About

Mark E. Nunnally is a Professor of Anesthesia and Critical Care at the Biological Sciences Division of The University of Chicago. His research focuses on various aspects of anesthesiology and critical care, including the impact of pharmacological treatments for alcohol withdrawal syndrome, anesthetic approaches for pregnant patients with malaria, and perioperative considerations for older kidney and liver transplant recipients. He has contributed to the understanding of extracorporeal life support practices during the COVID-19 pandemic, medication safety through vial standardization, and the sustainability of the subspecialty of anesthesiology critical care. His work also encompasses topics such as the stress index in anesthesiology, medication error reduction, and research priorities in sepsis management. Dr. Nunnally's expertise and research have been published in numerous peer-reviewed journals, reflecting his significant contributions to advancing clinical practices in anesthesia and critical care.

Research topics

• Medicine
• Intensive care medicine
• Emergency medicine
• Internal medicine
• Family medicine
• Pathology
• Surgery
• Anesthesia
• Immunology

Selected publications

• Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026

  Universität Zürich, ZORA · 2026-03-23

  articleOpen access
  PublisherDOI

• Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026

  Pediatric Critical Care Medicine · 2026-03-23 · 4 citations

  article

  OBJECTIVES: To update evidence-based management recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with sepsis or septic shock. DESIGN: A panel of 68 international experts, representing 13 international organizations, as well as six methodologists, was convened. A formal conflict-of-interest policy was developed at the onset of the process and applied throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and subgroup leads as well as within subgroups, served as an integral part of the guideline development process. METHODS: New priority topics and recommendations from the prior guideline iteration were used to identify Population, Intervention, Control, and Outcomes (PICO) questions likely to have new or updated evidence. We conducted a systematic review to identify the best available evidence, summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or conditional, or as a good practice statement. "In our practice," statements were included when evidence was inconclusive to issue a recommendation but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS: The panel provided 61 statements on the management of children with sepsis or septic shock. Overall, five were strong recommendations, 24 were conditional recommendations, and ten were good practice statements. For 22 PICO questions, no recommendations could be made, but, for seven of these, "in our practice" statements were provided. Compared with the 2020 guidelines, 20 recommendations were new, 13 were updated for clarity and/or new evidence, six were reviewed but not changed, and 22 were carried forward based on consensus of the panel that new evidence was not available. Only three recommendations were based on high or moderate certainty of evidence. CONCLUSIONS: Updated management guidelines were issued by a panel of international experts for the best care of children with sepsis or septic shock, acknowledging that most aspects of care continue to have relatively low quality of evidence.

