Guidelines

The 2024 ATS update conditionally supports corticosteroids for ARDS, VV-ECMO in selected severe ARDS, neuromuscular blockade in selected early severe ARDS, and higher PEEP without prolonged recruitment maneuvers in moderate-to-severe ARDS; it strongly recommends against prolonged lung recruitment maneuvers. Low tidal-volume ventilation and prolonged prone positioning remain foundational recommendations from the prior ATS/ESICM/SCCM guideline.

SCCM conditionally suggests neuromuscular blockade for adults with ARDS and PaO2/FiO2 <150 who remain persistently hypoxemic and/or are not achieving mechanical-ventilation targets despite sedation. Prone positioning by itself does not mandate neuromuscular blockade.

SCCM suggests a geriatric model of care for adults aged 65 years and older and suggests against antipsychotics for delirium prevention. Evidence is insufficient to recommend for or against antipsychotics for delirium treatment or a universal MAP 60–65 mmHg target versus higher usual-care targets in all older adults with vasodilatory shock.

For adults with S. aureus bacteremia, use risk stratification and ongoing reassessment; routinely obtain TTE, obtain follow-up blood cultures at about 48 hours and then every 24–48 hours until clearance, and use TEE selectively when endocarditis-risk features or management impact justify it rather than making TEE mandatory for every patient.

Use multidisciplinary Endocarditis Team assessment, modern multimodality diagnostics and organism/prosthesis-specific antimicrobial and procedural management. In staphylococcal prosthetic-valve endocarditis, avoid routine gentamicin because harms outweigh benefit.

HRS-AKI requires cirrhosis with ascites, AKI by creatinine and/or urine-output criteria, no improvement within about 24 hours after adequate resuscitation when indicated, and no strong alternative primary cause. HRS-AKI may coexist with tubular injury, proteinuria or CKD; a systematic 48-hour albumin challenge is not required for diagnosis.

Use pharmacologic stress-ulcer prophylaxis in critically ill adults with meaningful bleeding-risk factors, reassess the indication as risk changes, and stop prophylaxis when critical illness or relevant risk factors resolve. Mechanical ventilation or systemic corticosteroid use alone should not be treated as an automatic universal indication.

For adults with primary ITP requiring initial therapy, ASH 2026 conditionally suggests rituximab plus corticosteroids (with or without IVIG) or a thrombopoietic agent plus corticosteroids (with or without IVIG) rather than corticosteroids alone when those agents are available and appropriate. If rituximab/TPO agents are not available options, corticosteroids (with or without IVIG) remain appropriate. After failure of first-line corticosteroids, a thrombopoietic agent is strongly recommended and rituximab is a conditional option. Shared decision-making, toxicity, access and patient preference matter.

Use pre-treatment TLS risk assessment, timely hydration and urate-lowering therapy matched to risk, ensure prompt access to rasburicase when indicated, and monitor closely for electrolyte/renal complications requiring urgent escalation.

Myasthenic crisis requires rapid respiratory assessment and ICU support; IVIG, plasma exchange or immunoadsorption are established rapid immunomodulatory options, while longer-term disease control increasingly incorporates antibody status, disease activity and newer targeted immunotherapies.

Regional consensus supports structured diagnosis, respiratory surveillance and rapid rescue with IVIG or plasma exchange for crisis, with individualized chronic immunotherapy including contemporary targeted agents according to antibody status, severity, access and patient factors.

Prevention strategy is organ- and risk-specific rather than universal. In liver transplant recipients, IDSA suggests against universal anti-Aspergillus prophylaxis and favors risk-targeted prevention approaches; recommendations differ by transplanted organ and local epidemiology.

For complicated intra-abdominal infection, use syndrome-specific imaging and risk assessment; obtain blood cultures selectively when systemic instability or resistant-pathogen risk makes results actionable, and obtain intra-abdominal cultures when source-control procedures are performed for complicated infection.

Patients with current or recent glucocorticoid exposure who may have adrenal suppression require stress-dose coverage during significant stress; suspected adrenal crisis with hemodynamic instability or persistent vomiting/diarrhea should be treated promptly with parenteral glucocorticoid and fluid resuscitation without waiting for confirmatory testing.

Choose hyperosmolar therapy according to the underlying neurologic condition and physiology. For SAH, symptom-based hypertonic-sodium boluses are preferred over routine sodium-target dosing; there is insufficient evidence for a universal continuous-infusion sodium target to improve neurologic outcomes.

Acute liver failure requires urgent etiologic evaluation, early transplant-center involvement, cause-specific therapy and neurocritical/supportive management. N-acetylcysteine is mandatory for acetaminophen toxicity and may be considered in selected non-acetaminophen ALF, while evidence for universal benefit across all etiologies and coma grades is not established.

For hyperkalemia with toxic ECG changes, give an equivalent IV calcium dose promptly: 30 mL of 10% calcium gluconate over about 10 minutes for most patients or 10 mL of 10% calcium chloride over about 5 minutes in resuscitation/peri-arrest settings, with ECG reassessment and repeat calcium if changes persist or recur.

Recognize PICS as a multidomain post-critical-illness syndrome, screen for clinically important physical and cognitive impairment, and use individualized multidisciplinary rehabilitation and longitudinal follow-up rather than a one-size-fits-all recovery pathway.

Life-threatening sodium-channel blocker cardiotoxicity, including TCA poisoning, should be treated with sodium bicarbonate; refractory cardiogenic shock may require advanced rescue strategies including VA-ECMO in selected cases.

Defines myocardial injury using cardiac troponin above the assay-specific 99th percentile and requires a rise/fall for acute injury. Myocardial infarction requires acute myocardial injury plus evidence that the injury is ischemic. MI is classified clinically as primary, secondary, or procedure-related; the document also reframes MINOCA as myocardial injury with non-obstructive coronary arteries requiring etiologic evaluation.

Updates heart-failure classification, prevention, diagnosis and therapy. The ESC framework now uses two LVEF phenotypes—HFrEF with LVEF <50% and HFpEF with LVEF >=50%—and adds stage-based terminology emphasizing prevention, early recognition and timely intervention. Acute/decompensated presentations remain phenotype- and hemodynamic-context dependent rather than governed by one universal treatment recipe.

Provides a harmonized heart-failure framework, reaffirms stages A through D, and groups HF into clinically actionable reduced-EF, preserved-EF and improved-EF categories while cautioning against over-reliance on rigid numeric thresholds across populations and imaging methods.

Summarizes ENRICH and MIND and supports considering minimally invasive evacuation in selected patients rather than routine surgery for all ICH. The advisory highlights lobar ICH 30–80 mL, good premorbid status, NIHSS >5, GCS >5, and surgery within the first 24 hours as a practical candidate profile, while noting that MIND was neutral for 180-day mortality and functional outcome.

Recommends multidisciplinary rehabilitation beginning during the acute phase, sufficient task-specific practice, coordinated transitions of care, standardized outcome assessment, prevention of immobility-related complications, and longitudinal reassessment for new or worsening recovery needs.

