Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021

We recommend continuously re-evaluating and searching for alternative diagnoses and discontinuing empiric antimicrobials if an alternative cause of illness is demonstrated or strongly suspected.

We recommend that treatment and resuscitation begin immediately.

We suggest that at least 30 mL/kg of IV crystalloid fluid should be given within the first 3 hr of resuscitation.

We suggest using dynamic measures to guide fluid resuscitation, over physical examination, or static parameters alone.

We suggest guiding resuscitation to decrease serum lactate in patients with elevated lactate level, over not using serum lactate.

We suggest using capillary refill time to guide resuscitation as an adjunct to other measures of perfusion.

We recommend an initial target mean arterial pressure (MAP) of 65 mm Hg over higher MAP targets.

We suggest admitting the patients to the ICU within 6 hr.

We recommend using norepinephrine as the first-line agent over other vasopressors.

We suggest adding vasopressin instead of escalating the dose of norepinephrine.

We suggest adding epinephrine.

We suggest against using terlipressin.

We suggest either adding dobutamine to norepinephrine or using epinephrine alone.

We suggest against using levosimendan.

We suggest invasive monitoring of arterial blood pressure over noninvasive monitoring, as soon as practical and if resources are available.

We suggest starting vasopressors peripherally to restore mean arterial pressure rather than delaying initiation until a central venous access is secured.

We recommend discussing goals of care and prognosis with patients and families over no such discussion.

We suggest addressing goals of care early (within 72 hr) over late (72 hr or later).

There is insufficient evidence to make a recommendation on any specific standardized criterion to trigger goals of care discussion.

We recommend that the principles of palliative care (which may include palliative care consultation based on clinician judgement) be integrated into the treatment plan, when appropriate, to address patient and family symptoms and suffering.

We suggest against routine formal palliative care consultation for all patients over palliative care consultation based on clinician judgement.

We suggest referral to peer support groups over no such referral.

We suggest using a handoff process of critically important information at transitions of care over no such handoff process.

There is insufficient evidence to make a recommendation on the use of any specific structured handoff tool over usual handoff processes.

We recommend screening for economic and social support (including housing, nutritional, financial, and spiritual support), and make referrals where available to meet these needs.

We suggest offering written and verbal sepsis education (diagnosis, treatment, and post-ICU/post-sepsis syndrome) prior to hospital discharge and in the follow-up setting.

We recommend the clinical team provide the opportunity to participate in shared decision making in post-ICU and hospital discharge planning to ensure discharge plans are acceptable and feasible.

We suggest using a critical care transition program, compared with usual care, upon transfer to the floor.

We recommend reconciling medications at both ICU and hospital discharge.

We recommend including information about the ICU stay, sepsis and related diagnoses, treatments, and common impairments after sepsis in the written and verbal hospital discharge summary.

We recommend hospital discharge plans include follow-up with clinicians able to support and manage new and long-term sequelae.

There is insufficient evidence to make a recommendation on early post-hospital discharge follow-up compared with routine post-hospital discharge follow-up.

There is insufficient evidence to make a recommendation for or against early cognitive therapy.

We recommend assessment and follow-up for physical, cognitive, and emotional problems after hospital discharge.

We suggest referral to a post-critical illness follow-up program if available.

We suggest referral to a post-hospital rehabilitation program.

We recommend administering antimicrobials immediately, ideally within 1 hr of recognition.

We recommend rapid assessment of the likelihood of infectious versus noninfectious causes of acute illness.

We suggest a time-limited course of rapid investigation and if concern for infection persists, the administration of antimicrobials within 3 hr from the time when sepsis was first recognized.

We suggest deferring antimicrobials while continuing to closely monitor the patient.

We suggest against using procalcitonin plus clinical evaluation to decide when to start antimicrobials, as compared to clinical evaluation alone.

We recommend using empiric antimicrobials with MRSA coverage over using antimicrobials without MRSA coverage.

We suggest against using empiric antimicrobials with MRSA coverage, as compared with using antimicrobials without MRSA coverage.