  PublisherDOI

• Executive Summary: Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026

  Pediatric Critical Care Medicine · 2026-03-23

  article

  The Surviving Sepsis Campaign International Guidelines for Management of Sepsis and Septic Shock in Children 2026 provide guidance on the identification and management of sepsis in pediatric patients with sepsis based on Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. This executive summary reviews the history, methodology, content, and major changes since the 2020 guidelines. HISTORY AND SPONSORSHIP OF THE GUIDELINES The first Surviving Sepsis Campaign (SSC) guidelines specific to pediatrics were published in 2020 as a joint effort of the Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) (1). The 2026 guidelines are an update from 2020 and focus on evidence published through July 2024 with key studies added if published later and identified by the panelists during the final evidence review. Studies that used either the 2005 severe sepsis or septic shock criteria, the 2024 Phoenix sepsis or septic shock criteria, or a more general definition of severe infection leading to life-threatening organ dysfunction were included in the evidence review. These guidelines were funded by SCCM and ESICM with methodological support by the Guidelines in Intensive Care Development and Evaluation group. In addition, 14 professional societies have either sponsored or endorsed these guidelines. There was no industry funding. Details about selection of the 68-person panel and the management of conflict of interests are detailed in the full guidelines document. METHODOLOGY Evidence Synthesis Population, Intervention, Control, and Outcome (PICO) questions addressed in the 2020 guidelines were reviewed for continued relevance, and new PICO questions were developed with input from each subgroup. Only PICO questions that were specific to sepsis or septic shock and determined likely to have substantial new evidence published on the topic were included. Individual studies were assessed for risk of bias using the Cochrane Risk of Bias-2 tool or the Clinical Advances through Research and Information Transfer (CLARITY) Risk of Bias tool for randomized controlled trials or cohort studies, respectively (2,3). We used the GRADE methodology to rate the certainty of evidence as high, moderate, low, or very low considering the risk of bias, inconsistency, indirectness, imprecision, publication bias, of the total available evidence (4–8). The panel considered evidence for each PICO question in a hierarchy of indirectness. Studies focusing on children with sepsis or septic shock were prioritized, although studies inclusive of more general pediatric populations (all PICU patients) were considered on a case-by-case basis. Evidence synthesized for the concurrent adult SSC guideline was considered according to an a priori framework to determine appropriateness of including indirect evidence (Fig. 1). Evidence from adult studies was generally downgraded due to the indirectness of the evidence.Figure 1.: Framework to determine the appropriateness of using indirect evidence from studies of children without sepsis or from adults.Types of Recommendation Statements Recommendations were specified as strong or conditional (previously referred to a “weak” recommendations in prior guidelines) as outlined in Table 1. We used the language “we recommend” for strong recommendations and “we suggest” for conditional recommendations. A strong recommendation indicates that most, if not all, individuals in the relevant clinical situation should receive (or avoid) the intervention. In contrast, a conditional recommendation acknowledges that the balance between desirable and undesirable may vary depending on patient values, clinical circumstances, or resource availability. Conditional recommendations may not be universally implementable and are less likely to be suitable for rigid performance metrics or enforcement. Flexibility and local context should guide their adaptation into policy. Good practice statements (GPSs) were developed in accordance with GRADE guidance when the panel judged unequivocal benefit (or harm) was present but there was an absence of direct evidence. Where there was insufficient evidence to formulate a recommendation, but the panel felt that some guidance based on current practice patterns may be appropriate, we issued an “in our practice” statement summarizing the results of the panel’s practice. We required a minimum 75% response rate and 80% agreement among eligible panelists for all statements to be included in these guidelines. TABLE 1. - Types of Recommendation Statements and Implications of the Strength of Recommendation Category Strength Quality of Evidence Implications to Patients Implications to Clinicians Implications to Policymakers Strong recommendation Strong High or moderate Most individuals in this situation would want the recommended course of action, and only a small proportion would not Most individuals should receive the recommended course of action. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences Can be adapted as policy in most situations, including for use as performance indicators Conditional recommendationa Weak Any The majority of individuals in this situation would want the suggested course of action, but many would not Different choices are likely to be appropriate for different patients, and therapy should be tailored to the individual patient’s circumstances, such as patients’ or family’s values and preferences Policies will likely be variable Good practice statement Strong Ungraded Same as strong recommendation Same as strong recommendation Same as strong recommendation In our practice statement Not a recommendation NA NA NA NA NA = not applicable.aConditional recommendations were previously categorized as “weak recommendation” in prior guideline iterations. Scope These guidelines apply to all patients from greater than or equal to 37 weeks of gestation at birth to 18 years with probable or confirmed sepsis or suspected or confirmed septic shock. For these guidelines, sepsis is defined as severe infection leading to life-threatening organ dysfunction and septic shock is defined as a subset of sepsis that includes life-threatening cardiovascular the of sepsis may be in clinical we language for sepsis and suspected septic shock all and with with organ dysfunction are included in this For we will use the to to and in these guidelines. TABLE - Sepsis in This Sepsis leading to life-threatening organ inclusive of patients with septic shock Septic shock of sepsis with cardiovascular dysfunction not to a concurrent or sepsis Clinical consistent with but infection not confirmed septic shock Shock of but suspected to be to infection Septic shock with Sepsis with of recommendations apply to children with sepsis or septic shock specific subset with are included in the We that sepsis as a and some children without organ dysfunction may benefit from as with organ Recommendations were developed to be that of and and will determine the of these guidelines. These guidelines not or when with clinical OF THE 2026 SSC GUIDELINES The 2026 guidelines statements and management of infection and and and were strong were conditional were and were statements of insufficient evidence to a with the 2020 guidelines, recommendations are were for new were reviewed but not and were based on of the panel that new evidence was not Only recommendations were based on or moderate of evidence. “in our practice” statements were included the panel’s practice as determined of the panel These statements are not an of a specific but panelists by absence of or clinical key recommendations to the of children with probable sepsis or suspected septic guide for in children with probable sepsis without shock or suspected septic shock. A summary of key recommendations for and with of the of recommendations. therapy and should be = = practice = = The 2026 guidelines statements new questions not in the 2020 - 2026 Recommendation and management of infection For children with probable sepsis or septic there is insufficient evidence to a recommendation for or for or for was addressed for the first in the 2026 guidelines. studies in pediatrics clinical trials in have an between and clinical the panel of and to there about the of with for or and about the required for of these therapy For children with confirmed sepsis with there is insufficient evidence to for or using a with for were addressed for the first in the 2026 guidelines. a of clinical trials in with sepsis a small in at for of with pediatric are and is required to including of and recommendation of in clinical practice. For children with sepsis or septic shock with we not using to guide of therapy when are in recommendation, moderate certainty of The of was not addressed in the prior of guidelines. For the 2026 guidelines, the panel