Updates adult CAP guidance on lung ultrasound, antibacterial treatment when respiratory viral testing is positive, shorter antibiotic courses after clinical stability, and corticosteroids. ATS recommends against routine systemic corticosteroids in non-severe CAP and conditionally suggests them in severe CAP. IDSA did not endorse the update because of disagreement with some viral-positive CAP antibacterial recommendations, so those decisions require clinical-context and bacterial-coinfection assessment.

Provides a practical ICU framework for acute cor pulmonale and RV failure, emphasizing diagnosis of the precipitating cause, cautious preload optimization, maintenance of systemic perfusion, reduction of reversible pulmonary vascular load, ventilator optimization, selective vasoactive/inotropic therapy, and specialist mechanical support for refractory cases.

Use structured, timely, culturally responsive communication; identify the patient's values and preferred surrogate; support shared decision-making, family presence and participation when appropriate; and provide interdisciplinary psychosocial, spiritual and bereavement support according to patient/family needs.

Provide patient-centered symptom control, clear and repeated communication about prognosis and treatment options, shared decision-making based on the patient's values and goals, and a planned interdisciplinary approach when life-sustaining treatments are withheld or withdrawn.

After death determination and in coordination with the organ-procurement organization, use protocolized donor management to preserve organ perfusion and oxygenation, treat hypotension and endocrine/metabolic derangements, use lung-protective ventilation, and reassess organ-specific suitability without allowing donor-management goals to influence the preceding determination of death.

Takotsubo syndrome should be managed after exclusion of acute coronary syndromes and with phenotype-specific assessment for shock, LV outflow tract obstruction, right-ventricular involvement, arrhythmia and thromboembolism; treatment evidence remains limited and management should be individualized to hemodynamic mechanism.

Recognize ACLF as acute decompensation with organ failure requiring early triage, treatment of precipitants, organ support, repeated prognosis assessment and timely liver-transplant evaluation in appropriate candidates.

Contemporary liver-transplant care should integrate candidate and graft risk, donor type and ischemia, early recognition of vascular/biliary and allograft complications, individualized immunosuppression and infection prevention, with multidisciplinary transplant-center management.

Risk-stratify TLS before cytotoxic or targeted therapy, use hydration and risk-appropriate urate-lowering therapy, monitor electrolytes and kidney function closely, and escalate urgently for life-threatening potassium, phosphate, calcium, urate or renal complications.

Use real-time two-dimensional ultrasound guidance for adult central venous access, visualize needle and guidewire before dilation, combine ultrasound with aseptic technique and maximal sterile barriers, and use ultrasound to reduce mechanical and infectious complications.

Prevent CLABSI through evidence-based insertion and maintenance bundles, maximal sterile barrier precautions, chlorhexidine skin antisepsis when appropriate, daily review of line necessity and prompt removal of unnecessary catheters.

Adult tracheostomy care should use standardized multidisciplinary protocols for airway assessment, humidification, suctioning, cuff and speaking-valve management, emergency readiness, communication, mobility and decannulation planning.

Kidney-transplant recipient care requires structured graft-function monitoring, individualized immunosuppression, prevention and treatment of infection and cardiovascular complications, and prompt evaluation of graft dysfunction for rejection, obstruction, vascular causes, drug toxicity and infection.

Life-threatening or recurrent hemoptysis should be stabilized with airway and hemodynamic priorities, localized with appropriate CT/bronchoscopic imaging, and treated with bronchial artery embolization when the bleeding source and clinical scenario are suitable.

Pleural infection management centers on prompt antibiotics and effective drainage of infected collections, with intrapleural therapy and surgical escalation considered when drainage is inadequate or clinical progress is poor.

Supports restrictive RBC transfusion strategies for most critically ill adults while emphasizing subgroup-specific decisions, including important nuance for acute coronary syndromes and other populations in whom a single universal hemoglobin threshold is inappropriate.

National evidence-based recommendations covering lung-protective ventilation, ARDS adjuncts/rescue therapies, sedation, liberation, airway management and supportive ICU care.

Conditionally suggests against ketamine monotherapy for routine ICU analgo-sedation when other agents are available; adjunct ketamine or usual non-ketamine sedation are both acceptable individualized approaches, with very low certainty for many outcomes.

Suspect adult HLH in an unexpectedly unwell patient with the practical pattern of fever, falling blood counts and raised ferritin; use structured assessment and trigger investigation because no single ferritin threshold or marrow finding is diagnostic.

Use susceptibility- and host-informed therapy for invasive candidiasis, with echinocandins remaining preferred initial therapy for many critically ill adults, prompt source control, follow-up cultures, and individualized step-down once clinically stable and an active oral agent is available.

Recognize acute versus chronic exposure and administer digoxin-specific immune Fab for life-threatening digoxin toxicity; extracorporeal removal is not a substitute for Fab in severe poisoning.

Use the treatment nomogram only for acute ingestions with a reliable time in the first 24 hours; treat repeated supratherapeutic ingestion by concentration/liver tests rather than the nomogram; do not stop acetylcysteine solely at a fixed 20-21 hour time point—continue until stopping criteria are met. High-risk ingestion (>=30 g or concentration on/above the high-risk line) warrants toxicology/poison-center consultation because no single intensified NAC regimen is established.

For immune TTP, the 2025 focused update did not materially change the 2020 acute-event recommendations (urgent plasma exchange plus immunosuppression, with caplacizumab in appropriate patients). The update mainly addresses congenital TTP prophylaxis and ADAMTS13 replacement, favoring recombinant ADAMTS13 where available or prophylactic plasma over watch-and-wait in selected cTTP remission settings.

Treat suspected or proven mucormycosis urgently with multidisciplinary source control when feasible and an active systemic antifungal. High-dose liposomal amphotericin B is strongly recommended first-line; isavuconazole or delayed-release/IV posaconazole are alternatives in selected settings and important salvage options.

Use contemporary adult advanced-life-support algorithms for cardiac arrest and peri-arrest tachyarrhythmia/bradyarrhythmia management, including high-quality CPR, timely defibrillation when indicated, evidence-based vasoactive/antiarrhythmic therapy and treatment of reversible causes.

Evidence-based recommendations for initial treatment, treatment phase and extended-phase antithrombotic therapy in venous thromboembolism. Agent, intensity and duration should be selected according to VTE phenotype, bleeding risk, renal function, cancer/pregnancy status and procedural context rather than by a single ICU-wide regimen.

For serious MRSA infection, target AUC24/MIC 400–600 when MIC is assumed to be 1 mg/L and favor AUC-guided monitoring over routine trough-only 15–20 mg/L targeting. In critically ill adults, loading doses based on actual body weight may be used when rapid target attainment is needed; maintenance dosing requires individualized renal-function and drug-exposure assessment.

For acute variceal hemorrhage, combine prompt vasoactive therapy and endoscopic therapy with short-course antibacterial prophylaxis (commonly ceftriaxone 1 g IV daily in hospitalized patients where appropriate). Duration is generally no more than 7 days and should be individualized to clinical stability, hemorrhage control, discharge, local resistance and patient-specific factors rather than taught as an obligatory exact 7-day course.

