Sepsis Algorithm 2026

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Pre-Hospital / EMS

EMS Sepsis Protocol

Field recognition · SIRS criteria · Prehospital treatment · 2026 SSC prehospital recommendations

EMS

⏱

Time is Life — Sepsis is a time-dependent emergency

Use a standard sepsis screening tool in ambulances/flight 2026 NEW
Consider giving antibiotics en route if in-hospital evaluation is > 60 minutes away and patient has likely septic shock 2026 NEW
Consider a "Code Sepsis" / Sepsis Huddle protocol on arrival 2026 NEW

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Suspected Infection — Consider Appropriate PPE & Infection Control

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Age (common in elderly and very young)
Presence and duration of fever
Previously documented infection or illness (UTI, pneumonia, meningitis, encephalitis, cellulitis, abscess)
Recent surgery or invasive procedure
Immunocompromised (transplant, HIV, diabetes, cancer)
Bedridden or immobile patients
Prosthetic or indwelling devices
Immunization status

Hyper or hypothermia
Rash and/or excessive bruising
Chills · Myalgia (muscle aches)
Markedly decreased urine output
Altered mentation
Delayed capillary refill
Elevated blood glucose (unless diabetic)

Cardiogenic shock · Hypovolemic shock · Dehydration
Hyperthyroidism · Medication/drug interaction
Non-septic infection · Allergic reaction/anaphylaxis
Toxicological emergency

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SIRS Criteria — any of the following:

SBP < 90 mmHg
Heart rate > 90/min
Respiratory Rate > 20/min
GCS < 15
Temperature ≥ 100.4°F (38°C) or ≤ 96.0°F (35.6°C)

✗ NO — SIRS Not Met

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Exit to appropriate protocol — continue monitoring

✓ SIRS Criteria Met — Initiate Sepsis Protocol

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IV Fluid Resuscitation

Normal Saline 500 mL bolus — then reassess SIRS criteria and re-examine
Repeat 500 mL boluses to maximum 2 litres as long as any SIRS criteria present
STOP if concern for fluid overload (known CHF, ESRD on dialysis, signs of pulmonary oedema)
Aggressive IV fluid is the most important prehospital treatment for sepsis

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✓ EtCO₂ < 26 — Declare Sepsis Alert

📢

Declare Sepsis Alert during radio call-in to destination hospital

EtCO₂ levels are correlated with lactate levels — a useful marker of hypoperfusion

✗ EtCO₂ ≥ 26

Continue monitoring — reassess frequently

EtCO₂ may normalize with fluid resuscitation
Elevated serum lactate often precedes hypotension

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⚠ Refractory Hypotension — Vasopressor

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Norepinephrine IV Infusion

1–10 mcg/min IV infusion titrated to SBP > 90 mmHg
Start peripherally — do not delay for central access 2026

✓ Responding to Fluids

Continue monitoring en route

Continue reassessing vital signs
Notify destination hospital

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Notify Destination per usual procedures or Contact Medical Control

Attempt to identify source of infection (skin, respiratory, urinary) — relay to ED
DIC is an ominous late manifestation — frank extensive bruising, bleeding from multiple sites
Avoid excessive tidal volumes if ventilating — CPAP airway pressure limited to 5 cmH₂O

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Early recognition allows attentive care and early antibiotics — early is everything
Aggressive IV fluids are the most important prehospital treatment
Septic patients are especially susceptible to traumatic lung injury and ARDS — avoid excessive tidal volumes
Elevated serum lactate often becomes elevated prior to onset of hypotension
Disseminated Intravascular Coagulation (DIC) is an ominous, late-stage manifestation — frank extensive bruising, bleeding from multiple sites, tissue death
2026 SSC: Use standard sepsis screening tool in ambulance/flight NEW
2026 SSC: Give antibiotics en route if hospital arrival > 60 min and likely septic shock NEW
2026 SSC: Out-of-hospital approach should store baseline blood samples for rapid analysis at hospital admission NEW