issued a conditional recommendation to not use to guide of for this statement from and pediatric randomized clinical in or of use with a for with that included The added of a such as is likely on the context and on the of and For children with sepsis or septic shock with we or for management recommendation, very low certainty of For children with sepsis or septic shock without there is insufficient evidence to provide a recommendation about should The of or was not addressed in the prior of guidelines. For the 2026 guidelines, the panel that studies the of for children with have including and the of was felt to be most relevant for patients with confirmed in and is that some patients without a infection would benefit from such there was insufficient evidence to a for children with sepsis or septic shock should be by clinical of of including of and from shock to that be by in of and In a prior this guidance was only included as a For although there insufficient pediatric to a GRADE recommendation to use clinical of to guide and new evidence benefit to an the panel that a more statement was needed that should be by clinical of of For children with sepsis or septic we using and to guide not using to guide if local and recommendation, low certainty For children with sepsis or septic help to and In the prior the of to guide was not have that is to of shock and and all be present during septic shock. the of and management on patient that is an in many and to clinical of and with some evidence of benefit to patient the panel issued a new conditional recommendation to use and to guide if local and For children with septic there was insufficient evidence to a recommendation on either or of The prior included a that is to of at that were from studies that in children with septic shock with to of the first of from small pediatric randomized trials either or of therapy not in proportion with or to of or clinical between but that patients with less the absence of a benefit on the of to the of the panel that there was insufficient evidence to a recommendation and that is to either or of For children with septic shock with with there was insufficient evidence to a recommendation for with with was not addressed in the prior of guidelines. For the 2026 guidelines, studies were identified on the use of for pediatric septic but all were small or and not of to a recommendation about with for children with septic shock with with For children with septic shock with with there was insufficient evidence to a recommendation for with with was not addressed in the prior of guidelines. For the 2026 guidelines, to as to management in for septic shock in a This a more in in the with but in and there was no in The of indirect adult and pediatric not provide evidence to a recommendation for with for children with with For children with sepsis or septic shock we to a a more conditional recommendation, moderate certainty of The prior guideline not for For from in in children not to of of and when was to on these the panel issued a new conditional recommendation to a a more for children The conditional recommendation during the of and in specific of children with severe of low organ dysfunction that includes and For children with sepsis or septic shock and there was insufficient evidence to a recommendation on the use of with was not addressed in the prior of guidelines. For the 2026 guidelines, no pediatric and only studies the of for in children were for with was not with A that was with only among patients with and low is low in and there was not evidence to a GRADE recommendation for or in children with sepsis or septic shock with and support is to to total and in of is and changes to The prior of guidelines not to For the 2026 guidelines, the panel considered that studies have to be with of and of was to a due to the of that as a major for There were no pediatric studies that the of sepsis on there was insufficient evidence available to a GRADE recommendation and the panel that is to to total and to in of is and changes to For children with sepsis or septic there was insufficient evidence to a recommendation on the use of with than was not addressed in the prior of guidelines. For the 2026 guidelines, a of the not provide evidence to a recommendation on the use of to or The panel that a published based on from small studies, suggested be to children with septic with organ dysfunction or organ when shock was to the of this a for and the of in the panel that are to a GRADE For children with sepsis or septic there was insufficient evidence to a recommendation on to or The to for was not addressed in the prior of guidelines. children for are at risk for of sepsis and of the response may be for or of a risk of there was insufficient evidence on the of during sepsis in children to a GRADE For children with sepsis or septic shock with evidence of or there was insufficient evidence to a recommendation on the use of an The with for children with sepsis or septic shock with evidence of or was not addressed in the prior of guidelines. In studies, of have with in children with including organ and of small in children have that be with no studies have that with clinical a GRADE recommendation not be For children with sepsis or septic shock and there was insufficient evidence to a recommendation on the use of The use of for children with sepsis or septic shock and was not addressed in the prior of guidelines. may be by and in some children with with and that may benefit evidence the use of in children with sepsis and and most available were from small studies at risk for bias with of criteria, and a GRADE recommendation not be For children with sepsis or septic we an during the than not using a recommendation, very low certainty and were not addressed in the prior of guidelines. For the 2026 guidelines, the panel that pediatric sepsis is with and and there were no studies on for children with general studies of children were with with of of and without an in most studies of are from studies have that are in with low PICU and have to be when is For children with sepsis or septic there was insufficient evidence to for or to of children sepsis that for to there is that of help by to new or there were no studies on children with sepsis or septic evidence from trials in general PICU populations that included children with sepsis that a was with less and for the and the low proportion of sepsis in these studies, the certainty of evidence was insufficient to for or for children with sepsis or septic shock. For children sepsis or septic is risk for the and on the of and for Children with of and organ of and are at risk of and is needed to determine the by to support children sepsis and their the panel issued a to children for risk with provide to patients, their and relevant about the of and to for new these are more likely than not to have an on the continued of children sepsis or septic shock. = practice GRADE = Grading of Recommendations, Assessment, Development, and = = randomized controlled = The 2026 guidelines statements questions that were from the 2020 guidelines. of these statements were from prior guidance for new the were not statements included in the 2020 guidelines were not reviewed and not included in the 2026 guidelines, these statements either referred to general that were not specific to shock or have addressed by guidelines or and management - 2026 Recommendation and management of infection 1. In children are there was insufficient evidence to sepsis in to clinical for the of sepsis and septic shock. In the prior of the guidelines, the panel issued a conditional recommendation to for of sepsis and septic shock. For the 2026 guidelines, the panel the statement that there is insufficient evidence to sepsis and is considered a key for sepsis studies in new randomized pediatric clinical not that to a benefit for or of most studies were sepsis the of on the evidence was based on and the panel that may be appropriate in different the balance of with the of the new pediatric clinical not either or the and the of on the the panel was to a recommendation either for or the panel continued to the of children with sepsis or septic a for more to in and of clinical to and children For children with sepsis or septic we that a performance including for recommendation, low certainty of In the prior of the guidelines, the panel issued a practice statement to a for the management of children with sepsis and septic shock. For the 2026 guidelines, new evidence for an statement as a strong recommendation that should for as of a performance for pediatric Quality for children with sepsis to and clinical management of children with sepsis and septic shock through to to local and performance These have to and of in Most studies have on as of of and that of performance should be adapted for and by local with and with a focus on appropriate use of For children