In adults hospitalized with moderate-severe TBI and no prior clinical/electrographic seizure, either prophylactic ASM or no prophylaxis may be used (weak, low-quality evidence). If an ASM is used, levetiracetam is suggested over phenytoin/fosphenytoin (weak, very-low-quality evidence), for a short duration of no more than 7 days (weak, low-quality evidence).

Neuroprognostication after moderate-severe TBI should integrate the complete clinical condition rather than a single early variable, explicitly acknowledge uncertainty, and avoid nihilistic ultra-early prognostication. The guideline suggests at least 3 days of full support before prognosis based only on early injury characteristics, and when feasible 1-2 weeks of support may be appropriate because meaningful uncertainty often persists.

Use a planned linear rescue strategy from tracheal intubation to supraglottic-airway ventilation, facemask ventilation, and emergency front-of-neck airway; maximize first-attempt success, continue oxygen delivery throughout airway management, use videolaryngoscopy whenever possible, confirm ventilation with sustained waveform capnography, and limit laryngoscopy attempts to 3 plus one final attempt by a more experienced operator.

Time-critical treatment with an adequately dosed benzodiazepine followed promptly by a second-line antiseizure medication; refractory status after failure of these stages requires critical-care support, continuous EEG and escalation to continuous anesthetic therapy selected according to patient physiology and local protocol.

Use a bundle of evidence-based prevention practices focused on avoiding intubation when possible, minimizing sedation, daily assessment for liberation, early mobility, head-of-bed elevation/oral care practices, and other implementation strategies appropriate to the population; prevention guidance is distinct from the ATS/IDSA treatment guideline.

Use objective blood-loss assessment and initiate rapid treatment when postpartum hemorrhage is recognized, including the MOTIVE bundle: uterine massage, oxytocic therapy, tranexamic acid, intravenous fluids, vaginal/genital-tract examination, and escalation of care. The guideline supports earlier action at measured blood loss >=500 mL, or >=300 mL with abnormal hemodynamic signs.

Use a Pregnancy Heart Team for women with significant cardiovascular disease and apply pregnancy-specific guidance to heart failure, peripartum cardiomyopathy, anticoagulation, arrhythmia, aortopathy, pulmonary hypertension, and acute cardiovascular emergencies. PPCM therapy should distinguish pregnancy from postpartum pharmacology and individualize bromocriptine, anticoagulation, and mechanical support.

Use restrictive, indication-specific platelet thresholds. Examples include <10,000/uL for prophylaxis in nonbleeding hypoproliferative thrombocytopenia and compressible-site central venous catheter placement, <20,000/uL for lumbar puncture, and <50,000/uL for major non-neuraxial surgery. Avoid routine platelet transfusion for nonoperative intracranial hemorrhage when platelet count is >100,000/uL, including antiplatelet-associated ICH.

Current GOLD strategy for COPD, including controlled oxygen in exacerbations, short-acting bronchodilators, short systemic corticosteroid courses for significant exacerbations, selective antibiotics, and NIV as preferred ventilatory support for acute hypercapnic respiratory failure with acidosis when appropriate.

Current GINA strategy for assessment and treatment of asthma, including acute severe asthma: repeated inhaled short-acting bronchodilator therapy, early systemic corticosteroids, oxygen titrated to target saturation, and IV magnesium for selected severe/nonresponding exacerbations; escalation is guided by clinical trajectory and ventilatory failure.

Updates prehospital triage and acute reperfusion care, expands tenecteplase use within 4.5 hours, broadens endovascular thrombectomy eligibility including selected large-core and posterior-circulation stroke populations, and updates supportive early management.

Evidence-based guidance for children and adults with community-acquired meningitis covering urgent diagnosis, empiric antimicrobial treatment without harmful delay, adjunctive therapies, supportive care, and follow-up for sequelae.

Hypertensive emergency is defined by severe BP elevation with new or worsening acute target-organ damage and requires monitored, syndrome-specific treatment. Without a compelling organ-specific condition, avoid excessive first-hour reduction and then lower more gradually. For acute pulmonary edema the guideline lists clevidipine, nitroglycerin or nitroprusside and lists beta blockers as contraindicated; severe hypertension without acute target-organ damage should not be reflexively treated with rapid IV BP normalization.

After ROSC, avoid hypoxemia and hyperoxemia, target appropriate ventilation and perfusion, use a deliberate temperature-control strategy in unresponsive patients for at least 36 hours, and apply multimodal, appropriately timed neuroprognostication.

Current European post-resuscitation guidance addresses oxygenation/ventilation, coronary reperfusion, hemodynamic management, seizure treatment, active fever prevention/temperature control, multimodal prognostication, rehabilitation, and organ donation.

Use serial multimodal perfusion assessment, dynamic tests rather than static preload markers to predict fluid responsiveness, cardiac-output/stroke-volume monitoring when shock persists, and echocardiography as first-line imaging to define shock phenotype.

Current multisociety guidance for STEMI/NSTE-ACS, including antithrombotic therapy, invasive strategy, cardiogenic shock, and revascularization; in ACS with cardiogenic shock, emergency culprit-vessel revascularization is indicated while routine immediate nonculprit PCI is avoided.

Current European guidance for acute and chronic native/prosthetic valvular disease, emphasizing Heart Team assessment, contemporary imaging, and timely surgical or transcatheter intervention according to valve lesion, hemodynamic impact, anatomy, and patient risk.

Hypertensive emergency requires acute hypertension plus new/worsening target-organ damage, with organ-specific, carefully titrated blood-pressure reduction—typically using short-acting IV therapy in a monitored setting rather than a single universal BP target.

Favor lactated Ringer's and moderately aggressive early hydration with frequent reassessment, initiate early oral/enteral feeding as tolerated, and do not use prophylactic antibiotics for sterile pancreatic necrosis.

Patients with acute decompensated heart failure and fluid overload should be promptly treated with IV loop diuretics at doses equal to or exceeding their chronic oral dose. In hypertensive pulmonary edema (SCAPE), IV vasodilators (nitroglycerin) should be rapidly titrated with noninvasive ventilation.

IV alteplase/tenecteplase is recommended within 4.5 hours of symptom onset (target BP < 185/110 mmHg). Endovascular thrombectomy is indicated within 6 hours for anterior circulation LVO and up to 24 hours in selected patients meeting DAWN or DEFUSE-3 perfusion imaging criteria.

Defines AKI by a rise in serum creatinine of ≥0.3 mg/dL within 48 hours, or ≥1.5x baseline within the prior 7 days, or urine output <0.5 mL/kg/h for ≥6 hours, and stages severity 1-3 by the same criteria. This remains the only final, published KDIGO AKI guideline as of this writing.

A draft guideline, released for public review in early 2026 (review period extended to May 11, 2026), proposing the first major update to AKI/AKD guidance since 2012 — an expanded framework spanning AKI and Acute Kidney Disease (AKD), updated definitions incorporating structural biomarkers alongside functional (creatinine/urine-output) criteria, and updated guidance on kidney replacement therapy timing, modality, dosing, and discontinuation. This is a public-review draft, not a finalized guideline — its specific recommendations are not yet an established standard of care and are not reproduced here beyond this general description, since the Work Group may still revise them based on review feedback.