MedPearls

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2026 SSC Definitions

Sepsis Definitions & Criteria

Diagnostic criteria · SOFA · Septic shock · Biomarkers

Definitions

2026 Key Change — Clinical Diagnosis NEW

Sepsis is a clinical diagnosis and should not be ruled in or out by any single biomarker
qSOFA is demoted — poor sensitivity; use NEWS, NEWS2, MEWS, or SIRS instead STRONG REC
Phoenix criteria (2024) incorporated alongside older 2005 definitions for paediatrics

Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection (Sepsis-3, 2016)

Practical trigger: Suspected infection + SOFA score ≥ 2

General Variables (infection + any of)

Fever (> 38.3°C) or Hypothermia (core temp < 36°C)
Heart rate > 90/min or > 2 SD above normal for age
Tachypnoea
Altered mental status
Significant oedema or positive fluid balance (> 20 mL/kg over 24h)
Hyperglycaemia (plasma glucose > 7.7 mmol/L or 140 mg/dL) in absence of diabetes

Inflammatory Variables

Leucocytosis (WBC > 12,000/µL)
Leukopenia (WBC < 4,000/µL)
Normal WBC with > 10% immature forms
CRP > 2 SD above normal · Procalcitonin > 2 SD above normal

Haemodynamic Variables

Arterial hypotension (SBP < 90 mmHg, MAP < 70 mmHg, or SBP decrease > 40 mmHg)

Organ Dysfunction Variables

Arterial hypoxaemia (PaO₂/FiO₂ < 300)
Acute oliguria (urine output < 0.5 mL/kg/hr for ≥ 2 hrs despite adequate resuscitation)
Creatinine increase > 44.2 µmol/L (0.5 mg/dL)
Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)
Ileus (absent bowel sounds)
Thrombocytopenia (platelet count < 100,000/µL)
Hyperbilirubinaemia (total bilirubin > 70 µmol/L or 4 mg/dL)

Tissue Perfusion Variables

Hyperlactataemia (> 1 mmol/L)
Decreased capillary refill or mottling

System	0	1	2	3	4
Respiration PaO₂/FiO₂	≥ 400	< 400	< 300	< 200 + vent	< 100 + vent
Coagulation Platelets (×10³/µL)	≥ 150	< 150	< 100	< 50	< 20
Liver Bilirubin (µmol/L)	< 20	20–32	33–101	102–204	> 204
Cardiovascular MAP	≥ 70	< 70	Dopa ≤ 5 or Dobu	Dopa 5.1–15 or Norepi/Epi ≤ 0.1	Dopa > 15 or Norepi/Epi > 0.1
CNS GCS	15	13–14	10–12	6–9	< 6
Renal Creatinine (µmol/L)	< 110	110–170	171–299	300–440 or UO < 500 mL/d	> 440 or UO < 200 mL/d

Sepsis = SOFA score ≥ 2 with suspected infection. Each organ system scored 0–4.

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Septic Shock = Sepsis + ALL of:

Vasopressor requirement to maintain MAP ≥ 65 mmHg
Serum lactate > 2 mmol/L
Despite adequate fluid resuscitation

Practical field definition: Sepsis-induced hypotension persisting despite adequate fluid resuscitation

OR: MAP < 65 mmHg OR lactate ≥ 4 mmol/L

2026 SSC: Recommended Screening Tools STRONG

NEWS (National Early Warning Score)
NEWS2
MEWS (Modified Early Warning Score)
SIRS criteria

⚠ qSOFA — DEMOTED 2026 CHANGE

qSOFA has poor sensitivity for sepsis as a single screening tool
No longer recommended as primary screening — use NEWS/NEWS2/MEWS/SIRS instead
qSOFA (quick SOFA): RR ≥ 22, altered mentation, SBP ≤ 100 — still useful for clinical awareness but not recommended as sole screen

Biomarkers — 2026 Position

Sepsis is a clinical diagnosis — no single biomarker rules in or out
Lactate: measure and remeasure if > 2 mmol/L — strong recommendation
Procalcitonin: can guide de-escalation but not diagnostic alone
Novel rapid host-response diagnostics: insufficient evidence to recommend

The Phoenix Sepsis Score (2024) is now incorporated alongside older 2005 paediatric definitions. The guidelines do not mandate a single diagnostic framework — both may be used based on institutional resources.