with probable sepsis or suspected septic we as of and management recommendation, very low certainty In the prior of the guidelines, the panel was to a recommendation about using values to risk for sepsis or septic but using in to guide For the 2026 guidelines, the panel these statements into strong recommendation to as of and are with in pediatric studies and are of used to septic shock in the Phoenix should be as of the and management of children with probable sepsis or suspected septic shock. The strong recommendation the to of in the a is to for cardiovascular dysfunction in the Phoenix criteria, in may insufficient organ and for septic shock. therapy For children with suspected septic we therapy as as of of sepsis recommendation, very low certainty of For children with probable sepsis without we a course of and if for sepsis is therapy as as appropriate of recommendation, very low certainty of For children with probable is and there may be a due to in clinical should as as practice with the prior 2020 guidelines, the panel issued no changes to the or certainty of evidence for these recommendations but update the review. A new of children to was into the evidence This that and very of were with than more in the subset with In addition, a of studies that of was with a for on these and an strong to the likely of septic shock as as the panel but a strong recommendation to therapy as as and of for children with septic shock. For children with probable sepsis but without therapy should be For this later the panel the of an to determine such as than sepsis or likely for therapy may not be in some with when may not be a of sepsis and of may as as For children with septic we when is not recommendation, very low certainty For the 2026 guidelines, the panel a more general conditional recommendation to use to guide to focus on specific including the conditional recommendation to when is This recommendation was based on pediatric clinical trials with a patients that suggested a in with due to or in some this recommendation may not be universally For children with sepsis and septic there was insufficient evidence to a recommendation on use of with clinical to guide to to and and an to clinical of such as or with the of addressed the panel that there was insufficient evidence to recommendations on the use of Most is or studies that cardiovascular and septic dysfunction and that may not have as on clinical and some help to a will or For children with septic shock there was insufficient evidence to a recommendation on the use of or for therapy in children with septic shock. In the prior of these guidelines, and were recommended in the panel that there was insufficient evidence to either or as the in children in septic shock. new studies were into the evidence a clinical of children with to In this there were no in shock at of or although children in the shock a of pediatric sepsis without evidence for dysfunction no in the of major by between with or but was with was to provide evidence on the for all the panel there continued to be a general for to dysfunction and low and to are the panel that to use either or based on individual patient local and For children with septic shock we through therapy is recommendation, very low certainty of In the prior the panel was to a recommendation about through in children with septic shock. with new available for the 2026 guidelines, the panel this statement to provide a conditional recommendation to through therapy is A of studies including children a risk of with of through with a low risk of of to be with in a the For children with septic shock and there was insufficient evidence to a recommendation on to with use of in children with sepsis or septic shock is not should be for suspected or In the prior of these guidelines, the panel issued a conditional recommendation to with either or no if and therapy are not to For this 2026 the panel this statement to that there was insufficient evidence to a recommendation on to with evidence in conflict about the and of use as therapy in children with septic shock and studies in children these studies, as with the 2020 evidence by small and the to the of from of and For children with sepsis or septic shock with there was insufficient evidence to a recommendation on to or a to In the prior of these guidelines, the panel issued a conditional recommendation to with either therapy or a to in children with sepsis or septic shock. For this 2026 the panel this statement to that there was insufficient evidence to recommendation on to or a to is an with by of and the this response is or a in children with sepsis to The panel identified small pediatric clinical that a to to a more only when There was a small in between the of but no in clinical and support For children with sepsis or septic shock we using conditional recommendation, low certainty of The panel the 2020 statement from a using in children with sepsis or septic shock are with therapy to the new 2026 conditional recommendation to use a of clinical trials that included a total of children with sepsis with with of therapy although of was not different between In of these studies, were with with the all trials used as the of these be to The panel that this may not be available in some = = = = THE The 2020 guidelines statements that were but not and statements that were from the 2020 SSC guidelines without an evidence on panel a priori that new evidence was to be available to a from the prior In these the 2020 statements were without an evidence as by changes were statements that were to with new or in this of the guidelines. Statements that were reviewed but not an and in contrast, by - 2026 Recommendation 2020 to 2026 and management of infection Clinicians should therapy in this not therapy Clinicians should therapy with or more to all likely the and are therapy should be no is should or therapy according to clinical of risk and of clinical in with For children for sepsis or septic shock with are at risk for we using therapy recommendation, very low of should be as as a of an infection to a For children with sepsis or septic we of that are confirmed to be the of sepsis or septic shock and depending on the and the of a recommendation, low certainty of therapy For children with septic shock in with we to in the first of no recommendation, low certainty For children with sepsis without in with no we using recommendation, certainty For children with septic shock with in with no we to in the first of no therapy recommendation, low certainty should be therapy should be to clinical of and if shock or if of 2020 For the of children with sepsis or septic we using than recommendation, moderate certainty of For children with septic shock with we with or recommendation, very low certainty of For children with sepsis or septic there was insufficient evidence to a recommendation about to at the or for For children with septic shock we either or recommendation, low certainty of For children with septic shock and dysfunction with there was insufficient evidence to a recommendation about an For children with septic shock in be with and we the use of recommendation, low certainty of For children with septic there was insufficient evidence to a recommendation about to in the absence of For children with sepsis or septic we using when recommendation, low certainty of For children with sepsis or septic we the use of conditional recommendation, very low certainty For children with sepsis or septic we the use of conditional recommendation, very low certainty For children with sepsis or septic we the of in the absence of clinical recommendation, very low certainty of and For children with sepsis or septic there was insufficient evidence to a recommendation about to or For children with sepsis or septic shock in a we the use of in children with septic shock and organ dysfunction recommendation, low certainty of and support For children with sepsis or septic shock for the organ there was insufficient evidence to a recommendation on to with For children with sepsis or septic we using when is present recommendation, very low certainty of For children with septic we using as a therapy only if shock is to all recommendation, very low certainty of For children with sepsis or septic we the use of recommendation, low certainty of The use of is not patients, such as with or with low may benefit from such = = practice = This executive summary the of the 2026 pediatric Surviving Sepsis guidelines and and The guidelines all statements and to or We the to the guidelines from our patient and we the support of the Society of Critical Care Medicine in the guidelines including and of the Surviving Sepsis Campaign Children and and and and and and and and and Critical Care Critical Care of of of Society of European Society for and Intensive Society of Sepsis and of Intensive and Critical Care for and Society of Intensive