Suspected acute liver failure warrants early referral/transfer to a liver-transplant center. N-acetylcysteine is standard for acetaminophen-associated ALF; evidence for non-acetaminophen ALF is strongest for transplant-free survival in selected early encephalopathy. Prognostic tools such as King's College Criteria support, but do not replace, serial transplant-team assessment.

All patients with acute liver failure should be referred to a liver transplant center for urgent evaluation; referral and transfer planning should begin early, before deterioration makes transport unsafe. Transplant-center involvement does not imply that transplantation is inevitable because some patients recover with specialist supportive care.

Routine ICU delirium screening should be performed with CAM-ICU or ICDSC. Non-pharmacological bundles (ABCDEF bundle, early mobility, sleep hygiene) are recommended. Use non-benzodiazepine sedatives (propofol or dexmedetomidine) over benzodiazepine infusions to reduce delirium incidence.

Analgesia-first approach using validated pain scores (CPOT/BPS). Target light sedation (RASS -1 to 0) over deep sedation. Non-benzodiazepine sedatives (propofol or dexmedetomidine) are strongly preferred over benzodiazepine infusions to reduce ventilation time and delirium. Routine delirium screening (CAM-ICU/ICDSC). Implement the multi-component ABCDEF bundle (Assess/treat pain, Both SAT and SBT, Choice of sedation, Delirium monitoring/management, Early mobility, Family engagement). Do not use antipsychotics routinely to treat delirium.

For life-threatening bleeding: reverse Dabigatran with Idarucizumab 5 g IV; reverse Factor Xa inhibitors with 4F-PCC (institutional protocol; commonly 25–50 U/kg). Andexanet alfa has historical efficacy data but is discontinued in the U.S. as of 2026; reverse Warfarin with 4F-PCC (25-50 U/kg) plus IV Vitamin K 10 mg; reverse Unfractionated Heparin with Protamine sulfate.

Acute aortic syndromes require immediate anti-impulse therapy. Unless contraindicated, IV beta-blockade is recommended as initial therapy; add a vasodilator when BP remains above target after rate/impulse control. Target systolic BP <120 mmHg or the lowest BP that maintains end-organ perfusion and heart rate 60–80 bpm. Type A aortic dissection requires emergent surgical repair. Uncomplicated Type B dissection is managed with initial medical therapy as the foundational strategy; TEVAR may be considered in selected uncomplicated patients with high-risk anatomical features (e.g., aortic diameter > 40 mm, false-lumen diameter > 20-22 mm, entry tear > 10 mm or on the lesser curvature) via individualized, shared decision-making rather than as an automatic indication. Complicated Type B dissection (rupture, branch-vessel occlusion/malperfusion, extension, progressive enlargement, intractable pain, or uncontrolled hypertension) mandates intervention, generally TEVAR when anatomy is favorable.

Type A acute aortic dissection requires emergent surgical repair. For uncomplicated Type B dissection, initial optimal medical (anti-impulse) therapy is the foundational strategy; for uncomplicated Type B dissection with anatomy favorable for endovascular repair, TEVAR in the subacute phase is recommended (Class IIa, Level of Evidence B). For complicated Type B dissection with favorable anatomy, endovascular repair is recommended (Class I, Level of Evidence B), with open surgery as an alternative when anatomy is unsuitable. Selected uncomplicated patients with high-risk anatomical features (e.g., larger aortic or false-lumen diameter, larger entry tear) may be considered for individualized, multidisciplinary pre-emptive TEVAR rather than on the basis of the feature alone.

Consider neuromuscular blockade in patients with early, severe ARDS, while recognizing the certainty of evidence for a mortality benefit is low.

Use higher PEEP without a lung recruitment maneuver, rather than lower PEEP, in patients with moderate-to-severe ARDS.

Do not use prolonged, aggressive lung recruitment maneuvers in patients with moderate-to-severe ARDS.

Use a higher-PEEP strategy rather than a lower-PEEP strategy in patients with moderate-to-severe ARDS, titrated against oxygenation and respiratory mechanics rather than applied as a fixed protocol.

Use low tidal volume ventilation (approximately 4-8 mL/kg predicted body weight) with attention to plateau pressure, rather than higher tidal volume ventilation, in adults with ARDS.

Use prone positioning for more than 12 hours per day in patients with severe ARDS (PaO2/FiO2 < 150), rather than keeping patients supine.

Recognizes AF as a progressive disease with staged management (risk factors through permanent AF), with recommendations spanning thromboembolic risk assessment and anticoagulation, rate and rhythm control strategies, and catheter/surgical ablation. Early rhythm control is associated with better maintenance of sinus rhythm and reduced AF progression in appropriate candidates.

Unstable wide-complex tachycardia with hypoperfusion mandates immediate synchronized direct-current cardioversion. Hemodynamically stable sustained monomorphic VT may be treated with IV procainamide or IV amiodarone. Calcium channel blockers (verapamil, diltiazem) are strictly contraindicated in wide-complex tachycardia of uncertain mechanism. Polymorphic VT / Torsades de Pointes associated with QT prolongation is treated with IV magnesium sulfate (2 g bolus) and temporary overdrive transvenous or isoproterenol pacing.

First-line therapy for acute severe asthma consists of continuous or frequent short-acting beta-2 agonists combined with ipratropium bromide, early systemic corticosteroids, controlled oxygen targeting SpO2 93-95%, and considering IV magnesium sulfate as an adjunct for severe, life-threatening, or refractory exacerbations.

39 recommendations spanning the temporal course of trauma hemorrhage management: early recognition and risk stratification, damage-control resuscitation, tranexamic acid as early as possible, viscoelastic-guided or ratio-based blood product replacement, fibrinogen/cryoprecipitate for hypofibrinogenemia, calcium correction, avoidance of hypothermia and acidosis, and surgical/interventional source control.

A unified, 85-recommendation consensus guideline for BD/DNC determination in adults and children, covering examiner qualifications, prerequisites (excluding confounding drug effect, hypothermia, and severe metabolic derangement), the clinical examination (coma plus absent brainstem reflexes), apnea testing, ancillary testing when the clinical exam or apnea test cannot be completed, and special populations.

Legacy broad burn-care entry retained for historical context. Contemporary burn-shock resuscitation should use the dedicated 2024 ABA burn-shock CPG; airway intervention, bronchoscopy, escharotomy and inhalation-injury adjuncts remain indication- and center-specific rather than automatic for every major burn.

For adults with burns >=20% TBSA, initiate crystalloid resuscitation using 2 mL/kg/%TBSA as the starting estimate and titrate to the patient's evolving perfusion and resuscitation response. Consider human albumin, particularly in larger burns, to reduce crystalloid volume and improve urine output. Use selective intra-abdominal and intraocular pressure monitoring rather than routine monitoring in every patient. Evidence was insufficient for firm recommendations on high-dose vitamin C, fresh frozen plasma, early CRRT, or vasopressors as routine adjuncts to burn-shock resuscitation.

Tocilizumab (8 mg/kg IV) is recommended as first-line targeted therapy for Grade >= 2 Cytokine Release Syndrome (CRS). Corticosteroids (dexamethasone or methylprednisolone) are first-line therapy for Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS); tocilizumab is not indicated for isolated ICANS without CRS.

