UMEM Educational Pearls

Click the link for below to read the bulleted, abridged version of the Executive Summary of the Updated SSC Guidelines for Adults with Sepsis and Septic Shock 2026…

• Strength of guidelines provided as conditional “suggestions” or strong “recommendations"
• Amount of certainty given existing evidence (very low [VL], low, moderate)
  • Note “very low” certainty may simply indicate there isn't a study or any reliable data
• Please refer to the article (linked in References) for given rationales from the SSC

Additional Information

New Statements for 2026:

• Suggest using a standard sepsis screening tool over not  (VL cert)
• Recommend initial MAP goal >65 over higher targets (moderate) 
  • Describes allowing a range within 5 mmHg… (so perhaps MAP 60-70 mmHg?)
• For adults 65yrs+ still suggest MAP 60-65mmHg over higher ranges (low)
• For likely septic shock if prehospital time is likely to be >60 min, suggests prehospital abx (VL)
  • Commented that this should only be w/ use of sepsis screening tool
• Suggest empiric abx without anaerobic coverage unless there are risk factors for anaerobic infection (VL)
  • Okay to use ones with anaerobic coverage (such as piperacillin-tazobactam) if otherwise required for resistant infections
  • Risk factors listed: intraabdominal or gyn/OB source, necrotizing STI, HEENT infection, CNS abscess/empyema
• Suggest empiric abx WITH anaerobic coverage if risk factors are there (VL)
• Suggest selective decontamination of digestive tract  in mechanically-ventilated adults in units with low prevalence of antimicrobial resistance (moderate)
• After acute resuscitation phase, ‘suggest” using active fluid removal (diuretics, dialysis, etc.) (VL)

Changes in Suggestion/Recommendations from 2021:

• Suggest against using empiric antifungal (low certainty) instead of using empiric antifungal for those at risk
• Suggest using either invasive or NIBP monitoring (VL) instead of recommending invasive monitoring in patients with septic shock
  • Still recommends invasive for intermediate-to-high dose pressors, escalating or multiple pressors, needing frequent  ABGs, or inconsistent NIBP measurements
• Suggest using crystalloids alone over crystalloids with supplemental albumin (moderate) instead of conditional recommendation for albumin if large volumes of crystalloid given
  • Notes albumin may be appropriate for pts who have received a lot of crystalloid already or have cirrhosis, and to avoid in TBI patients

Changes in Strength of Recommendation or Evidence Certainty since 2021:

Upgrades

• “Strong” recommendation (from “conditional”) for prolonged infusion maintenance beta-lactams after initial loading dose (moderate certainty)
• “Strong” recommendation to deescalate abx to appropriate narrower therapy once bacteria/susceptibility profile is available (from “conditional”; VL)
• “Moderate” certainty evidence for suggestion to use balanced crystalloids over 0.9% saline (from "low”)
• “Low” certainty evidence suggestion to use dynamic measures (response to passive leg raise or test bolus using stroke volume, stroke volume variation, pulse pressure, or pulse pressure variation) to guide initial fluid resuscitation over physical exam or static measures alone (from “very low”)

Downgrades

• “Conditional” suggestion (from recommendation) to use NE (norepinephrine) first over vasopressin (low cert) or Ang II (VL cert)
  • Strong rec to use NE first over dopamine/epi/selepressin still in place
• “Very low” evidence for suggestion to add Epi if MAP inadequate despite NE and vasopressin (from “low”)
• “Very low” certainty of evidence for suggestion to add dobutamine to NE, or use epinephrine alone, for pts with persistent shock & cardiac dysfunction despite adequate fluid resus and appropriate MAP
  • no guidance on dobutamine vs milirinone
• “Low” certainty of evidence for suggestion for IV corticosteroids in septic shock (from “moderate”)

Otherwise the same:

• Treat sepsis / septic shock immediately and as emergencies
• Suggest at least 30mL/kg IV crystalloid in the first 3 hours for sepsis-related hypoperfusion/shock (low certainty) using adjusted or ideal BW in patients with BMI>30. 
• Recommend abx within 1hr of recognition for probable/definite sepsis and for possible/definite septic shock (VL)
• Suggest a time-limited course of investigation for possible sepsis and if infection likely, abx within 3 hrs (VL)

References

Prescott HC, Antonelli M, Alhazzani W, et al. Executive Summary: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026. Crit Care Med. 2026 Mar 23. doi: 10.1097/CCM.0000000000007089. Epub ahead of print.