Trials and Guidelines Shaping Critical Care, With Rhea Votipka, NP

The past year produced several high-impact trials and guideline updates that are actively informing how critical care clinicians manage their most complex patients, according to Rhea Votipka, AGACNP-BC, Adult Gerontology Acute Care Nurse Practitioner at Lahey Hospital and Medical Center and Assistant Professor of Medicine at UMass Chan Medical School, who co-presented a critical care year in review session at the Association of Pulmonary Advanced Practice Providers (APAPP) National Conference, held June 28-20 in Las Vegas, Nevada.¹

Among the most consequential updates were the 2026 Surviving Sepsis Campaign guidelines and the new pulmonary embolism (PE) guidelines, which Votipka identified as the 2 overarching documents that most reshaped how APPs are approaching critically ill patients.^2,3 On the sepsis side, one of the most clinically actionable updates was an accelerated antibiotic administration recommendation — moving the target window from 3 hours to 1 hour for patients with highly suspected septic shock. While the importance of early antibiotics was not a new concept, Votipka noted the guideline formalized it with a more aggressive timeline that has direct implications for bedside decision-making. The 2026 guidelines also notably incorporated patient-centered outcomes — including mental health recovery and post-ICU physical rehabilitation — alongside traditional hemodynamic endpoints, a shift Votipka described as overdue.

"We really want to see patients thrive, not just survive," she said, noting that post-intensive care syndrome and ICU-related PTSD are well-documented but have historically received insufficient attention in guideline frameworks.

Among the randomized controlled trials featured in the session, ANDROMEDA-SHOCK-2 drew significant attention. Published in JAMA in October 2025, the multinational trial enrolled 1,467 patients across 86 ICUs and tested a personalized hemodynamic resuscitation strategy targeting capillary refill time (CRT) normalization against usual care in early septic shock. The CRT-guided approach was superior on a hierarchical composite outcome of 28-day mortality, duration of vital support, and hospital length of stay — driven primarily by shorter duration of organ support — providing evidence for individualized, physiology-based resuscitation over standardized protocols.⁴

The EVERDACT trial addressed a fundamental question in ICU monitoring: whether noninvasive blood pressure cuff monitoring is noninferior to early arterial catheter placement in patients admitted with circulatory shock. Conducted across 9 French hospitals, the trial found noninvasive monitoring to be noninferior for 28-day mortality, while also revealing that arterial catheter placement was associated with a substantially higher rate of hematoma and hemorrhage (8.2% versus 1.0% with noninvasive monitoring) — findings with practical implications for how and when arterial lines are placed in the ICU.⁵

The Randomized Trial of Sedative Choice for Intubation (RSI trial), published in the New England Journal of Medicine in December 2025, enrolled 2,365 critically ill adults across 14 sites comparing ketamine with etomidate for emergency tracheal intubation induction. Ketamine did not reduce 28-day in-hospital mortality compared with etomidate, while also being associated with a higher incidence of cardiovascular collapse during the intubation procedure — a finding that challenges the longstanding clinical preference for ketamine in this setting and provides the first large-scale randomized data to guide induction agent selection.⁶

Looking ahead, Votipka identified POCUS as the clearest growth trajectory for 2026 and beyond — with emerging literature exploring serial POCUS-guided de-resuscitation to accelerate ventilator liberation and reduce fluid overload in ICU patients. "POCUS really is the future — it's coming into every aspect of medicine, whether you're inpatient or outpatient," she said.

Votipka has no relevant disclosures to report.

References

1. Lonidier L, Votipka R. Year in review: critical care. Presented at: APAPP 2026; Las Vegas, NV.

2. Prescott HC, Antonelli M, Alhazzani W, et al; Surviving Sepsis Campaign. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2026. Crit Care Med. 2026;54(4):725–812. doi:10.1097/CCM.0000000000007075

3. Creager MA, Barnes GD, Giri J, et al. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN guideline for the evaluation and management of acute pulmonary embolism in adults: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2026;87(13). doi:10.1016/j.jacc.2025.11.005

4. ANDROMEDA-SHOCK-2 Investigators; Hernandez G, Ospina-Tascón GA, et al. Personalized hemodynamic resuscitation targeting capillary refill time in early septic shock: the ANDROMEDA-SHOCK-2 randomized clinical trial. JAMA. 2025;334(22):1988–1999. doi:10.1001/jama.2025.20402

5. Dres M, Raux M, Houzé-Cerfon CH, et al; CRICS-TRIGGERSEP Group. Noninvasive versus invasive blood pressure monitoring in ICU patients with shock (EVERDACT). Intensive Care Med. 2025. doi:10.1007/s00134-025-07789-9

6. Casey JD, Semler MW, Rice TW, et al; Pragmatic Critical Care Research Group. Ketamine or etomidate for tracheal intubation of critically ill adults. N Engl J Med. 2025. doi:10.1056/NEJMoa2511420