Post-ROSC care requires targeted temperature management: actively prevent fever (temperature <= 37.5°C) or maintain targeted hypothermia (32-36°C) for at least 72 hours in comatose patients. Maintain MAP >= 65 mmHg, target normoxia (SpO2 92-98%) avoiding hyperoxia, and target normocapnia (PaCO2 35-45 mmHg). Immediate coronary angiography is indicated for post-arrest STEMI or cardiogenic shock. Multimodal neuroprognostication must be delayed until >= 72 hours post-ROSC (incorporating clinical exam, SSEPs, EEG, serum NSE, and brain MRI/CT).

Emergency revascularization (PCI or CABG) is indicated for cardiogenic shock complicating acute MI. Norepinephrine is the initial vasopressor of choice to maintain coronary perfusion; inotropes (dobutamine or milrinone) are added for low cardiac index; routine IABP is not recommended.

Noninvasive positive pressure ventilation (NIV) is the first-line ventilatory support for acute hypercapnic respiratory failure (pH < 7.35, PaCO2 > 45 mmHg) in COPD. Systemic corticosteroids should be given for 5 days (oral prednisone 40 mg daily). Antibiotics are indicated for patients with all 3 cardinal Anthonisen symptoms or those requiring mechanical ventilation.

Diagnose overt DIC using a 4-parameter score (platelet count, D-dimer/fibrin-related marker, prothrombin time prolongation, fibrinogen) in a patient with a clinical condition known to be associated with DIC; a score ≥5 is compatible with overt DIC. Revises D-dimer thresholds from the original 2001 ISTH score and introduces a broader pre-DIC/early-phase/overt-DIC conceptual framework.

For adult DKA and HHS, begin isotonic saline or balanced crystalloid with frequent reassessment, check potassium before insulin and delay insulin if potassium is below 3.5 mmol/L. Pure HHS without significant ketosis/acidosis generally uses lower-dose IV insulin after initial fluids, while mixed DKA/HHS follows the DKA insulin strategy; avoid overly rapid osmotic correction.

ELSO guidance supports considering VV-ECMO for selected patients with severe, potentially reversible respiratory failure despite optimized conventional management. EOLIA trial entry criteria included PaO2/FiO2 <50 mmHg for >3 h, PaO2/FiO2 <80 mmHg for >6 h, or pH <7.25 with PaCO2 >=60 mmHg for >6 h despite optimized ventilation. These trial thresholds should not be presented as universal stand-alone indications. During ECMO, use a lung-protective or lung-rest strategy individualized to mechanics and gas-exchange goals rather than fixed PEEP, respiratory-rate, driving-pressure, or tidal-volume numbers for every patient.

Adult VA-ECMO should be used as a time-limited bridge in carefully selected patients with potentially reversible or bridgeable cardiac failure. Management requires attention to cannulation strategy, adequate systemic perfusion, LV loading and aortic-valve opening, differential hypoxemia, limb perfusion, anticoagulation, complications, and repeated assessment for recovery, durable support or transplantation.

ECPR is a resource-intensive rescue strategy for selected refractory cardiac arrest when a reversible cause is plausible and a trained system can establish extracorporeal flow rapidly. Programs should use explicit local selection criteria and a coordinated pathway rather than treating ECPR as routine care for all arrests.

Anticoagulation during ECMO should be individualized to patient bleeding/thrombotic risk, circuit conditions, center protocol and assay characteristics. UFH is commonly used, but no single anti-Xa, aPTT or ACT target should be presented as universally correct across all ECMO patients; multimodal assessment of coagulation and circuit thrombosis is important.

Safe ECMO management requires understanding of the drainage and return cannulae, centrifugal pump, membrane lung, heat exchanger, sweep-gas source, pressure monitoring and circuit safety systems. Trends in flow, pressures, gas transfer, visible clot and hemolysis should be interpreted together when circuit dysfunction is suspected.

ECMO patients require serial assessment of fluid balance, kidney function and electrolytes. Avoid both inadequate preload that compromises circuit drainage and persistent fluid overload that worsens organ edema; use kidney replacement therapy for standard indications and when fluid/electrolyte goals cannot otherwise be achieved.

Adult ECMO care should include structured neurologic monitoring, attention to early post-cannulation physiologic changes associated with acute brain injury, prompt evaluation of neurologic deterioration, and multimodal prognostication rather than premature conclusions based on one examination or test.

Early rehabilitation or mobilization can be considered during ECMO in appropriately selected patients when cannula security, hemodynamics, oxygenation, staffing and rescue capability permit. Mobilization should be protocolized and multidisciplinary rather than assumed unsafe solely because ECMO is present.

Urgent surgery is indicated in patients with native or prosthetic valve endocarditis presenting with acute severe regurgitation, heart failure, cardiogenic shock, uncontrolled infection (perivalvular abscess, false aneurysm), or high embolic risk with vegetations >10 mm (Class 1, LOE B).

Thyroid storm requires immediate multi-targeted ICU therapy: (1) Beta-blocker (propranolol 60-80 mg PO q4h or esmolol infusion), (2) Thionamide (PTU 200 mg q4h or methimazole 20 mg q6h) to block new hormone synthesis, (3) Inorganic iodine (SSKI 5 drops q6h or Lugol solution) administered AT LEAST 1 HOUR AFTER thionamide to prevent Wolff-Chaikoff escape, (4) IV hydrocortisone (100 mg q8h) to reduce peripheral T4-to-T3 conversion and treat adrenal insufficiency, (5) Bile acid sequestrants (cholestyramine) to block enterohepatic recirculation.

Empiric broad-spectrum antipseudomonal beta-lactam monotherapy (cefepime, piperacillin-tazobactam, or meropenem) must be initiated within 1 hour of triage in febrile neutropenic patients. Vancomycin is not routinely recommended unless hemodynamic instability, catheter infection, pneumonia, or severe mucositis is present.

Febrile neutropenia is an oncologic emergency requiring prompt risk stratification, diagnostic sampling without delaying therapy, immediate empiric antibacterial treatment in high-risk patients, epidemiology- and resistance-informed escalation/de-escalation, and a structured approach to persistent fever and empirical or pre-emptive antifungal treatment.

Intravenous immunoglobulin (IVIG 2 g/kg total over 2–5 days) or plasma exchange (200–250 mL/kg across 5 sessions) is recommended in patients with Guillain-Barré syndrome with severe or rapidly progressive weakness. Corticosteroids alone are not effective and should not be administered.

Use the 4Ts score (not gestalt) to estimate pretest probability of HIT. For intermediate/high-probability scores, obtain a PF4 immunoassay. Discontinue heparin and start a non-heparin anticoagulant for intermediate/high-probability suspected or confirmed HIT, at an intensity guided by bleeding risk when no other indication for therapeutic anticoagulation exists.

Use noninvasive ventilation as first-line respiratory support in acute hypercapnic respiratory failure due to COPD exacerbation with respiratory acidosis, to reduce the need for intubation and improve survival.