  PublisherDOI

• Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026

  Critical Care Medicine · 2026-03-23 · 5 citations

  article

  Sepsis, life-threatening acute organ dysfunction due to infection (1), is a global health priority (2,3) with approximately 49 million cases and 13 million sepsis-related deaths each year (4–6). Beyond being acutely deadly, sepsis contributes to new and worsened physical, cognitive, and mental health problems in many survivors (7,8). Early identification and treatment are critical to improving outcomes. The Surviving Sepsis Campaign (SSC) guidelines are intended to support clinicians caring for adult patients with sepsis, focusing on management in the hospital, the immediate prehospital setting, and the immediate post-hospital setting. These guidelines incorporate principles of antimicrobial stewardship through responsible antimicrobial use, proper diagnostic strategies, and de-escalation of antimicrobial therapy. The recommendations reflect evidence-based best practice, distilling a large body of research into actionable recommendations. They empower individuals and health systems to make informed choices about care and support improvements in management and outcomes of sepsis (Table 1).TABLE 1.: Table of StatementsMETHODS Details on the guidelines scope, relationship to SSC bundles, history, and sponsorship; committee selection, characteristics, and organization; conflicts of interest management; patient, intervention, comparator, outcome (PICO) question selection; outcomes prioritization; evidence synthesis; certainty of evidence assessment; recommendation formulation; consensus voting; and implications of strong vs. conditional recommendations are presented in Supplemental Digital Content 1 (https://links.lww.com/CCM/H904). We highlight key aspects of the methodology here. The SSC guidelines were fully funded by Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM), with methodological support from the Guidelines in Intensive Care Medicine, Development, and Evaluation group. Sponsoring professional societies supported the participation of their representatives. There was no industry support. The 69-person guidelines committee had broad geographic diversity, representing 23 countries, with 38% of panelists currently or previously practicing in a low- or middle-income country (LMIC). The guidelines committee also had broad diversity of clinical professions and disciplines, as detailed in Supplemental Digital Content 1 (https://links.lww.com/CCM/H904). We convened a patient and family advisory panel who worked with the committee throughout the guidelines development process to ensure incorporation of patients’ values and preferences. The guidelines committee was organized into six subgroups based on clinical domain: screening and early management; infection; hemodynamics; respiratory support; adjunctive and additional therapies; and goals of care, transitions of care, and long-term outcomes, as well as a usability workgroup that developed material to support dissemination and uptake of the guidelines. Each subgroup had at least one panelist currently practicing in a LMIC. Evidence Synthesis The process for selecting PICO questions and completing evidence synthesis is detailed in Supplemental Digital Content 1 (https://links.lww.com/CCM/H904). Prioritized patient-centered outcomes were selected a priori for each question. PICO questions addressed in this guideline update are presented in Supplemental Digital Content 2 (https://links.lww.com/CCM/H905). Evidence synthesis followed the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. Evidence profiles for each PICO question are presented in Supplemental Digital Content 3 (https://links.lww.com/CCM/H906), Supplemental Digital Content 4 (https://links.lww.com/CCM/H907), Supplemental Digital Content 5 (https://links.lww.com/CCM/H908), Supplemental Digital Content 6 (https://links.lww.com/CCM/H909), Supplemental Digital Content 7 (https://links.lww.com/CCM/H910), and Supplemental Digital Content 8 (https://links.lww.com/CCM/H911). The certainty of evidence was graded as high, medium, low, or very low according to GRADE methodology. We used the Evidence to Decision (EtD) framework (9) to support consistent, transparent, and structured formulation of statements across the guideline. The EtD framework considers the balance of effects, the certainty of evidence, as well as patient values, resource intensity, equity, and cost effectiveness (9). The EtD summary of judgements for each PICO question is presented in Supplemental Digital Content 3 (https://links.lww.com/CCM/H906), Supplemental Digital Content 4 (https://links.lww.com/CCM/H907), Supplemental Digital Content 5 (https://links.lww.com/CCM/H908), Supplemental Digital Content 6 (https://links.lww.com/CCM/H909), Supplemental Digital Content 7 (https://links.lww.com/CCM/H910), and Supplemental Digital Content 8 (https://links.lww.com/CCM/H911). We used standardized language to summarize the findings of evidence syntheses based on effect size (i.e., point estimate) and certainty of the evidence, as recommended by GRADE methodology (10). Process for Determining the Type of Statement Figure 1 summarizes the stepwise process we used to determine the type of statement for each PICO question. In contrast to many other guidelines, we always provided a graded recommendation when there was at least low certainty evidence to inform a recommendation. For most PICO questions, we relied most heavily on the balance of desirable and undesirable effects to inform recommendations. However, when the balance of effects was equivalent, we relied on other domains in the EtD framework to determine the type of recommendation and used “either/or” statements when the balance of all EtD domains for two different approaches or therapies were equivalent. However, for PICOs where the comparator was usual care alone, we used the language of “we make no recommendation due to equal balance of effects” since suggestions to use or not use a particular therapy were viewed as potentially confusing and unhelpful.Figure 1.: Process for selecting the type of statement.Types of Graded Recommendations Using the GRADE approach, we classified each graded recommendation as either “strong” or “conditional” (referred to as “weak” recommendations in prior SSC guidelines). We used the language “we recommend” for strong recommendations and “we suggest” for conditional recommendations, consistent with GRADE guidance. Implications of Graded Recommendations A strong recommendation indicates that most, if not all, individuals in the relevant clinical situation should receive, or avoid, the intervention. In contrast, a conditional recommendation acknowledges that the balance between desirable and undesirable may vary depending on patient values, clinical circumstances, or resource availability. Conditional recommendations may not be universally implementable and are less likely to be suitable for rigid performance metrics or enforcement. Flexibility and local context should guide their adaptation into policy. Further details on implication of strong vs. conditional recommendations are presented in Table 2 and Supplemental Digital Content 1 (https://links.lww.com/CCM/H904). TABLE 2. - Implications of Strong Vs. Conditional Recommendations Stakeholder Strong Recommendation Conditional Recommendation Patients and families All or most would want the intervention. Most would want the intervention, a would The should be to all or most There is for for to The should be for most clinicians should clinical and for or performance be less for or performance are on other research may be and may recommendations. We followed the GRADE to statements that were classified as statements to as in prior SSC guidelines These statements that not on a evidence We used this in where evidence was as a a recommendation had to all of the was and addressed a practice, the was the evidence was or to summarize the was and GRADE were not suitable to certainty of were to additional context when the statement not fully the recommendation. were used to or in where the evidence was or In We a priori to statements the in where evidence was to support a recommendation or where evidence was as low or very low certainty and the panel that statement would be to of the guideline. In statements are not or of a intervention. panelists currently by of or clinical The of statements is to on when evidence is We statements from the SSC guidelines that and to sepsis These statements addressed new evidence or where research was to prior SSC guidance. These statements not evidence as were to new evidence to a in based on the of the However, the panel and for each statement for and We a and at least panelists to a recommendation For new or statements that not the consensus on the we two additional of to statements were based on panel statements were one of We a for each of Sepsis These guidelines sepsis as life-threatening acute organ dysfunction due to and as a of patients with dysfunction that a of consistent with the for Sepsis and In clinical practice, of sepsis and should be based on clinical may vary across depending on local as availability. The recommendations in the SSC guidelines are intended to be to patients with sepsis and according to local we not or evidence syntheses to the as prior sepsis are to the of sepsis may be in clinical practice, we developed standardized language for and sepsis, are used throughout the SSC guidelines (Table TABLE - Sepsis in sepsis Sepsis is based on history, clinical and diagnostic is very sepsis for Sepsis is the most likely based on history, clinical and diagnostic is less sepsis for Sepsis is a is also likely based on history, clinical and diagnostic sepsis for is not consistent with sepsis, or is likely based on history, clinical and diagnostic - For and health we a performance for sepsis, sepsis screening for acutely for and of sepsis certainty evidence for very low certainty evidence for certainty evidence for and may vary by and in with a to with screening and The recommendations for sepsis screening and were not evidence However, relevant since the SSC guidelines, recommendations. with patients in the and this was with to and effect on with a point a large in the large of and was with in patients with and sepsis The recommendation for was is a and to evidence-based care as with the of improving clinical outcomes. a potentially for improving systems performance and patient In a of sepsis were with of recommended care and and improvements in of care and clinical outcomes in in sepsis most the of are we one a the of a sepsis early in the health with health Patients to this had to antimicrobial therapy vs. and and of at vs. The panel the balance of effects, and and that the desirable effects of to undesirable effects in most recommendation for a performance for sepsis and is consistent with the for and Sepsis The summarize key of or health performance for sepsis for in sepsis to support of evidence-based management Most were in resource on sepsis and be in with However, is to with of the and the particular that the of sepsis research should effects and best to In likely sepsis of care and may effects on They are recommended as of a to improving sepsis the of a performance for sepsis, screening of patients and standardized treatment stewardship patient outcomes and antimicrobial use - 2. 