Sepsis and septic shock

Recognize

• Screen with NEWS, NEWS2, MEWS or SIRS, not qSOFA. This is a strong recommendation (moderate certainty).^1,2
• Diagnosis is clinical. Don't rule sepsis in or out on one biomarker or test.^1,2
• Measure lactate (conditional, low certainty). Serial lactate can guide resuscitation, with capillary refill time as an adjunct.^1,2
• Get blood cultures as soon as possible, ideally before antibiotics (strong, low certainty).^1,2

First hour

1. Decide how likely infection is, and whether there is shock. That decision sets the antibiotic clock (table below).^1,2
2. Draw blood cultures and lactate, without delaying antibiotics.^1,2
3. Give antibiotics within 1 hour for shock or probable sepsis.^1,2
4. Start crystalloid: at least 30 mL/kg within 3 hours for hypoperfusion or shock. Base the dosing weight on BMI.^1,2
5. If hypotension persists after the first bolus, start norepinephrine, peripherally if needed. In unstable shock, vasopressors can run alongside fluids.^1,2
6. Look for a source that needs control, and aim to control it within 6 hours.^1,2

From the 2026 Surviving Sepsis Campaign adult guidelines.^1,2 Use clinical evaluation, not procalcitonin, to decide whether to start antibiotics.²

Fluids

• Crystalloids first (strong, moderate certainty). Prefer balanced crystalloids over 0.9% saline (conditional, moderate). Saline is suggested instead in traumatic brain injury.^1,2
• Crystalloid alone over adding albumin (conditional, moderate). Albumin may suit very large volumes or cirrhosis; avoid it in traumatic brain injury.^1,2
• No starches (strong, high certainty) and no gelatin (conditional).^1,2
• Beyond the first 30 mL/kg, use dynamic measures such as a passive leg raise or fluid challenge over static ones.^1,2

Vasopressors

Support for the lower target in older adults: in the 65 trial (n = 2,463, age ≥ 65), permissive hypotension cut vasopressor exposure. Mortality at 90 days was 41.0% vs 43.8%, not significant.⁸ The guideline's new recommendation is MAP 60–65 for this group.²

Corticosteroids

The guideline suggests IV corticosteroids in septic shock (conditional, low certainty).^1,2

• ADRENAL (n = 3,800, ventilated septic shock): hydrocortisone 200 mg/day did not lower 90-day mortality (27.9% vs 28.8%), but shock resolved faster (median 3 vs 4 days).⁶
• APROCCHSS (n = 1,241): hydrocortisone plus fludrocortisone lowered 90-day mortality (43.0% vs 49.1%).⁷

Antimicrobials and source control

• Cover multidrug-resistant organisms only if the patient is at high risk for them. Skip routine empiric antifungal and anaerobic coverage unless risk factors are present.^1,2
• Give beta-lactams as a prolonged infusion after a loading dose (strong, moderate certainty).^1,2
• Evaluate quickly for a source needing emergent control (good practice), and control it early, ideally within 6 hours.^1,2
• De-escalate once a pathogen and its susceptibilities are known.^1,2

Other ED decisions

• Oxygen: for hypoxemic respiratory failure, high-flow nasal cannula over conventional oxygen and as first-line over noninvasive ventilation (conditional).^1,2
• Bicarbonate: not for improving hemodynamics in lactic acidemia. Consider it when pH ≤ 7.2 with stage 2–3 acute kidney injury (conditional, very low).^1,2
• Glucose: start insulin at ≥ 180 mg/dL (strong).^1,2
• Not recommended: IV vitamin C, IV immunoglobulin, routine blood purification.^1,2
• Transfusion: restrictive thresholds over liberal (strong).^1,2
• Prehospital: screening en route and, where in-hospital evaluation will take over 60 minutes, antibiotics for septic shock once a structured screening process exists.^1,2

Where experts disagree

Pitfalls

• Using qSOFA as the screening tool. The guideline recommends against it as a single screen.^1,2
• Waiting for a central line before starting norepinephrine.^1,2
• Holding antibiotics while cultures are drawn. Cultures should come first only if they don't delay treatment.^1,2
• Pushing fluid past the first 30 mL/kg without checking whether the patient is still fluid-responsive.^1,2,4
• Chasing a MAP above 65 in older adults by default.^2,8

How strong is the evidence?

The 2026 update has 129 statements, 46 of them new, and covers evidence through June 2025. Most recommendations are conditional and rest on low or very low certainty evidence.² The guideline's full text was not openly accessible, so the recommendations here come from the official SCCM summary and are cited to both.^1,2 For a podcast discussion of CLOVERS, see REBEL EM.¹⁰

On-shift teaching

Questions to ask a learner at the bedside. Tap a question to see the answer. Every answer uses facts cited above.

References

1. 1
   Prescott HC, Antonelli M, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026. Crit Care Med. 2026;54(4):725–812.GuidelinePMID 41869847DOIPubMed record; full text not openly accessible
2. 2
   Society of Critical Care Medicine. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (recommendation summary).Summarysccm.orgPage read
3. 3
   Seymour CW, Gesten F, Prescott HC, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med. 2017;376(23):2235–2244.CohortPMID 28528569PMCPubMed
4. 4
   NHLBI PETAL Clinical Trials Network; Shapiro NI, Douglas IS, et al. Early restrictive or liberal fluid management for sepsis-induced hypotension (CLOVERS). N Engl J Med. 2023;388(6):499–510.RCTPMID 36688507PMCPubMed
5. 5
   Semler MW, Self WH, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adults (SMART). N Engl J Med. 2018;378(9):829–839.RCTPMID 29485925PMCPubMed
6. 6
   Venkatesh B, Finfer S, Cohen J, et al. Adjunctive glucocorticoid therapy in patients with septic shock (ADRENAL). N Engl J Med. 2018;378(9):797–808.RCTPMID 29347874PubMed
7. 7
   Annane D, Renault A, Brun-Buisson C, et al. Hydrocortisone plus fludrocortisone for adults with septic shock (APROCCHSS). N Engl J Med. 2018;378(9):809–818.RCTPMID 29490185PubMed
8. 8
   Lamontagne F, Richards-Belle A, Thomas K, et al. Effect of reduced exposure to vasopressors on 90-day mortality in older critically ill patients with vasodilatory hypotension (65 trial). JAMA. 2020;323(10):938–949.RCTPMID 32049269PMCPubMed
9. 9
   Spiegel R, Haycock K, Miller A, et al. The 2026 Surviving Sepsis Campaign Guidelines: the dissenting opinion. Am J Emerg Med. 2026;110:411–415.CommentaryPMID 42767105PubMed
10. 10
    REBEL EM. REBEL Cast Ep116: The CLOVERS trial: restrictive vs liberal fluids in sepsis-induced hypotension.FOAMrebelem.comLink checked
11. 11
    Emergency Medicine Cases. Sepsis. Further reading; not used for any claim above.FOAMemergencymedicinecases.comLink checked