Sodium zirconium cyclosilicate is recommended as an option in the emergency management of acute, life-threatening hyperkalaemia (potassium ≥ 6.5 mmol/L); patiromer is recommended for initiation in secondary care rather than for acute emergency treatment.

Hypertensive emergency is defined by acute, severe blood pressure elevation with progressive target-organ damage (encephalopathy, ICH, ischemic stroke, acute pulmonary edema, ACS, dissection, AKI, eclampsia). For most emergencies, reduce MAP by <= 20-25% in the first hour using titratable IV infusions (nicardipine, clevidipine, labetalol), then toward 160/100 mmHg over 2-6 hours. Exceptions: Aortic dissection mandates rapid SBP < 120 mmHg within 20 min; Acute Ischemic Stroke requires permissive hypertension unless candidate for thrombolysis (target < 185/110 mmHg).

Suggest HFNC over conventional oxygen therapy in hypoxemic acute respiratory failure; suggest HFNC over noninvasive ventilation in hypoxemic acute respiratory failure; suggest HFNC over conventional oxygen during breaks from NIV. All conditional recommendations.

For mild-to-moderate spontaneous ICH presenting with SBP 150–220 mmHg, lowering to a target of 140 mmHg with maintenance 130–150 mmHg is safe and may be reasonable; SBP <130 mmHg is potentially harmful. Anticoagulant reversal should follow agent-specific guideline recommendations. Platelet transfusion is not routinely recommended for non-surgical aspirin-associated ICH and may be harmful.

ICP monitoring is recommended in salvageable patients with severe TBI and an abnormal CT. Treat ICP above approximately 22 mmHg, integrated with clinical/imaging findings. A large frontotemporoparietal decompressive craniectomy (rather than a small one) is recommended over a smaller craniectomy when the procedure is performed for refractory intracranial hypertension (2020 update).

Voriconazole or isavuconazole is recommended as primary therapy for invasive pulmonary aspergillosis in immunocompromised patients (Strong recommendation, High-quality evidence). Serum and BAL galactomannan testing is recommended to establish microbiological diagnosis.

For candidemia in critically ill adults, an echinocandin is preferred initial therapy; obtain follow-up blood cultures to document clearance, pursue source control, and treat uncomplicated candidemia for 14 days after documented clearance and symptom resolution.

Use risk tools such as the Oakland score to support disposition; a score <=8 can help identify very-low-risk patients who may be suitable for outpatient management when otherwise appropriate, whereas higher scores do not by themselves mandate ICU admission. In ongoing hemodynamically significant hematochezia, CTA is an important early localization test that can guide transcatheter embolization. Consider an upper GI source and urgent EGD when the clinical presentation supports it rather than requiring nasogastric aspiration/EGD before all lower-GI investigations. Most inpatient colonoscopy can be performed nonurgently after adequate preparation once the patient is stabilized.

Use Glasgow-Blatchford score 0–1 to identify very-low-risk patients who may be discharged with outpatient follow-up when otherwise appropriate; use a generally restrictive RBC transfusion threshold around 7 g/dL in stabilized patients; perform endoscopy within 24 hours after resuscitation; use effective endoscopic hemostasis for high-risk ulcer stigmata and high-dose PPI after successful hemostasis, with transcatheter arterial embolization favored after failed endoscopic therapy.

Diagnose overt hepatic encephalopathy clinically while identifying and treating precipitants. Lactulose remains first-line therapy for overt HE and should be titrated to clinical response rather than excessive catharsis; rifaximin is used as add-on therapy to reduce recurrence in appropriate patients. Ammonia concentration alone does not establish or grade the clinical severity of HE.

A living, question-based guidance document (most recent version 2026) covering ESBL-E, AmpC-E, carbapenem-resistant Enterobacterales, difficult-to-treat-resistance Pseudomonas aeruginosa, carbapenem-resistant Acinetobacter baumannii, and Stenotrophomonas maltophilia — generally preferring newer beta-lactam/beta-lactamase-inhibitor combinations or cefiderocol over older salvage agents (e.g. polymyxins) for carbapenem-resistant infections outside the urinary tract.

Conduct spontaneous breathing trials with inspiratory pressure augmentation (5-8 cmH2O) rather than unsupported T-piece trials; use protocols that minimize sedation; and use planned post-extubation noninvasive ventilation in patients at high risk for extubation failure.

Adjunctive dexamethasone (10 mg IV) should be given prior to or with the first antibiotic dose in suspected or proven pneumococcal meningitis. Empiric therapy consists of vancomycin plus a 3rd-generation cephalosporin (plus ampicillin for Listeria in age >50 or immunocompromised).

Biphasic contrast-enhanced multidetector CT angiography (CTA) is the primary diagnostic imaging of choice. Immediate systemic unfractionated heparin anticoagulation should be initiated upon suspicion. Hemodynamic resuscitation must avoid splanchnic vasoconstrictors (vasopressin and high-dose epinephrine). Emergent revascularization (endovascular thrombectomy/stenting or surgical embolectomy) must precede or accompany laparotomy. Mandatory planned second-look laparotomy at 24-48 hours to assess bowel viability.

In myasthenic crisis with respiratory failure or severe bulbar weakness, plasma exchange or IVIG is recommended as rapid-acting first-line therapy. Concomitant high-dose corticosteroids should be titrated under IVIG/PLEX cover while holding oral cholinesterase inhibitors during mechanical ventilation.

IDSA recommends prompt surgical consultation when necrotizing fasciitis or gas gangrene is suspected. Empiric therapy should be broad (for example, vancomycin or linezolid plus piperacillin-tazobactam or a carbapenem, or plus ceftriaxone and metronidazole). Penicillin plus clindamycin is recommended for documented group A streptococcal necrotizing fasciitis; penicillin plus clindamycin is also definitive therapy for clostridial myonecrosis.

The 2019 ESPEN ICU nutrition guideline supported early enteral nutrition when feasible, avoidance of early overfeeding, progressive protein delivery, and individualized use of parenteral nutrition. It has been partially revised and operationalized by the 2023 ESPEN practical ICU nutrition guideline; use the newer entry for current bedside recommendations.

When oral intake is not possible, start enteral nutrition early (generally within 48 hours) when the gastrointestinal tract can be used, and prefer EN over routine early PN. Use indirect calorimetry to estimate energy expenditure in mechanically ventilated patients when feasible. Avoid full early feeding: if predictive equations are used, provide hypocaloric nutrition (<70% of estimated needs) during the early acute phase and increase progressively after the first several days; when energy expenditure is measured, advance toward measured needs as clinical stability improves. Protein provision should be progressive and individualized; approximately 1.3 g/kg/day is suggested, while recent randomized trials do not support routine very-high early protein dosing.

Treat postpartum hemorrhage with rapid cause-directed control and resuscitation. Give tranexamic acid 1 g IV as soon as PPH is diagnosed and within 3 hours of birth, repeat 1 g if bleeding continues after 30 minutes or restarts within 24 hours, escalate promptly to tamponade or surgical/radiologic control when medical treatment fails, and use a local massive-transfusion protocol for severe bleeding with fibrinogen replacement when levels are critically low (commonly <200 mg/dL).

