated movements and other movements of unclear origin are common in comatose patients at risk of brain death and are not associated with cerebral blood flow. They should not be misinterpreted as a sign of brain viability during a DNC evaluation. Fourth: Financial toxicity is a major burden for ICU families, with over 60% reporting difficulty paying for care. This is linked to significant psychological distress and medical mistrust. Finally: For nosocomial pneumonia treated with continuous infusions of ceftolozane/tazobactam or ceftazidime/avibactam, standard doses appear to achieve adequate lung concentrations for susceptible pathogens.

That's your roundup for This Week in Critical Care. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.