Phoenix Sepsis Criteria (simplified)

Suspected infection + Phoenix Sepsis Score ≥ 2 points
Scores organ dysfunction across: Respiratory, Cardiovascular, CNS, Coagulation systems
Septic shock = Phoenix cardiovascular score ≥ 1

Previous 2005 Criteria (still valid)

Sepsis = SIRS + suspected/confirmed infection
Severe sepsis = Sepsis + organ dysfunction or tissue hypoperfusion
Septic shock = Sepsis + cardiovascular dysfunction despite ≥ 40 mL/kg fluid bolus in 1 hour

MedPearls

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2026 SSC Adult Guidelines

Adult Sepsis Algorithm

Hour-1 bundle · Resuscitation · Antimicrobials · Respiratory support

Adult

Suspected Infection + SOFA ≥ 2 — SepsisUse NEWS / NEWS2 / MEWS / SIRS for screening (qSOFA demoted — 2026)

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Hour-1 Bundle — Start ALL within 1 hour 2026 SSC

1. Measure lactate — remeasure if initial > 2 mmol/L
2. Obtain blood cultures before antibiotics (2 sets, 10 mL each, aerobic + anaerobic)
3. Administer broad-spectrum antibiotics (within 1 hour for septic shock; up to 3 hours for possible sepsis without shock)
4. Administer 30 mL/kg crystalloid IV for hypotension or lactate ≥ 4 mmol/L
5. Apply vasopressors if hypotensive during/after fluids to maintain MAP ≥ 65 mmHg

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Monitor, support ABCs — insert urinary catheter and monitor urine output
Check vital signs: BP, MAP, PR, RR, SpO₂, ToC, RBS, Serum lactate
Start Oxygen IF SpO₂ < 94% — maintain SpO₂ ≥ 94%
Establish IV access — FBC, MPS, UEC, ABG, Serum lactate
Obtain 2 sets blood cultures (10 mL each, aerobic + anaerobic) from different sites before antibiotics
Brief, targeted history and physical exam
CXR · Urinalysis + MCS
Give antipyretic if indicated: Paracetamol 1g IV
Consider: echocardiogram, imaging for source

2026 New — Respiratory Assessment

High-flow nasal cannula (HFNC) suggested over conventional O₂ and NIV for hypoxaemic respiratory failure NEW
Trial of awake proning suggested for non-intubated patients NEW
Note: pulse oximetry may overestimate oxygenation in patients with darker skin tones and in shock NEW

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Timing

Septic shock or probable/definite sepsis: within 1 hour STRONG
Possible sepsis without shock: time-limited 3-hour assessment window

Empiric Antibiotics (Severe Sepsis/Septic Shock)

Ceftriaxone 2g IV stat — community-acquired general sepsis
Imipenem 500 mg IV infusion over 3 hours then QID — probable neutropenic patients or hospital-acquired infection in last 3 months
Meropenem 1g IV infusion over 3 hours then TDS — possible CNS infection
Full loading dose even if decreased GFR suspected

2026 New — Extended Infusion STRONGLY REC NEW

Prolonged (extended/continuous) infusion of beta-lactams now strongly recommended over bolus dosing
Upgraded to high-certainty evidence following BLING III trial

De-escalation

Strong recommendation: de-escalate once cultures and susceptibilities available STRONG
Tailor empiric MDR and anaerobic coverage to risk factors — not routine NEW
Selective digestive decontamination (SDD) conditionally suggested for ventilated patients in low-resistance settings NEW

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Crystalloid Resuscitation

30 mL/kg IV crystalloid within 3 hours of identification STRONG
Use ideal/adjusted body weight in obese patients — not actual weight 2026 NEW
Caution in low-resource settings 2026 NEW
More rapid and greater amounts may be needed in some patients

Fluid Approach

Liberal vs restrictive fluid approach: equivalent — either acceptable 2026
Use dynamic measures to guide resuscitation (pulse pressure variation, fluid responsiveness assessment)
Serial lactate and capillary refill time endorsed for resuscitation guidance NEW
Active fluid removal suggested after acute resuscitation phase NEW