Use the 2026 AHA/ACC acute-PE clinical categories to match monitoring and reperfusion intensity to severity. Advanced therapies are reasonable in Category E1 and can be considered in selected D1-D2 patients; systemic thrombolysis is also reasonable in E2 when appropriate to the arrest/refractory-shock context. Choice among systemic thrombolysis, catheter-based therapies, surgical embolectomy, and mechanical circulatory support depends on bleeding risk, anatomy, shock/arrest phenotype, time to treatment, and local expertise. PERTs are recommended to improve timely individualized decision-making.

Moderate goal-directed fluid resuscitation with Lactated Ringer's is recommended over aggressive over-resuscitation. Routine prophylactic antibiotics in sterile necrotizing pancreatitis are not recommended. A minimally invasive step-up approach is preferred for infected necrotizing pancreatitis.

Pulmonary hypertension is hemodynamically defined as mean pulmonary arterial pressure (mPAP) >20 mmHg at rest. In acute RV failure/PH decompensation, support systemic perfusion, correct reversible triggers such as hypoxemia and severe acid-base derangement, optimize preload and ventilation, and use vasoactive/inotropic or pulmonary-vasodilator therapy according to the hemodynamic phenotype. Continuous parenteral prostacyclin therapy should not be abruptly interrupted because rebound pulmonary hypertension can occur. Mechanical circulatory support such as VA-ECMO is a specialist rescue/bridge option in selected refractory cases rather than a universal indication.

Severe CAP requires ICU admission based on major/minor criteria. Empiric therapy should combine a potent beta-lactam with a macrolide or respiratory fluoroquinolone. Empiric MRSA or Pseudomonas coverage should only be added if validated local risk factors or prior respiratory isolation exist.

Small-bore chest drains (10-14 Fr) are recommended as first-line for secondary spontaneous and iatrogenic pneumothoraces requiring intervention. Tension pneumothorax mandates immediate needle or finger decompression in the 2nd intercostal space MCL or 4th/5th ICS AAL without awaiting radiographic confirmation.

Magnesium sulfate is recommended for the prevention and treatment of seizures in women with preeclampsia with severe features or eclampsia. Immediate antihypertensive therapy (IV labetalol, hydralazine, or nicardipine) is indicated within 30–60 minutes for persistent SBP >= 160 mmHg or DBP >= 110 mmHg.

Acute RV failure resuscitation requires careful volume optimization (avoiding overfilling that exacerbates ventricular interdependence), restoration of systemic blood pressure (norepinephrine or vasopressin to maintain RV coronary perfusion gradient MAP - CVP), inotropic support (dobutamine or milrinone), and reduction of RV afterload using inhaled pulmonary vasodilators (inhaled nitric oxide or inhaled epoprostenol).

For septic shock and for sepsis without shock, administer antimicrobial therapy immediately, ideally within 1 hour of recognition. For possible sepsis without shock, suggest rapid investigation with therapy within 3 hours if concern for infection persists.

Collect blood cultures as soon as possible, ideally before starting antimicrobial therapy, provided this does not substantially delay treatment.

Recommend antimicrobial de-escalation once a microbiological diagnosis and susceptibility results are available; suggest de-escalation when no pathogen is identified on final cultures and the patient is improving.

Suggest early source control, within 6 hours of diagnosis, over delayed intervention when an anatomic source amenable to control is identified.

Suggest active fluid removal (diuretics or ultrafiltration) once the acute resuscitation phase has resolved and the patient is fluid-overloaded, rather than passive fluid balance alone.

Suggest using balanced crystalloids rather than 0.9% saline for resuscitation, with an exception for patients with sepsis and traumatic brain injury, where saline is preferred.

Suggest against sodium bicarbonate to improve hemodynamics or reduce vasopressor requirements in lactic acidemia generally, but suggest sodium bicarbonate in severe metabolic acidemia (pH ≤ 7.2) with concurrent acute kidney injury (AKIN stage 2-3).

Suggest using IV corticosteroids in adults with septic shock, most often in patients with an ongoing vasopressor requirement.

Suggest administering at least 30 mL/kg IV crystalloid within the first 3 hours of resuscitation in sepsis-induced hypoperfusion, individualizing further fluid administration to the patient's response rather than a fixed volume.

For adults aged 65 years and older with septic shock, suggest a mean arterial pressure target of 60-65 mmHg over a higher target. This is a specific recommendation for age ≥65 years, not a general statement about 'older' or 'frail' patients.

Recommend an initial mean arterial pressure target of 65 mmHg in adults with septic shock requiring vasopressors, rather than a higher target, recognizing that exactly maintaining 65 mmHg is impractical and a reasonable range (roughly ±5 mmHg) is appropriate in practice.

Recommend norepinephrine as the first-line vasopressor over dopamine, epinephrine, or selepressin in adults with septic shock.

Suggest adding vasopressin in patients with septic shock requiring escalating doses of norepinephrine, rather than escalating norepinephrine alone. The guideline does not specify a single universal starting dose as a formal recommendation.

Shock is defined as life-threatening generalized maldistribution of blood flow resulting in failure of oxygen delivery. Norepinephrine is recommended as the first-choice vasopressor. Dynamic measures of fluid responsiveness (PLR, stroke volume variation) are preferred over static filling pressures.

Severe symptomatic hyponatremia (seizures, coma) should be treated with rapid boluses of 3% hypertonic saline (100-150 mL IV over 10-20 min) targeting an immediate 4-6 mEq/L rise. Chronic correction must not exceed 8-10 mEq/L in 24 hours (4-6 mEq/L in high-risk patients) to prevent osmotic demyelination syndrome.

First-line: IV lorazepam, IV diazepam, or IM midazolam (Level A). Second-line if seizures continue: IV fosphenytoin/phenytoin (Level A), valproic acid (Level C), or levetiracetam (evidence indeterminate). The guideline does not address treatment of refractory status epilepticus beyond this point.

Emergent intermittent hemodialysis is strongly recommended for: (1) Toxic alcohols (methanol or ethylene glycol with severe acidemia, end-organ injury, or level > 50 mg/dL), (2) Salicylates (level > 100 mg/dL, severe acidemia pH < 7.20, or neurological impairment), (3) Severe Metformin-Associated Lactic Acidosis (MALA with pH < 7.00 or refractory shock), (4) Lithium toxicity (level > 4.0 mEq/L or severe neurological toxicity).

For hemodynamically stable hospitalized adults without a hemoglobinopathy, cyanotic heart disease, or severe hypoxemia, use a restrictive transfusion strategy, transfusing at a hemoglobin threshold below 7 g/dL (strong recommendation, moderate certainty). Consider a threshold of 7.5 g/dL for cardiac surgery and 8 g/dL for orthopedic surgery or pre-existing cardiovascular disease.

In acute variceal hemorrhage: restrictive RBC transfusion (target Hb 7.0-9.0 g/dL); early vasoactive therapy (octreotide 50 mcg bolus + 50 mcg/h for 5 days); short-term antibiotic prophylaxis (ceftriaxone 1 g daily for 7 days); and emergent EGD with band ligation within 12 hours.

