Blood conservation in cardiac surgery: ITACS and ANH

The quiet stretch broke. criticalcarereviews.com journal-watch finally posted its Aug 21/22/23 listings overnight (absent on the 2026-08-24 run) and the Aug 21 RCT list was substantial.

1. ITACS — Intravenous iron to treat anaemia before cardiac surgery

Journal · Published: The BMJ, 19–20 August 2026 — genuinely new Myles et al., Alfred/Monash, ANZCA CTN

International double-blind placebo-controlled RCT, 33 hospitals across 10 countries, enrolled Jul 2016–Dec 2023. 955 anaemic adults randomised (921 assessed; mean age 66, 60% male), single IV iron infusion vs placebo 1–26 weeks preoperatively.

• Primary outcome (days alive and at home to 90 days): 81 vs 80 days. The authors themselves concede “a one day difference in a 90 day recovery period is in itself a very small treatment effect.”
• RBC transfusion 262/429 (61%) vs 302/444 (68%); ~44 units of blood product saved per 100 patients treated.
• No difference in major complications or hospital length of stay.

Flagged to the user. Press coverage — BMJ Group’s own release, Monash, Nursing Times — framed this as “reduces complications and boosts recovery.” The data do not support that headline. It is a blood-product-sparing result, not an outcome-improving one.

Interpretation. This is the cardiac-surgery counterpart to PREVENTT (Lancet 2020, Richards — IV iron before major abdominal surgery, negative for transfusion-or-death, reduced readmissions), and follows the same group’s IDOCS cohort (Lancet Haematol 2022, non-anaemic iron deficiency and worse cardiac surgery outcomes). It lands in the same place as PREVENTT: iron moves haematological endpoints, not clinical ones.

Read the paper

2. Should the esophageal balloon catheter be deployed to personalize ventilation of ARDS?

Journal · Published: Intensive Care Medicine, What’s New in Intensive Care, online 24 August 2026 — genuinely new, one day old Marini, Ferguson & Talmor

Position piece, not new data. The argument: airway pressure alone doesn’t represent lung-distending force; airway-minus-oesophageal pressure approximates transpulmonary (alveolar) distending pressure, which is the right variable for VILI risk. But clinical evidence remains inconclusive, so they endorse selective use — abnormal chest-wall mechanics (obesity, abdominal hypertension, chest-wall oedema, post-surgical) and vigorous spontaneous effort — rather than routine deployment. They close calling it “an important but unresolved question that warrants incisive future research.”

Interpretation. This sits on the EPVent arc: EPVent (Talmor, NEJM 2008, oesophageal-guided PEEP improved oxygenation and compliance), EPVent-2 (Beitler, JAMA 2019, no mortality benefit vs empirical high PEEP), and the Sarge et al. 2021 reanalysis (benefit may depend on whether lung or systemic pathology drives outcome). Talmor is the original EPVent investigator, so this is the principals staking out a position on their own reanalysis.

Read the paper

3. A Randomized Trial of Acute Normovolemic Hemodilution in Cardiac Surgery

Journal · Published: NEJM, 12 June 2025 — ~14 months old, sent as older-but-still-hot, deliberately paired with ITACS as the other half of the cardiac-surgery blood-conservation question Monaco, Lei, Bonizzoni et al.

Multinational single-blind RCT, 32 centres, 11 countries, N=2,010. ANH (withdrawal of ≥650 mL whole blood after induction, retransfused post-bypass) vs usual care.

• Primary outcome — ≥1 unit allogeneic RBC during hospitalisation: 27.3% (274/1,005) vs 29.2% (291/997), RR 0.93 (95% CI 0.81–1.07), P=0.34.
• No differences in death, bleeding, ischaemic complications or AKI.

Interpretation — why it’s still live. Co-author Kenichi Tanaka’s caveat is that <5% of participants were US-based (larger patients, different bleeding/transfusion patterns) and that the trial “does not exclude the possibility that ANH could help some patients” — pointing at higher-bleeding-risk subgroups and Jehovah’s Witness planning. The ongoing debate spans NEJM correspondence (NEJMc2513087), two JCVA editorials (“Evidence-Based Exit or a Chance for Refinement?”; “Concentrating on the Right Population”), a BJA meta-analysis of ANH RCTs (Br J Anaesth 2026;136:836–46) which has itself drawn three comment letters in 2026, and a new Can J Anesth retrospective on ANH and cardiac-surgery-associated AKI. Before this trial, ANH rested on small trials and meta-analyses plus a Class IIa/IIb STS/SCA patient-blood-management endorsement.

Read the paper · PMID 40503713

Considered but not sent

• OFACAR — Opioid Free anesthesia in cardiac surgery (Anesthesiology, DOI 10.1097/ALN.0000000000006164, PMID 42190101). Third run blocked: journals.lww.com returned 402 on the direct fulltext URL, the Ovid mirror is gated, the PubMed article page unusable. Re-flagged to the user with the PDF offer. Still high priority.
• Gan et al. — Fifth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting: Executive Summary — Anesth Analg 2026;143(3):497–513 (print Sept 2026), PMID 41237407, online ~Nov 2025. Major anaesthesiology guideline update superseding the 4th consensus (2020), squarely on topic. Not sent only because two guideline items went out on 2026-08-22 and genuinely-new RCTs were in hand. Strong candidate for the next quiet run. DOI 10.1213/ANE.0000000000007816
• Pittaway et al. — Extracorporeal haemoadsorption in cardiac surgery (systematic review), Br J Anaesth 2026;137(3):676–689. On topic; details unconfirmable (BJA blocked as usual). Worth retrying.
• McDougall et al. — Induction agents network meta-analysis, Chest 2026, epublished 18 Aug. Would pair with the RSI ketamine/etomidate trial sent on 2026-08-22, but searches kept returning the adjacent Crit Care 2026 NMA (DOI 10.1186/s13054-026-06067-w) and the BJA ketamine meta-analysis (S0007-0912(26)00132-7) instead. Retry.
• Other Aug 21 journal-watch RCTs, lower priority or outside core scope: BETULA (low-dose catheter-directed thrombolysis for intermediate-high-risk PE, EuroIntervention 2026;22(16)); Wang — renal resistive index-guided MAP titration in sepsis (Nat Commun 2026;17:8759 — interesting personalised-MAP angle vs SEPSISPAM/65, unconfirmed, worth a retry); HeadSOAR (head positioning after EVT, BMJ); Maity — dexmedetomidine vs dopamine renoprotection in off-pump CABG (JCVA, epub Aug 21 — on topic but small); Antonenko — transcranial stimulation and postoperative delirium (JAMA Netw Open).
• Aug 23 journal-watch guidelines noted but not pursued: Hong et al. prolonged-infusion beta-lactams in severe illness (Pharmacotherapy 2026;46(9):e70188); iCHOP consensus on critically ill cancer patients (Eur J Cancer 2026;245:116924).