Monitoring

Repeat vital signs: BP, MAP, PR, RR, SpO₂, ToC, serum lactate
Urine output (< 0.5 mL/kg/h = concern)
Diuresis < 0.5 mL/kg/h · Lactate · SvO₂ · ΔPCO₂
Capillary refill time/skin · Mental status · Oxygenation
3P: MAP/SAP/DAP · POCUS where available NEW

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✓ Haemodynamically Stable

Assess continuously: vital signs, diuresis, lactate, capillary refill, mental status, oxygenation
Adjust antibiotic therapy according to initial microbiology and expert consultation
Optimize antimicrobial doses — consider duration of therapy
Remove intravascular access devices that could be possible sources after other IV access established
Register all interventions and clinical variables

If NO current indication for admission

Clinically stable with NO signs of severe sepsis or septic shock
Identify source of infection — if amenable to oral antibiotics, initiate and consider discharge with follow-up

✗ SHOCK — Vasopressors + ICU

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Conditionally Suggested — 2026

IV Corticosteroids for septic shock — now conditionally suggested (shift toward favoring) UPDATED
Active fluid removal after acute resuscitation phase NEW
HFNC over conventional O₂ for hypoxaemic respiratory failure NEW
Awake proning for non-intubated patients NEW

Suggest AGAINST — 2026

Antipyretics for outcome improvement NEW
Probiotics NEW
Vitamin D NEW
Vitamin C (maintained against) REVISITED
IVIG (maintained against)
Blood purification techniques (maintained against)
Routine beta-blockers NEW
XueBiJing (outside approved jurisdictions) NEW

Insufficient Evidence — No Recommendation

Methylene blue · Midodrine

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New 2026 Post-Discharge Recommendations NEW

Offer post-critical-illness follow-up services
Physical rehabilitation for patients ventilated > 48 hours
Mental health support after discharge
Advance directives discussion
Time-limited trials of critical care
Post-discharge care coordination

MedPearls

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2026 SSC Paediatric Guidelines

Paediatric Sepsis Algorithm

61 statements · 5 strong recommendations · Phoenix criteria 2024

Paediatric

Suspected Paediatric SepsisSuspected infection + Phoenix Sepsis Score ≥ 2 OR 2005 SIRS-based criteria

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2026 Change — Systematic Screening REVERSED

The 2020 weak recommendation for systematic screening was withdrawn
Insufficient evidence (including a new RCT) to recommend systematic sepsis screening
Clinical recognition and bedside assessment remain primary

POCUS — New 2026 Recommendation NEW

POCUS (cardiac and lung) is newly suggested to guide resuscitation where training/resources allow

Lactate — Strengthened to Strong STRONG UPGRADED

Measure blood lactate as part of initial evaluation — now a strong recommendation (was previously non-recommendation)

Performance Improvement Programs STRONG

Performance improvement programs with standard operating procedures are now strongly recommended

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Suspected septic shock: within 1 hour
Probable sepsis without shock: within 3 hours (after time-limited rapid investigation)
Obtain blood cultures before antibiotics whenever possible

De-escalation — 2026 NEW

Procalcitonin is suggested against for routine antibiotic de-escalation where good stewardship already exists (moderate certainty)
Infectious diseases consultation suggested for documented bloodstream infections NEW

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✓ ICU Available

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Fluid Bolus Protocol

Up to 40–60 mL/kg in boluses of 10–20 mL/kg each
Reassess after every bolus — stop if fluid overload develops
Crystalloid (NS or Ringer's Lactate)

✗ No ICU — Without Hypotension

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Do NOT give fluid boluses STRONG · HIGH CERTAINTY

In settings without intensive care and without hypotension — do not give fluid boluses
One of the few high-quality evidence recommendations in paediatric sepsis

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Epinephrine (adrenaline) or Norepinephrine — both acceptable first-line agents
Start peripherally rather than delaying for central access
Choice between epinephrine vs norepinephrine: insufficient evidence — either acceptable
Timing of vasoactives relative to fluid volume: insufficient evidence
Angiotensin II, Methylene blue: insufficient evidence

Doses

Norepinephrine: titrate to MAP ≥ 65 mmHg (or age-appropriate MAP)
Epinephrine (adrenaline): 0.05–0.3 µg/kg/min IV infusion
Start with lowest effective dose — titrate to response