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A is in approximately of patients with sepsis, are in approximately of patients There is evidence the clinical of However, the and with sepsis and the of antimicrobial the panel a strong recommendation for of should be as as to in antimicrobial therapy. the of the of of the the use of and prior use The panel guidelines and a the of based on with a or equal to are from two different is recommended based on the to from when different and for with two of one for from to when two of were vs. one However, Guidelines from a based on a of that may in a of the recommended less and less The of and the use of should be in low resource A of with in In most this not a from as in clinical where treatment the use of be since may not additional are In low resource of a of be based on the between vs. to the aspects of is to diagnostic and and additional should be that of antimicrobial therapy may their In a of patients to the with or or 4 from to at a a and in should be of should not the antimicrobial in patients with are recommended to of or for and the PICO question on additional to the of infection should be depending on the of - For with or sepsis or we low certainty statement on performance was the SSC guidelines for - Sepsis and are treatment and should For with or we at least of in the 3 low certainty should be to patient and context when selecting should and patients to of or should be based on body or by or body in patients with body is for the of in sepsis and recommended in SSC guidelines, should of sepsis or and clinicians should a low for in patients with sepsis evidence in support of from and as of a of care there are no new a is from prior SSC guidelines. TABLE - in by and for patients with body body values, for patients with body was as where was the for with and SSC guidelines, we at least of for in patients with or may be be or or equal to 4 the for 2 to 4 is in patients with with consistent with for the of 2 and may also from to to or should in patients with if there are no to The of is based on evidence with most body There are no different for in sepsis or A of to with sepsis or that to of therapy 3 of sepsis was with of of and of in patients with and of in the a of for patients with sepsis who with very low or very In the and the of was also in the of that this in clinical A and the effect of early on in sepsis that a was when was 3 to of very large of in the panel that may be or body in patients with body In low resource where the of respiratory support may be the of are the clinical context should be when However, prior from in low resource used For in the patients to the a in the 6 based on from vs. in the usual care is that be to body in or patients to The panel the for clinical and to the of either or Table 4 in for patients of and The SSC conditional recommendation to or equal to of from the clinical guidelines to of in the The SSC panel acknowledges that vary across patients and to or However, most patients with and from or equal to and with of to - For with we followed by support if very low certainty In patients with immediate of with may be on a of should be by clinical of and is a critical that and to and the of The of or a of The for in of and of is with outcomes in evidence on the of in relevant and were that early of is with and However, were by a to in the findings of were to that early use may be with The no in organ or of between with early vs. that of is and early is to all The panel based recommendations on a of evidence, the of early in patients with life-threatening the of evidence use in all as well as the of in patients be with is to that patients with or in critical may the of most not for local in sepsis care may outcomes. Further with are to the for in There are currently 5 the of are likely to evidence on the of - In with we to is very low certainty are to a of use, or of or were not were through of for with from that clinicians and are with with of if no is The panel one of patients to immediate vs. no effect on very low certainty We also when effect on with with 3 with very low the for was very low The panel that balance of effects and resource use evidence certainty was very we to is in with the SSC guidelines of in the of a to ensure the was for and when the details of vary In low resource where for of and of is not should be used with are to inform the for the of use, and and the and of to in adult is a research of panel use on at least panel be use for to 6 use for to and not a for of panel and are panel to to panel also clinical of additional for and of when to to - For with we of certainty In practice, is not to at a 5 should be should be to this with new For with or we of low certainty is a key of in is a of and in and the of as the and a to be approximately are with organ with The SSC guidelines recommended of or for The recommendation was based on in patients who were to a of a of no in between a subgroup a in therapy with patients with However, a with was with a of A of this was that the in the A of two that may in to no in in low The to in patients and with The a of with in the usual care patients there was less to in the by of and in the vs. usual care was vs. patient that this and two a point for that with a with a the not the of low In a for the guidelines to patients or a was with at of patients or to a with a was the guidelines was with the In the of to support a the panel to of certainty and a new conditional recommendation for of in or low certainty in the of new evidence of a There is a of evidence from low resource of recommendations is likely to be in all to Intensive Care - For with sepsis or who we the patients to the 6 low certainty statement on performance was the SSC guidelines for of in - For with or we antimicrobial therapy 1 of very low certainty For with or sepsis we antimicrobial therapy 1 of very low certainty For with sepsis we a of and if for infection the of antimicrobial therapy 3 from the when sepsis was very low certainty of should a of the of vs. of acute in with sepsis For with a low of infection and we antimicrobial therapy to the very low certainty of Early of antimicrobial therapy is the most to in patients with sepsis or with antimicrobial therapy to patients with sepsis or should be as may antimicrobial therapy or antimicrobial therapy in a patient who being for The to antimicrobial therapy as early as be the undesirable effects of antimicrobial use in patients infection antimicrobial to the and other of antimicrobial is since approximately of patients for sepsis a of or However, in of antimicrobial for sepsis and antimicrobial stewardship are the of infection (Table and of for each patient with sepsis should inform the and of antimicrobial therapy a and through patients We the from this with two additional and two early antimicrobial therapy was with a in for with sepsis or patients who 1 3 and 6 from with that no was in and in the and in the evidence to the as well as The with early antimicrobial therapy and most consistent in patients with The recommended for antimicrobial that 1 and 3 were selected based on the summary the of the evidence at of with that no and in the and of The two not between early treatment and patients and the in between the early vs. were well 3 the in evidence since the SSC guidelines the certainty of evidence was as very low due to of body of evidence of with of and most used in and in the of and the certainty of evidence for the effects of early antimicrobial therapy in with sepsis or large would be are from and is The recommendations on of antimicrobial therapy are from the SSC guidelines the of with and the consistent and of antimicrobial and in patients with the panel a strong recommendation to antimicrobial therapy 1 in with and and in with or sepsis (Table For with sepsis where the of infection is less the panel a conditional recommendation for a 3 of and of may additional history, clinical and diagnostic to determine antimicrobial therapy should be therapy should be as as infection to be the most likely of the and no 3 if a for infection from low resource that of antimicrobial therapy in patients with sepsis and is also and in and of a of antimicrobial therapy may the and for diagnostic and also vary by and For this the of the for vs. of vary by setting. In of the in diagnostic a panel of global with sepsis where as or to a of acute are not and if for infection antimicrobial therapy should be of to - For with or sepsis and (i.e., and who to of we antimicrobial therapy in or very low certainty should be a structured process in to for sepsis in or as in recommendation sepsis treatment is one to the to for the of sepsis patients who by are in other and outcomes for acutely patients the of prehospital on Most were of was a in with prehospital very low of also that prehospital may low with most of the to a no in when were in the prehospital the was a low The two with the had the the two with the had the this the panel this recommendation to patients with evidence of as by or sepsis and in patients with The panel also In systems with and prehospital may the may be in with or with the were in the panel this recommendation to in the from to was to consistent with the recommendation to antimicrobial therapy 1 for patients with may not be in all due to and early sepsis identification and the In other systems that may be to a of on the evidence, the panel that the balance of effects prehospital in patients with sepsis and and who to