We suggest using two antimicrobials with gram-negative coverage for empiric treatment over one gram-negative agent.

We suggest against using two gram-negative agents for empiric treatment, as compared to one gram-negative agent.

We suggest against using double gram-negative coverage once the causative pathogen and the susceptibilities are known.

We suggest using empiric antifungal therapy over no antifungal therapy.

We suggest against empiric use of antifungal therapy

We suggest using prolonged infusion of beta-lactams for maintenance (after an initial bolus) over conventional bolus infusion.

We recommend optimising dosing strategies of antimicrobials based on accepted pharmacokinetic/pharmacodynamic (PK/PD) principles and specific drug properties.

We recommend rapidly identifying or excluding a specific anatomical diagnosis of infection that requires emergent source control and implementing any required source control intervention as soon as medically and logistically practical.

We recommend prompt removal of intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has been established.

We suggest daily assessment for de-escalation of antimicrobials over using fixed durations of therapy without daily reassessment for de-escalation.

We suggest using shorter over longer duration of antimicrobial therapy.

We suggest using procalcitonin AND clinical evaluation to decide when to discontinue antimicrobials over clinical evaluation alone.

We recommend using crystalloids as first-line fluid for resuscitation.

We suggest using balanced crystalloids instead of normal saline for resuscitation.

We suggest using albumin in patients who received large volumes of crystalloids.

We recommend against using starches for resuscitation.

We suggest against using gelatin for resuscitation.

There is insufficient evidence to make a recommendation on the use of restrictive versus liberal fluid strategies in the first 24 hr of resuscitation.

There is insufficient evidence to make a recommendation on the use of conservative oxygen targets.

We suggest the use of high flow nasal oxygen over noninvasive ventilation.

There is insufficient evidence to make a recommendation on the use of noninvasive ventilation in comparison to invasive ventilation.

We recommend using a low tidal volume ventilation strategy (6 mL/kg), over a high tidal volume strategy (> 10 mL/kg).

We recommend using an upper limit goal for plateau pressures of 30 cm H2O, over higher plateau pressures.

We suggest using higher PEEP over lower PEEP.

We suggest using low tidal volume as compared with high tidal volume ventilation.

We suggest using traditional recruitment maneuvers.

We recommend against using incremental PEEP titration/strategy.

We recommend using prone ventilation for greater than 12 hr daily.

We suggest using intermittent NMBA boluses, over NMBA continuous infusion.

We suggest using Veno-venous (VV) ECMO when conventional mechanical ventilation fails in experienced centers with the infrastructure in place to support its use.

We suggest using IV corticosteroids.

We suggest against using polymyxin B hemoperfusion.

There is insufficient evidence to make a recommendation on the use of other blood purification techniques.

We recommend using a restrictive (over liberal) transfusion strategy.

We suggest against using IV immunoglobulins.

We suggest using stress ulcer prophylaxis.

We recommend using pharmacologic venous thromboembolism (VTE) prophylaxis unless a contraindication to such therapy exists.

We recommend using low molecular weight heparin over unfractionated heparin for VTE prophylaxis

We suggest against using mechanical VTE prophylaxis, in addition to pharmacological prophylaxis, over pharmacologic prophylaxis alone.

We suggest using either continuous or intermittent renal replacement therapy.

We suggest against using renal replacement therapy.

We recommend initiating insulin therapy at a glucose level of ≥ 180mg/dL (10 mmol/L).

We suggest against using IV vitamin C.

We suggest against using sodium bicarbonate therapy to improve hemodynamics or to reduce vasopressor requirements.

We suggest using sodium bicarbonate therapy

We suggest early (within 72 hr) initiation of enteral nutrition.

We recommend using a performance improvement program for sepsis, including sepsis screening for acutely ill, high-risk patients and standard operating procedures for treatment.

We recommend against using qSOFA compared with SIRS, NEWS, or MEWS as a single-screening tool for sepsis or septic shock.

We suggest measuring blood lactate.