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🫁

Conservative O₂ Targets for Intubated Children MODERATE CERTAINTY

SpO₂ 88–92% over liberal (>94%) for intubated children post-resuscitation
Based on OxyPICU trial — one of the rare moderate-certainty paediatric recommendations 2026 NEW
During resuscitation: maintain SpO₂ ≥ 94%

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High-Volume Haemofiltration > 35 mL/kg/hr now PREFERRED over standard-volume

Full reversal of the 2020 position — previously standard volume was recommended
Plasma exchange for TAMOF: insufficient evidence
Extracorporeal blood purification: insufficient evidence

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Early rehabilitation bundles during acute illness are newly recommended
Post-sepsis follow-up: assess risk factors, educate families, evaluate for long-term sequelae after discharge
Fever management: 2020 stance allowing antipyretics or permissive fever was downgraded to "insufficient evidence"

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Paediatric Sepsis — Where Evidence Remains Insufficient

Choice between epinephrine vs norepinephrine first-line
Timing of vasoactives relative to fluid volume
Angiotensin II · Methylene blue · Sodium bicarbonate
Extracorporeal blood purification · Plasma exchange for TAMOF
Immune stimulants/immunosuppressants for specific subphenotypes
Fever management (antipyretics vs permissive fever)
Systematic sepsis screening

MedPearls

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Adult — Severe Sepsis / Septic Shock

Septic Shock Algorithm

Vasopressors · MAP targets · Dobutamine · Hydrocortisone · ICU

Septic Shock

Septic Shock — MAP < 65 mmHg despite fluids OR Lactate ≥ 4 mmol/L

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Immediate — Consult Physician & ICU

Consult a Physician immediately
Start peripheral vasopressors if MAP < 65 mmHg — do not delay for central access 2026
All patients requiring vasopressors must have arterial catheter placed as soon as resources available
Admit HDU/ICU
Anticipate echocardiogram and central IV access
Follow protocolised early sepsis care bundles

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Standard target: MAP ≥ 65 mmHg — maintained STRONG
Patients aged ≥ 65: consider lower MAP range of 60–65 mmHg — conditional recommendation based on 65 trial 2026 NEW
Permissive hypotension in older patients may reduce fluid load and vasopressor burden
Prioritise MAP ≥ 65 mmHg to preserve tissue perfusion

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1st Line — Norepinephrine FIRST LINE

Start: 0.01 mcg/kg/min IV Titrate every 3–5 min to achieve MAP ≥ 65 mmHg Typical range: 0.1–1.3 µg/kg/min Start peripherally — do not delay for central access

If relative bradycardia with low-risk for arrhythmias — consider dopamine as alternative

2nd Line — Add Vasopressin (escalating doses)

0.03–0.04 units/min IV infusion

Add when norepinephrine dose escalating. May allow norepinephrine dose reduction.

3rd Line — Epinephrine (Adrenaline)

Adult: 0.05–0.3 µg/kg/min IV infusion Paeds: 0.05–0.3 µg/kg/min IV infusion

Add or substitute when norepinephrine + vasopressin insufficient

Concomitant Cardiac Dysfunction

Norepinephrine OR Epinephrine — both acceptable

New 2026 recommendation — either agent acceptable for cardiac dysfunction in septic shock

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Dobutamine (Adults)

Up to 20 µg/kg/min IV infusion (+ vasopressor if in use)

Indications: a) Myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output; OR b) Ongoing signs of hypoperfusion despite adequate intravascular volume and adequate MAP

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Hydrocortisone — Conditionally Suggested for Septic Shock SHIFT TOWARD FAVORING

IV Hydrocortisone 200 mg IV bolus — then continue infusion
Indicated when haemodynamic stability NOT achieved with adequate fluid resuscitation and vasopressor therapy
2026: Shifted from uncertain to conditionally suggesting steroids in septic shock

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✓ Haemodynamic Stability Achieved

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Admit HDU/ICU

Continue monitoring — de-escalate antibiotics when cultures available
Plan active fluid removal after acute phase 2026 NEW
Consider post-sepsis recovery planning

✗ Hypoperfusion Persists

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Escalate — Dobutamine + Intensivist Review

Give Dobutamine infusion up to 20 µg/kg/min + vasopressor if in use
Reassess continuously — rule out additional causes of shock
Assess valid dynamic predictive variables of volume response
Consider fluid challenge if fluid responsive
Intensivist consultation for ICU admission

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Admit HDU/ICU — connected to monitoring

MedPearls

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Drug Reference

Medications

Antibiotics · Vasopressors · Steroids · Doses · 2026 SSC recommendations

Medications

Ceftriaxone (3rd generation cephalosporin)

2g IV stat

Community-acquired general sepsis. Full loading dose even if decreased GFR suspected.

