Prolonged-infusion β-lactams upgraded to moderate certainty, an AHA statement on residual lesions after paediatric cardiac surgery, and a European consensus on imaging for LAA closure

Three new documents — the most this watch has found in a single day. Both sweeps ran clean with no query failures: the topic-wide guideline search across all journals for 5–8 September (32 hits, one in scope), and the named-journal sweep for 4–8 September, plus the French-society and European-society acronym sweeps.

One of the three is the document this archive has been circling for two weeks. The other two were missed by earlier sweeps because both were published on 1 September, the day Europe PMC returned HTTP 503 to every query — the outage that produced a false quiet day. They are recovered here.

1. Prolonged-infusion β-lactams — the recommendation is re-graded, not just repeated

Societies · Published: Endorsed by the American College of Clinical Pharmacy, British Society for Antimicrobial Chemotherapy, Cystic Fibrosis Foundation, European Society of Clinical Microbiology and Infectious Diseases, Infectious Diseases Society of America, Society of Critical Care Medicine, and Society of Infectious Diseases Pharmacists. Pharmacotherapy 2026;46(9):e70188, 1 September 2026 — one week old Hong, FakhriRavari, Ulldemolins, Roberts, Bonomo, Scheetz, and the Prolonged-Infusion Beta-Lactam Consensus Panel

Date note: this paper appeared on a journal-watch list on 23 August and was recorded then as a lead not pursued. Europe PMC gives its first publication date as 1 September 2026, with the September issue. It is written up properly here for the first time.

From the abstract:

In 2023, international consensus recommendations suggested the use of prolonged-infusion beta-lactam antibiotics over short-infusion dosing in severely ill adult patients to improve mortality or clinical cure, although the certainty of evidence was very low. With the availability of several new randomized controlled trials, this focused update re-evaluates the efficacy of prolonged versus short infusion among severely ill adult patients.

The numbers:

• The original PICO question was split into two — mortality (VIIa) and clinical cure (VIIb) — and Bayesian meta-analysis added to the original GRADE methods
• Mortality: 28 RCTs, RR 0.91 (95% CI 0.85 to 0.97), with a 98.76% posterior probability of benefit
• Clinical cure: 21 RCTs, RR 1.11 (95% CI 1.06 to 1.17), with a 99.97% posterior probability of benefit
• Certainty of evidence strengthened from very low to moderate for mortality, and to low for clinical cure
• Subgroup analysis again supports a loading dose before continuous infusion
• Open questions named: which subpopulations benefit most, the optimal prolonged-infusion strategy, and the role of therapeutic drug monitoring

Interpretation. This is the document that closes the thread, and it closes it in the way that matters: not by repeating the recommendation but by re-grading the evidence underneath it.

Track what this archive has assembled since 25 August. The IDSA multisociety sepsis position paper recommended defaulting antipseudomonal β-lactams to prolonged infusion. The French societies — SPILF, SFPC, SRLF, SFAR and others — published their own continuous- and prolonged-infusion recommendations in December 2024, twenty months earlier. The Surviving Sepsis Campaign upgraded the same recommendation in March 2026. Four bodies converging was already the strongest practical signal of the fortnight. What was missing was the evidence grade: every one of those documents rested on a 2023 consensus explicitly built on very low certainty.

That is what has changed. Moderate certainty for a mortality benefit is a different object from very low certainty for the same point estimate. It moves prolonged infusion out of the category of “biologically plausible, weakly supported, do it if your pharmacy can” and into the category of things a unit should have to justify not doing.

Two practical notes. First, the effect size is real but modest — RR 0.91, a 9% relative reduction, and the confidence interval reaches 0.97. This is not a transformative intervention; it is a free one, which is a different and in some ways better argument. Second, the loading dose is not optional. Continuous infusion without a loading dose delays time-to-target concentration in exactly the first hours that matter most, and the panel has now said so twice. That is the detail most likely to be lost when a protocol is written locally.

Read the focused update · PMID 42598847

Also noted, and not reported separately: a correction notice to the companion “Consensus Guidance for Beta-Lactam Antibiotic Dose Individualization in Acutely Ill Patients,” Pharmacotherapy, 1 September 2026.

2. AHA scientific statement — residual lesions and early unplanned reinterventions after paediatric cardiac surgery

Society · Published: American Heart Association, Congenital Cardiac Defects Committee; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Clinical Cardiology. Circulation, 1 September 2026 — one week old Costello, Mazwi, Riley, Gonzalez de Alba, Olivieri, Rigsby, Hill, Bacha, Newburger, Nathan

Squarely primary scope — cardiothoracic surgery and perioperative care — and it opens with an unusually explicit statement of what determines outcome:

Optimal outcomes for congenital heart surgery depend on the expertise and judgment of an integrated multidisciplinary clinical team… a comprehensive understanding of the patient’s anatomy and physiology, an appropriate therapeutic plan, a meticulously executed operation that is technically optimal and facilitated by lesion-specific anesthesia and perfusion strategies, and skilled perioperative care.