In patients with symptomatic severe aortic stenosis, intervention (SAVR or TAVR) is recommended to improve survival and quality of life (Class 1, LOE A). In acute severe MR due to mechanical causes or acute severe AR with hemodynamic compromise, urgent surgical intervention is indicated (Class 1, LOE B-NR).

A 7-day course is the 2016 default for most improving HAP/VAP patients, with shorter or longer treatment individualized to clinical response and infection complications. Empiric therapy should be guided by local antibiograms and patient-specific MRSA/Pseudomonas risk. As of 27 Aug 2026 this remains the published ATS/IDSA treatment guideline; IDSA lists a replacement HAP/VAP guideline as in development for Q4 2026, not yet final.

Management depends on disease severity and recurrence history; fulminant CDI requires urgent medical therapy plus early surgical assessment when shock, ileus, megacolon, or clinical deterioration is present.

In selected adults hospitalized with severe or fulminant C. difficile infection that is not responding to standard antimicrobial therapy, conventional fecal microbiota transplantation may be considered as adjunctive rescue therapy; this is a conditional recommendation based on very-low-certainty evidence.

Cirrhosis with ascites, SBP, or HRS-AKI requires rapid identification of precipitants, appropriate albumin use, vasoconstrictor therapy for HRS-AKI when indicated, and consideration of liver-transplant evaluation after decompensation.

Acute cholangitis management is severity based: begin resuscitation and antimicrobials promptly, then achieve early or urgent biliary drainage in moderate/severe disease according to clinical stability and source-control need.

ITP treatment is driven by bleeding, platelet count, comorbidity and need for procedures rather than the platelet count alone; corticosteroids and IVIG are core rapid therapies, with escalation individualized for severe or refractory disease.

Suspected immune TTP is a hematologic emergency: obtain ADAMTS13 testing before plasma therapy when feasible without delaying treatment, and initiate plasma exchange plus corticosteroids; caplacizumab and rituximab are incorporated according to the immune TTP pathway.

Intramuscular epinephrine is first-line treatment for anaphylaxis and should not be delayed for antihistamines or corticosteroids; refractory shock requires repeated epinephrine, fluids, airway planning, and escalation to monitored vasoactive support.

The 2025 focused update conditionally suggests dexmedetomidine over propofol when light sedation and/or reduction in delirium are highest priorities, enhanced mobilization/rehabilitation over usual mobility care, and melatonin over no melatonin. Evidence was insufficient to recommend for or against antipsychotics over usual care for delirium treatment or benzodiazepines for ICU anxiety. Apply these recommendations with the patient’s clinical status and the broader 2018 PADIS framework.

Benzodiazepines remain first-line therapy for alcohol withdrawal; resistant withdrawal in monitored ICU settings may require adjunctive phenobarbital, dexmedetomidine, or propofol when mechanical ventilation is already required.

Life-threatening poisoning requires toxin-specific resuscitation in addition to standard life support. The 2025 AHA guidance includes recommendations for opioid toxicity, organophosphate/carbamate poisoning, cyanide, digoxin, sodium-channel blockers, calcium-channel blockers, beta-blockers, local anesthetic toxicity and other critical poisonings.

Pleural procedures require ultrasound-guided site selection when appropriate, attention to bleeding and organ-injury risk, safe drain insertion technique, and structured post-procedure monitoring.

Measure intra-abdominal pressure in at-risk patients, use protocolized medical measures to reduce intra-abdominal pressure, and perform decompressive laparotomy for overt abdominal compartment syndrome when indicated.

Suspected adrenal crisis requires immediate parenteral hydrocortisone and rapid isotonic fluid resuscitation; treatment should not be delayed while awaiting confirmatory testing.

Thyroid storm requires simultaneous control of adrenergic effects, thyroid hormone synthesis and release, peripheral conversion, precipitating illness, and organ failure with ICU-level monitoring.

Treat thyroid storm as a clinical endocrine emergency in a high-dependency or intensive-care setting using coordinated supportive care, treatment of precipitants, beta-blockade when hemodynamically tolerated, high-dose antithyroid therapy, corticosteroids and appropriately timed iodide; use rescue therapies such as cholestyramine, lithium, plasma exchange, ECMO or thyroidectomy selectively for refractory disease.

Treat suspected myxoedema coma immediately in a high-dependency or intensive-care setting with supportive resuscitation, empiric stress-dose glucocorticoid, cautious IV levothyroxine replacement, treatment of precipitants, passive warming, and close cardiovascular, respiratory, metabolic and thyroid-function monitoring; liothyronine is reserved for selected cases because of cardiac risk.

Myxedema coma is a clinical emergency requiring prompt thyroid hormone replacement, empiric stress-dose glucocorticoid until adrenal insufficiency is excluded, careful supportive care, and treatment of the precipitating illness.

Inpatient central diabetes insipidus requires reliable access to water when safe, timely desmopressin, close sodium/fluid monitoring, and urgent correction of volume depletion before free-water replacement when hypernatremic and hypovolemic.

Airway strategy should explicitly plan oxygenation, first-pass success, rescue ventilation and emergency invasive airway access, with awake intubation considered when difficult ventilation, aspiration risk, apnea intolerance, or difficult rescue is anticipated.

Adult HLH requires rapid recognition of the hyperinflammatory syndrome, simultaneous trigger investigation, organ support, and early hematology-directed immunomodulatory therapy tailored to severity and cause.

Fibrotic ILD management depends on phenotype and progression; in acute ICU deterioration, evaluate infection, edema, PE and pneumothorax while recognizing the poor prognosis of invasive ventilation in advanced irreversible fibrosis without a reversible bridge or transplant strategy.

Bronchoscopy requires indication-specific risk assessment, oxygenation and sedation planning, correction of relevant bleeding risk, and monitoring appropriate to the physiologic vulnerability of the patient.

For adult ventilator liberation, an RSBI is not required to determine readiness for an SBT; SBTs may be performed with or without low-level pressure support; use a standardized daily SBT process; and do not increase FiO2 solely for the SBT.

Use rapid etiologic diagnosis, serial shock-severity assessment and hemodynamic phenotyping; norepinephrine is generally preferred when vasopressor support is required; use invasive hemodynamics selectively to guide phenotype and temporary mechanical circulatory support decisions, with early shock-team/advanced-center involvement for refractory shock.

Treat hemodynamically unstable wide-complex tachycardia with synchronized cardioversion. In stable regular monomorphic wide-complex tachycardia, antiarrhythmic therapy and selected diagnostic adenosine may be considered; avoid verapamil/diltiazem and avoid adenosine in unstable, irregularly irregular, or polymorphic WCT. For symptomatic bradycardia, correct reversible causes, use atropine when appropriate, and escalate to pacing and/or adrenergic support when instability persists.

Updates the 2011 AHA statement. Cerebral venous thrombosis accounts for 0.5% to 3% of all strokes and is diagnosed mainly by MR/CT venography; death or dependence occurs in 10% to 15% of patients despite intensive medical treatment. The statement reviews the evidence for anticoagulation and for endovascular therapy, considers craniectomy, and gives an algorithm for patients who deteriorate neurologically or show thrombus propagation despite maximal medical therapy. It is a scientific statement rather than a graded guideline, so it does not assign recommendation classes.