Imipenem (carbapenem)

500 mg IV infusion over 3 hours then QID

For probable neutropenic patients or hospital-acquired infection (admitted in last 3 months). Extended infusion per 2026 SSC strong recommendation.

Meropenem (carbapenem)

1g IV infusion over 3 hours then TDS

Possible CNS infections. Better CNS penetration than imipenem.

2026 SSC — Extended/Continuous Beta-Lactam Infusion STRONG · HIGH CERTAINTY NEW

Prolonged (extended/continuous) infusion of beta-lactams now strongly recommended over bolus dosing
Based on BLING III trial — upgraded to high-certainty evidence
Applies to all beta-lactam antibiotics including ceftriaxone, imipenem, meropenem, piperacillin-tazobactam

Norepinephrine (Noradrenaline)

Adults: start 0.01 mcg/kg/min IV Titrate every 3–5 min Range: 0.1–1.3 µg/kg/min EMS: 1–10 mcg/min IV infusion to SBP > 90

Start peripherally — do not delay for central access (2026 SSC). First-line for septic shock. Titrate to MAP ≥ 65 mmHg.

Adrenaline / Epinephrine

Adults: 0.05–0.3 µg/kg/min IV infusion Paeds: 0.05–0.3 µg/kg/min IV infusion

Add or substitute when norepinephrine insufficient. Also acceptable first-line in paediatrics (equal to norepinephrine per 2026 SSC — insufficient evidence for preference).

Vasopressin

0.03–0.04 units/min IV infusion

Add when escalating norepinephrine dose. May allow norepinephrine dose reduction.

Dopamine

2–20 µg/kg/min IV infusion

Only if relative bradycardia with low-risk for arrhythmias present. Norepinephrine preferred otherwise.

Dobutamine

Up to 20 µg/kg/min IV infusion (+ vasopressor if in use)

Indications: myocardial dysfunction with elevated cardiac filling pressures and low cardiac output; OR ongoing hypoperfusion despite adequate volume and MAP.

Hydrocortisone

200 mg IV bolus — then continuous infusion

2026 SSC: conditionally suggested for septic shock (shift toward favoring). Use when haemodynamic stability not achieved with adequate fluids and vasopressors.

Paracetamol

1g IV if indicated

Note: 2026 SSC suggests against antipyretics specifically for outcome improvement in sepsis — use for patient comfort only. Insufficient evidence in paediatrics.

Therapies to AVOID in Sepsis — 2026 SSC

Vitamin C — suggest against
IVIG — suggest against
Blood purification techniques — suggest against
Probiotics — suggest against (new 2026)
Vitamin D — suggest against (new 2026)
Antipyretics specifically for outcome improvement — suggest against (new 2026)
Routine beta-blockers — suggest against (new 2026)
XueBiJing outside approved jurisdictions — suggest against (new 2026)

