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,

Rhea Votipka, NP

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

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.

 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 

 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.

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.

The Randomized Trial of Sedative Choice for Intubation (RSI trial), published in the 

 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.

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.

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

Prescott HC, Antonelli M, Alhazzani W, et al; Surviving Sepsis Campaign. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2026. 

 2026;54(4):725–812. doi:10.1097/CCM.0000000000007075

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. 

 2026;87(13). doi:10.1016/j.jacc.2025.11.005

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. 

 2025;334(22):1988–1999. doi:10.1001/jama.2025.20402

Dres M, Raux M, Houzé-Cerfon CH, et al; CRICS-TRIGGERSEP Group. Noninvasive versus invasive blood pressure monitoring in ICU patients with shock (EVERDACT). 

Casey JD, Semler MW, Rice TW, et al; Pragmatic Critical Care Research Group. Ketamine or etomidate for tracheal intubation of critically ill adults. 

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From personalized sepsis resuscitation to the long-awaited ketamine versus etomidate verdict, a critical care NP highlights the evidence that defined the field last year.


POCUS is Standard of Care in Critical Care, With Rhea Votipka, NP

Point-of-care ultrasound (POCUS) has moved steadily from a niche procedural skill to a guideline-supported standard of care in critical care medicine, appearing in sepsis management guidance for dynamic volume responsiveness assessment and in the American Heart Association's post-cardiac arrest care recommendations, among others.

 For advanced practice providers (APPs) working in pulmonary and critical care settings, developing POCUS competency is no longer a differentiating credential — it is an expectation the field is moving toward, 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 participated in a POCUS bootcamp session at the 

Association of Pulmonary Advanced Practice Providers (APAPP) National Conference, held June 28-20 in Las Vegas, Nevada.

Votipka's message to APPs just beginning to integrate POCUS into their practice was direct: start with formal training, then commit to volume. "POCUS education is more of a marathon than a sprint," she said, emphasizing that an initial course providing didactic instruction and hands-on simulation with models is a necessary foundation — but only a foundation. The real skill development happens through repeated scanning of patients, building comfort with probe handling and equipment, and developing pattern recognition for normal and abnormal findings. Seeking out mentors who can review images and provide feedback accelerates that process significantly.

The 2024 Society of Critical Care Medicine critical care ultrasonography guidelines recommend POCUS for guiding management across 5 key clinical scenarios — cardiac arrest, sepsis, acute dyspnea and respiratory failure, volume management, and cardiogenic shock — and suggest it over usual care without POCUS for targeted volume management given evidence of improved outcomes.

 Ongoing clinical trials are further defining the role of POCUS-guided fluid management, and its integration into routine ICU care is expanding.

In many clinical scenarios — pneumothorax evaluation being a prime example — POCUS delivers the answer faster, without the delays of ordering and waiting for a portable radiograph, and with information that a plain film simply cannot provide. "When people can see the utility of POCUS in practice, that helps with the adoption process," she said. "If I'm concerned about a pneumothorax, I can take the probe and get my answer right away — and intervene right away. That's the beauty of ultrasound."

The primary limitation of POCUS, once training has been completed, is operator skill level — and Votipka described self-awareness on this point as a professional obligation. Knowing the boundaries of one's own competency, being willing to ask for a second opinion, and resisting overconfidence in image interpretation are as essential to safe POCUS practice as technical proficiency itself.

"I think the biggest message [about] POCUS is that you got to do it, that it's really going to be what's best for our patients, it's going to elevate your practice, it's going to elevate the care of your patients, and you might as well start now, because it is the standard,” she said.

Bhagra A, Tierney DM, Sekiguchi H, Soni NJ; Guidelines Committee. Guidelines on adult critical care ultrasonography 2024: focused update. 

 2025;53(3):e434–e453. doi:10.1097/CCM.0000000000006531

DeRienzo V, Jozefowski M, Votipka R. POCUS Bootcamp. Presented at: Association of Pulmonary Advanced Practice Providers Annual Meeting (APAP 2026); Las Vegas, NV

A critical care NP and POCUS educator says point-of-care ultrasound competency is no longer optional for pulmonary and critical care APPs.

Rhea Votipka, NP

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