The substance:

• A principal factor contributing to adverse outcomes is the presence of important residual lesions after surgery, which may require early unplanned reintervention during the index admission
• Such reinterventions occur in ≈5% of all paediatric cardiac operations, more often in younger patients and more complex procedures
• Residual lesions and unplanned reintervention are strongly associated with increased morbidity, mortality and resource use
• Wide centre-level variation in both incidence and timing — the statement’s own reading is that this “suggests an opportunity for quality improvement”
• The document covers incidence and risk factors, postoperative monitoring strategies and clinical indicators suggestive of a residual lesion, the non-invasive imaging used to identify and quantify them, the role of diagnostic and interventional catheterisation, surgical considerations for early reoperation, and communication with patients and families

Interpretation. The clause worth pulling out is “facilitated by lesion-specific anesthesia and perfusion strategies.” AHA statements on surgical outcomes do not usually name anaesthesia and perfusion in the definition of a technically optimal operation. That is a claim about where the outcome is made, and it places part of it inside the anaesthetist’s and perfusionist’s remit rather than adjacent to it.

The clinically actionable half is the monitoring and detection section. The framing here is that a residual lesion is not primarily a surgical failure to be audited afterwards but a postoperative diagnosis to be made early — the patient who will not wean, whose lactate will not clear, whose saturations sit wrong for the repair. The full text is not reachable from here, so the detection section is described from the abstract only and not quoted. What can be said is that the older literature it sits on points the same way: a 2013 JTCVS series of post-cardiotomy children on ECMO — located separately, not cited from this statement — found residual lesions in about a quarter of them, detected 28 of 35 by catheterisation and only 7 by echocardiography, with significantly better decannulation and survival when they were found in the first three days. That is the practical shape of it: in a post-bypass child who is not behaving as the repair predicts, a normal echo is not reassurance.

The centre-level variation line is the quality-improvement argument, and it is the same shape as several documents in this archive — a 5% event rate that varies by institution more than by patient is a systems finding, not a case-mix one.

Read the statement · PMID 42677479

3. ELAACC expert consensus — multimodality imaging for left atrial appendage closure

Society · Published: European Left Atrial Appendage Closure Club, in EuroIntervention (journal of EuroPCR in collaboration with the ESC Working Group on Interventional Cardiology), 7 September 2026 — published yesterday Wunderlich, Sanchis Ruiz, Aminian, Berti, Räber, Galea, Freixa, Hammerstingl, Nielsen-Kudsk, De Potter, Rroku, Cruz-Gonzalez, De Backer, Garot

Secondary scope — cardiology — but directly relevant to anyone providing anaesthesia for structural procedures.

The stated problem:

Imaging is central to procedural success and safety, yet variability in acquisition, measurement, and reporting contributes to inconsistent workflows and outcomes among centres.

What the consensus sets out:

• A unified framework for pre-, intra- and postprocedural imaging across the whole LAAC pathway
• Emphasis on high-quality acquisition, reproducible measurement, and prioritising three-dimensional imaging and multiplanar reconstruction
• Standardised terminology, core anatomical parameters and device-oriented requirements defined to support planning and device selection
• Intraprocedural: real-time guidance with 3D transoesophageal echocardiography, intracardiac echocardiography and fusion imaging for transseptal puncture, device alignment, deployment and seal assessment
• Postprocedural: harmonised echocardiographic and cardiac CT criteria, with structured follow-up pathways for device-related thrombus, peridevice leak and device stability

Interpretation. The honest reading is that this is a standardisation document, not an evidence document — it is about nomenclature, measurement reproducibility and workflow rather than about whether or when to close an appendage. That is worth saying plainly, because such documents are often quoted as though they had settled a clinical question they never addressed.

Within that limit it is useful, and the anaesthetic implications are concrete. The consensus prioritises 3D TOE and fusion imaging for intraprocedural guidance, which in most European centres means a general anaesthetic with a transoesophageal probe for the duration — the opposite direction from the ICE-based, lightly-sedated workflow that several groups have been moving toward. ICE is listed alongside 3D TOE rather than instead of it. If your centre has been reducing anaesthetic involvement in LAAC on the grounds that intracardiac echo removes the need for it, this document does not support that, and it is worth knowing before the argument is had.

The postprocedural half — harmonised criteria for device-related thrombus and peridevice leak — is the part with the clearest patient-level consequence, since those are the findings that determine whether a patient who had the appendage closed specifically to avoid anticoagulation ends up anticoagulated anyway.

Read the consensus · PMID 42703764

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Also seen in the topic-wide sweep and not pursued, as outside scope: an ERN-EYE consensus on assessing children with low vision, a FIGO statement on emergency contraception, ESSKA consensus documents on hip and groin pain and on rotator cuff tears, a Chinese expert consensus on traumatic brain injury in mass casualty incidents (no English text available), and an Austrian Society of Cardiology consensus on arrhythmias in adults with congenital heart disease (German, no abstract deposited).