MedPearls

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Quick Reference

Reference Guide

Bundle comparison · Monitoring targets · 2026 biggest changes · Scoring

Reference

Change	Direction	Strength
qSOFA demoted as screening tool	Use NEWS/NEWS2/MEWS/SIRS instead	Strong
Beta-lactam extended infusion	Now strongly recommended (BLING III)	Strong · High certainty
Corticosteroids in septic shock	Shift toward favoring (conditional)	Conditional
MAP target in elderly (≥65 yrs)	Lower range 60–65 mmHg acceptable	Conditional
Prehospital antibiotics	Give en route if hospital >60 min away	New recommendation
HFNC for respiratory failure	Suggested over conventional O₂ and NIV	New
Awake proning	Suggested for non-intubated patients	New
SDD in low-resistance settings	Conditionally suggested	New
Active fluid removal post-resuscitation	Conditionally suggested	New
Antipyretics for outcome improvement	Suggest against	New · Against
Post-sepsis recovery emphasis	New section: rehab, mental health, follow-up	New GPS
Paeds: lactate measurement	Upgraded to strong recommendation	Strong (upgraded)
Paeds: O₂ target intubated	Conservative SpO₂ 88–92% post-resuscitation	Moderate certainty
Paeds: High-volume haemofiltration	Now preferred >35 mL/kg/hr (reversal)	Reversed
Paeds: Systematic screening	Withdrawn — insufficient evidence	Withdrawn

Element	2018 Hour-1	2026 Status
Measure lactate	Yes — remeasure if >2	Retained — Strong
Blood cultures before antibiotics	Yes	Retained — GPS
Broad-spectrum antibiotics	Within 1 hour	Retained — Strong (with 3-hr window for possible sepsis)
30 mL/kg crystalloid	If hypotension or lactate ≥4	Retained — Strong (weight-adjusted)
Vasopressors for persistent hypotension	Yes — MAP ≥65	Retained — Strong (peripheral start endorsed)
ScvO₂ ≥70% / CVP ≥8 targets	Removed in 2016	Still removed — outdated
Activated protein C	Removed in 2012	Still removed
Quantitative resuscitation	Removed in 2016	Still removed

Outdated elements (CVP targets, ScvO2 goals, activated protein C) removed since 2016 and remain removed in 2026.

Parameter	Target	Notes
MAP	≥ 65 mmHg	≥ 60–65 acceptable in elderly ≥65 yrs (2026)
Lactate	≤ 2 mmol/L	Remeasure if >2; elevated lactate = poor perfusion marker
Urine output	≥ 0.5 mL/kg/h	Insert urinary catheter
SpO₂ (non-intubated)	≥ 94%	HFNC preferred if hypoxaemic respiratory failure
SpO₂ (intubated — paeds post-resus)	88–92%	Conservative target — OxyPICU trial (2026 paeds)
Capillary refill time	< 2 seconds	Endorsed as resuscitation guide (2026)
Diuresis	> 0.5 mL/kg/h	Reassess continuously
Blood cultures	2 sets before antibiotics	10 mL each — aerobic + anaerobic

Practices Removed from SSC Guidelines — No Longer Recommended

CVP target ≥ 8 mmHg (removed since 2016)
ScvO₂ ≥ 70% as fixed resuscitation goal (removed since 2016)
Activated protein C / Drotrecogin alfa (removed since 2012)
Quantitative resuscitation protocols
qSOFA as primary screening tool (demoted 2026)
Routine beta-blockers (new 2026 — suggest against)
Vitamin C (suggest against — maintained 2026)
IVIG (suggest against — maintained 2026)
Blood purification (suggest against — maintained 2026)
Systematic paediatric sepsis screening (withdrawn 2026)

SOFA — Sepsis Diagnosis (Preferred)

Sepsis = Suspected infection + acute SOFA ≥ 2
Assess: Respiration, Coagulation, Liver, Cardiovascular, CNS, Renal

qSOFA — Clinical Awareness Only (demoted 2026)

RR ≥ 22/min · Altered mentation · SBP ≤ 100 mmHg
Score 0–3; ≥ 2 = high risk
No longer recommended as primary screening tool — poor sensitivity

NEWS2 — Now Recommended for Screening (2026)

Respiratory rate · SpO₂ · Supplemental O₂ · Temperature · Systolic BP · HR · Level of consciousness
Score ≥ 5 = urgent review · Score ≥ 7 = emergency

2026 SSC — Health Equity & Low-Resource Settings

Attention to low-resource settings and health equity woven into nearly every 2026 recommendation
30 mL/kg fluid bolus: use ideal/adjusted weight in obese patients; caution in low-resource settings
Blood cultures: single-site cultures acceptable in low-resource settings
Paeds: do NOT give fluid boluses without ICU in low-resource settings without hypotension (strong, high certainty)
Pulse oximetry may overestimate oxygenation in patients with darker skin tones and in shock

MedPearls