  PublisherDOI

• Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2026.

  Apollo (University of Cambridge) · 2026-03-23

  articleOpen access
  PublisherDOI

• Medical Society Guideline Writing: The Why and How

  Anesthesia & Analgesia · 2026-01-13

  article
  PublisherDOI

• Executive Summary: Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026

  Universität Zürich, ZORA · 2026-04-01

  articleOpen access
  PublisherDOI

• Influence of Age in End-of-Life Practices in Worldwide ICUs (ETHICUS-2): A Prospective Observational Study

  Critical Care Medicine · 2026-03-16

  articleOpen access

  OBJECTIVES: The practice of limiting life-sustaining therapy (LST) at end-of-life is widespread globally. The goal of this study was to evaluate whether patient's age influences end-of-life limitations overall and of various LST in ICUs worldwide. DESIGN: Multinational, multicenter, prospective observational study. SETTING: One hundred ninety-nine ICUs in 36 countries worldwide. PATIENTS: Consecutive adult patients admitted to ICUs who died and/or had LST limitations (withholding, withdrawing, or active shortening of the dying process) were included during a 6-month period between September 2015 and September 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were grouped: younger than 65 years, 65-79 years old, and 80 years old or older. A total of 12,200 patients were included. In multivariate logistic regression analysis, odds ratio (OR) for any LST limitation in the 80 years old or older group was higher than in younger than the 65 years old group (OR 1.47 [95% CI, 1.22-1.76], p < 0.001). When stratified by region, this association was significant in Central and Southern Europe (OR 1.56 [95% CI, 1.11-2.20], p = 0.037 and OR 2.23 [95% CI, 1.58-3.17], p < 0.001, respectively), but not in the other regions. The proportion of withholding therapy of each LST was highest in the group of individuals 80 years or older, whereas the proportion of withdrawing therapy was highest in the group younger than 65 years. The 80-year-old or older group also had a shorter time from ICU admission to first limitation. The predominant reason for any LST limitation in all age groups was unresponsiveness to maximal therapy, followed by neurologic and chronic diseases. Patient age was rarely the primary reason for limitations for all groups. CONCLUSIONS: End-of-life limitations were higher in patients 80 years or older compared to those 65 years old or younger, with regional variations. The main reasons for limitations were comparable across age groups, with age not being the primary reason.

