We thank Pearson and Bauchmuller for their thoughtful commentary 1 on our systematic review and meta-analysis examining arterial catheter-related complications and failure in adult intensive care 2. We agree with their interpretation and welcome the opportunity to clarify the intent of our work and its place within a broader programme of research. As they note, heterogeneity in outcome definitions, limited reporting of catheter duration, and the inability to calculate incidence density constrained the clinical granularity of the pooled estimates. These limitations were acknowledged explicitly and reflect longstanding challenges in arterial catheter research. Importantly, however, the purpose of our review was not to provide admission-level risk prediction or to prescribe indications for arterial catheter insertion, but rather to quantify the baseline burden of complications and failure, highlight deficiencies in reporting and establish the need for more rigorous, decision-focused approaches to arterial catheter use. The review was undertaken deliberately as foundational epidemiological work to inform subsequent research addressing the question of appropriateness. Specifically, the findings informed the design of a future study of the appropriate use criteria for peripheral arterial catheters in acute and critical care 3. The appropriateness methods of this study are designed to address precisely the clinical nuance that population-level observational studies and trials cannot resolve. We also acknowledge the recently published multicentre randomised trial evaluating a non-invasive vs. early invasive arterial pressure monitoring strategy in patients with shock 4. That study provides high-quality evidence that a routine early arterial catheter strategy confers no survival advantage over a selective approach when assessed using 28-day mortality. These findings complement our programme of work. Pragmatic trials are essential for establishing the safety of broad strategies at a population level, whereas appropriateness frameworks provide the finer decision-making detail required at the bedside. Together, they reinforce a shared conclusion, which is that arterial catheter use should not be reflexive but tailored to patient need and clinical context. Our group has shown previously that arterial catheter use remains highly prevalent across Australian and New Zealand ICUs 5, underscoring the importance of moving beyond binary debates about benefit vs. harm toward more judicious, evidence-informed use. This perspective aligns with earlier calls to critically appraise routine arterial catheterisation and with emerging work examining alternatives, timing of insertion and early removal strategies. We agree with the Pearson and Bauchmuller that future research should focus on refining patient selection, clarifying indications and timing, and evaluating bundled approaches that support earlier deescalation once clinical stability permits. We believe that integrating epidemiological data, pragmatic trials and appropriateness-based guidance offer the most robust pathway to reducing unnecessary harm while preserving the benefits of arterial monitoring for patients most likely to require it.
Levido et al. (2026) studied this question.