Surviving Sepsis Campaign 2021‑2025 Guideline Summary

Immediate Recognition & Initial Resuscitation

• Treat sepsis and septic shock as medical emergencies and initiate therapy within 1 hour of recognition – strong recommendation from the Surviving Sepsis Campaign (Critical Care Medicine, 2017) 1.

Antimicrobial Therapy (≤ 1 hour)

• Give intravenous broad‑spectrum antimicrobials within the first hour of sepsis recognition – strong recommendation (Intensive Care Medicine, 2017) 2.
• Obtain at least two sets of aerobic and anaerobic blood cultures before antibiotics, provided this does not delay therapy by more than 45 minutes – strong recommendation (Intensive Care Medicine, 2017) 2.
• Empirically cover likely bacterial, fungal, and viral pathogens until culture results are available – strong recommendation (Intensive Care Medicine, 2017) 2.
• Reassess antimicrobial regimen daily and de‑escalate once pathogen identification and susceptibilities are known – strong recommendation (Intensive Care Medicine, 2017) 2.
• Use procalcitonin levels to guide discontinuation of empiric antibiotics when infection evidence is limited – strong recommendation (Intensive Care Medicine, 2017) 2.
• Typical antimicrobial course is 7–10 days; extend for slow clinical response, undrained foci, Staphylococcus aureus bacteremia, fungal/viral infections, or immunocompromised hosts – strong recommendation (Intensive Care Medicine, 2017) 2.

Fluid Resuscitation (First 3 hours)

• Administer at least 30 mL/kg of intravenous crystalloid within the first 3 hours of sepsis‑induced hypoperfusion or septic shock – weak recommendation (Critical Care Medicine, 2017) 1.
• Crystalloids are the preferred initial and ongoing resuscitation fluid – strong recommendation (Critical Care Medicine, 2017) 1.
• Add albumin to crystalloids when large fluid volumes are needed to maintain oncotic pressure – strong recommendation (Critical Care Medicine, 2013) 3.
• Never use hydroxyethyl starch solutions for volume expansion – strong recommendation against (Critical Care Medicine, 2013; Critical Care Medicine, 2017) 3.
• Continue fluid administration using a “fluid‑challenge” approach guided by hemodynamic improvement rather than fixed volumes – strong recommendation (Critical Care Medicine, 2017) 1.
• Prioritize dynamic hemodynamic variables (e.g., pulse‑pressure variation, stroke‑volume variation) over static measures such as central venous pressure to predict fluid responsiveness – strong recommendation (Critical Care Medicine, 2017) 1.

Vasopressor Management

• Norepinephrine is the first‑line vasopressor – strong recommendation (Intensive Care Medicine, 2017) 4.
• Target an initial mean arterial pressure (MAP) ≥ 65 mmHg – strong recommendation (Intensive Care Medicine, 2017) 4.
• Place an arterial catheter promptly in any patient receiving vasopressors for accurate blood‑pressure monitoring – strong recommendation (Intensive Care Medicine, 2017) 4.
• Add vasopressin (up to 0.03 U/min) to norepinephrine to raise MAP or reduce norepinephrine dose – strong recommendation (Intensive Care Medicine, 2017) 4.
• Add epinephrine if additional pressor support is required beyond norepinephrine – strong recommendation (Intensive Care Medicine, 2017) 4.
• Use dopamine only in highly selected patients (e.g., low risk of tachyarrhythmias, absolute or relative bradycardia) – weak recommendation (Intensive Care Medicine, 2017) 4.
• Do not use low‑dose dopamine for renal protection – strong recommendation against (Intensive Care Medicine, 2017) 4.
• Phenylephrine is not recommended except when norepinephrine causes serious arrhythmias, cardiac output is high with persistent hypotension, or as salvage therapy – weak recommendation (Intensive Care Medicine, 2017) 4.

Inotropic Support

• Dobutamine (up to 20 µg/kg/min) should be used in patients with persistent hypoperfusion despite adequate fluid resuscitation and vasopressor therapy, especially when myocardial dysfunction is suspected – strong recommendation (Intensive Care Medicine, 2017) 4.
• Titrate dobutamine to perfusion endpoints and discontinue if hypotension or arrhythmias worsen – strong recommendation (Intensive Care Medicine, 2017) 4.

Corticosteroid Therapy

• Do not give intravenous hydrocortisone if adequate fluid resuscitation and vasopressor therapy have restored hemodynamic stability – strong recommendation against (Intensive Care Medicine, 2017) 4.
• If hemodynamic stability is not achieved, consider hydrocortisone 200 mg/day – weak recommendation (Intensive Care Medicine, 2017) 4.
• Do not use ACTH stimulation testing to identify patients who should receive hydrocortisone – strong recommendation against (Intensive Care Medicine, 2017) 4.
• When hydrocortisone is used, taper gradually after vasopressors are no longer required – strong recommendation (Intensive Care Medicine, 2017) 4.
• Do not administer corticosteroids for sepsis in the absence of shock – strong recommendation against (Intensive Care Medicine, 2017) 4.

Blood Product Management

• Transfuse red blood cells only when hemoglobin falls below 7 g/dL after tissue hypoperfusion has resolved; target hemoglobin 7–9 g/dL – strong recommendation (Intensive Care Medicine, 2017) 4.
• Do not give fresh‑frozen plasma to correct laboratory clotting abnormalities without active bleeding or planned invasive procedures – strong recommendation against (Intensive Care Medicine, 2017) 4.
• Do not use antithrombin for treatment of severe sepsis or septic shock – strong recommendation against (Intensive Care Medicine, 2017) 4.
• Platelet transfusion thresholds: <10 × 10⁹/L without bleeding; <20 × 10⁹/L with high bleeding risk; ≥50 × 10⁹/L for active bleeding, surgery, or invasive procedures – strong recommendation (Intensive Care Medicine, 2017) 4.

Screening & Performance Improvement

• Hospitals should implement a performance‑improvement program for sepsis that includes screening of acutely ill, high‑risk patients – strong recommendation (Intensive Care Medicine, 2017) 2.
• Routine screening of seriously ill patients enables earlier implementation of therapy – strong recommendation (Intensive Care Medicine, 2017) 2.

Common Pitfalls to Avoid

• Do not delay antimicrobial administration to obtain cultures if this would postpone treatment beyond 1 hour – strong recommendation (Critical Care Medicine, 2017) 1.
• Do not give antimicrobials to patients whose severe inflammatory state is determined to be non‑infectious – strong recommendation (Intensive Care Medicine, 2017) 2.
• Do not use low‑dose dopamine for renal protection – strong recommendation against (Intensive Care Medicine, 2017) 4.

Revision History of the Surviving Sepsis Campaign Guidelines

Guideline Publication Timeline

• The Surviving Sepsis Campaign has issued major guideline revisions in 2004, 2008, 2012, 2016/2017 (the most recent comprehensive version), and targeted updates in 2021【@1】.