  PublisherDOI

• Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026.

  Apollo (University of Cambridge) · 2026-04-01

  articleOpen access
  PublisherOA PDFDOI

• Executive Summary: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026

  Critical Care Medicine · 2026-03-23 · 6 citations

  article

  The Surviving Sepsis Campaign (SSC): International Guidelines for Management of Sepsis and Septic Shock 2026 provide guidance on the identification and management of sepsis in adult patients with sepsis. They were developed according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. This executive summary reviews the history, methodology, content, and major changes since the 2021 guidelines. HISTORY AND SPONSORSHIP OF THE GUIDELINES The SSC has published guidelines for the management of sepsis and septic shock in 2004, 2008, 2012, 2016, and 2021. The 2026 SSC guidelines are an update from 2021 and focus on evidence published through June 2025. The guidelines are funded by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, with methodological support by the Guidelines in Intensive Care Development and Evaluation (GUIDE) group, and endorsement by 24 sponsoring professional societies. There was no industry funding. Panel membership, patient involvement, and conflict of interest management are detailed in the guidelines and the Supplemental Digital Content in the guidelines (1). METHODOLOGY Figure 1 in the guidelines (1) summarizes the process for determining the type of statement. We classified graded recommendations as strong (“we recommend”) or conditional (“we suggest”). A strong recommendation indicates that most, if not all, well-informed patients/caregivers in the relevant clinical situation would choose the recommended action or intervention. A conditional recommendation acknowledges that the balance between desirable and undesirable effects may vary depending on patient values, clinical circumstances, or resource availability. We used standardized language to summarize the findings of evidence syntheses based on effect size (i.e., point estimate) and certainty of the evidence, as recommended by GRADE methodology (2). We required a minimum 75% response rate and 80% agreement among eligible panelists for all statements and formal remarks. We retained several statements from the 2021 SSC guidelines that remain clinically relevant, accurate, and essential to comprehensive sepsis care. These “carry-over” statements did not undergo updated evidence synthesis but were voted on to ensure continued relevance and accuracy. We also considered the universal applicability of each recommendation and comment in the narratives about applicability to different settings, including low resource settings. Because the diagnosis of sepsis may be uncertain in clinical practice, we developed standardized language for definite, probable, possible, and unlikely sepsis, which are used throughout the SSC guidelines and described in Table 3 in the guidelines (1) . SUMMARY OF 2026 SSC GUIDELINES CONTENT The 2026 guidelines include 129 statements covering screening and early management (16 statements), infection (25), hemodynamic management (23), respiratory support (14), adjunctive therapies for sepsis (8), additional supportive management (13), goals of care (8), transitions of care (16), and long-term outcomes (6). Most statements (81, 63%) are conditional recommendations, 17 are strong recommendations, 19 are good practice statements, and 11 are statements of insufficient evidence to issue a recommendation. The 2026 SSC guidelines additionally include 13 “in our practice” statements describing the panel’s practice as determined via independent survey of the panel. These statements are not an endorsement of a specific intervention or treatment approach. Rather, they document how panelists currently approach situations characterized by uncertainty, absence of data, or context-specific clinical variability. Figures 2 and 3 in the guidelines (1) highlight key recommendations related to antibiotic timing and hemodynamic management, respectively. Table 1 in the guidelines (1) lists all 129 statements and describes how they relate to the 2021 SSC guideline statements. Below we highlight selected statements in the 2026 SSC guidelines that are new, changed, and consistent with the 2021 guidelines. WHAT IS NEW SINCE 2021 The 2026 SSC guidelines contain 46 statements addressing new questions not covered in the 2021 guidelines. Table 1 highlights seven new recommendations. TABLE 1. - Abridged Rationale for Selected New statements Selected New Statements Abridged Rationale 3. In acutely ill adults en route to hospital by ambulance or flight, we “suggest” using a standard sepsis screening tool over not using a screening tool.(conditional recommendation, very low certainty evidence) Sepsis is a time-sensitive medical emergency, and approximately half of patients hospitalized for sepsis arrive via ambulance. Prehospital screening has been associated with improved processes of care. The panel determined that the balance of effects probably favors prehospital, ambulance-based sepsis screening for identifying patients with sepsis and improving the timeliness of sepsis care. 13. For adults with septic shock, we “recommend” an initial MAP target of 65 mm Hg over higher MAP targets.(strong recommendation, moderate certainty evidence) Remark: In practice, it is not feasible to maintain MAP at exactly 65 mm Hg, so a reasonable range (e.g., within 5 mm Hg) should be used. Vasopressors should be titrated to maintain MAP within this range. 14. For adults with septic shock 65 yr old or older, we “suggest” an initial MAP range of 60–65 mm Hg over higher ranges.(conditional recommendation, low certainty evidence) Consistent with the 2021 guidelines, the 2026 guidelines recommend an initial MAP target of 65 mm Hg. However, the 2026 guidelines include a new remark acknowledging that MAP cannot be maintained at exactly 65 mm Hg, but instead requires a target range, for example, within 5 mm Hg. In a meta-analysis done for the guidelines limited to patients 65 yr old or older, a lower blood pressure target was associated with reduced mortality at longest follow-up. The panel thus determined that the balance of desirable and undesirable effects probably favors permissive hypotension over use of vasopressors to maintain a MAP > 65 mm in adults 65 yr old or older. 21. For adults with definite or probable sepsis and hypotension (i.e., septic shock) and who have an anticipated time to in-hospital medical evaluation of over 60 min, we “suggest” administering antimicrobial therapy in ambulance or flight.(conditional recommendation, very low certainty evidence). Remark: Prehospital antibiotic delivery should be implemented only after having a structured process in place to screen for sepsis in ambulance or flight, as discussed in recommendation 3. Sepsis is a time-sensitive medical emergency, and approximately half of patients hospitalized for sepsis arrive via ambulance. A meta-analysis of observational studies was uncertain but suggested a possible reduction in mortality with prehospital antibiotics. Meta-analysis of randomized controlled trials also suggested that prehospital antibiotics may reduce 28-d mortality. The panel determined that the balance of effects probably favors prehospital antibiotic administration in patients with sepsis and hypotension and who have an anticipated time to in-hospital medical evaluation of over 60 min. This recommendation aligns with the recommendation to administer antibiotics within 1 hr in patients with septic shock. 28. For adults with sepsis or septic shock without risk factors for anaerobic infection, we “suggest” using an empiric antibiotic regimen without anaerobic coverage.(conditional recommendation, very low certainty evidence) Remark: Agents with anaerobic activity that are needed to cover possible MDR pathogens (e.g., piperacillin-tazobactam, carbapenems) are reasonable to use to provide adequate MDR coverage if alternative agents without anaerobic coverage are inadequate. The prevalence of sepsis and septic shock due to anaerobic bacteria is low, compared with aerobic bacteria and fungi. Many patients with sepsis or septic shock, particularly of lung or urinary origin, are unlikely to benefit from empiric anaerobic coverage. Observational studies suggest an increased risk of adverse outcomes, including increased mortality, in patients treated with empiric anti-anaerobic antibiotics when no risk factors for anaerobic infection are present. The panel thus issued paired statements suggesting to withhold vs. include anti-anaerobic coverage based on clinical context. 29. For adults with sepsis or septic shock with specific risk factors for anaerobic infection, we “suggest” using an empiric antibiotic regimen that includes anaerobic coverage.(conditional recommendation, very low certainty evidence) Remark: Risk factors for anaerobic infection include intra-abdominal or deep seated gynecological/obstetric source of infection, necrotizing soft-tissue infection, head and neck infection, and CNS abscesses or empyema. 41. In mechanically ventilated adults with sepsis or septic shock in units with a low prevalence of antimicrobial resistance, we “suggest” using selective decontamination of the digestive tract (SDD).(conditional recommendation, moderate certainty evidence) Selective decontamination of the digestive tract (SDD) is a preventive infection control strategy consisting of the administration of nonabsorbable, topical antimicrobial agents to the oropharynx and upper gastrointestinal tract (oropharyngeal decontamination), with the administration of a short-term course of broad-spectrum IV antimicrobials in mechanically ventilated patients. SDD is specifically designed to eliminate pathogenic aerobic bacteria while preserving anaerobic gut bacteria essential to digestion and immune function. Meta-analysis of showed a probable reduction in short-term mortality and—counter to concerns—a possible reduction antimicrobial resistance. 89. For adults with septic shock after the acute resuscitation phase, we “suggest” using active fluid removal.(conditional recommendation; very low certainty evidence). Remark: Acute resuscitation refers to escalating doses of vasopressors, ongoing high doses of vasopressors, or needing ongoing volume expansion. Active fluid removal refers to diuretics and, if diuretics are insufficient, ultrafiltration or extracorporeal fluid removal. Factors to be considered when deciding to initiate active fluid removal include: cardiorespiratory function; vasopressor dose; clinical course; peripheral edema; weight; and fluid balance. Fluid overload in patients with sepsis and septic shock can lead to tissue edema, impaired oxygen delivery, and organ dysfunction and is associated, in observational studies, with increased mortality. The management of fluid balance appears to be important, therefore, particularly in the “evacuation” or “de-escalation” phase of resuscitation. We considered a recent meta-analysis that assessed de-resuscitation strategies. Across all critically ill patients, the pooled analysis demonstrated an uncertain effect of active fluid removal on mortality, with the use of diuretics only having a potentially more favorable effect than the use of diuretics with or without renal replacement therapy. Our suggestion for active fluid removal was influenced by input from patient representatives to the Surviving Sepsis Campaign guidelines, who placed a high value on avoiding edema. WHAT HAS CHANGED SINCE 2021 The 2026 SSC guidelines contain 38 statements addressing questions that were revisited from the 2021 guidelines. However, only three of these statements differ from prior guidance, as described in Table 2. TABLE 2. - Abridged Rationale for Statements that Differ From 2021 Surviving Sepsis Campaign Guidelines Statements that Differ From 2021 Abridged Rationale 27. For adults with sepsis or septic shock, we “suggest against” using empirical antifungal therapy.(conditional recommendation, low certainty evidence) Remark: Empiric antifungal therapy should be considered on a case-by-case basis in selected patients with sepsis or septic shock and risk factors for fungal infection, including immunosuppression, prolonged use of antibiotics, prolonged hospitalization, and intra-abdominal source of infection. The 2021 SSC guidelines contained a pair of conditional recommendations that suggested using empiric antifungal therapy in patients at high risk or fungal infection and suggested against using empiric antifungal therapy in patients at low risk of antifungal infection. There are no new data from 2021. The 2026 guidelines streamline the guidance to a single conditional recommendation against using empirical antifungal therapy, recognizing that the majority of patients do not warrant empiric antifungal therapy. However, we have included a remark for case-by-case consideration of empiric antifungal therapy in select circumstances. 42. For adults with septic shock, we “suggest” using either invasive or noninvasive blood pressure monitoring.(conditional recommendation; very low certainty evidence) Remark: Invasive blood pressure monitoring is advised in patients with shock who: require intermediate-to-high dose vasopressors, escalating doses of vasopressor, or multiple vasopressors; are receiving frequent arterial blood sampling; or have noninvasive blood pressure measurements which are inconsistent on repeated assessments. The 2021 SSC guidelines included a conditional recommendation for invasive blood pressure monitoring. However, considering the very low certainty of evidence, the lack of clear associations with clinical benefit, and concerns regarding equity, patient comfort, and measurement discordance, the panel issued a conditional recommendation supporting the use of either noninvasive or invasive blood pressure monitoring. The multicenter EVERDAC RCT testing a noninvasive strategy to blood pressure monitoring in circulatory failure (i.e., avoidance of arterial line unless pre-specified safety criteria were met) was published after the 2026 SSC guideline recommendations were finalized. EVERDAC found that, among 1010 patients randomized, 28-day all-cause mortality was noninferior in the noninvasive-strategy group (34.3% mortality vs. 36.9% in the invasive strategy, p = 0.006 for noninferiority). 45. For adults with sepsis or septic shock, we “suggest” using crystalloids alone over crystalloids with supplemental albumin for fluid resuscitation.(conditional recommendation; moderate certainty evidence). Remark: Use of supplemental albumin may be appropriate for patients who already received large crystalloid volumes or have cirrhosis. Supplemental albumin should be avoided in patients with traumatic brain injury. The 2021 SSC guidelines included a conditional recommendation for using albumin in patients who had received large volumes of crystalloid. An updated meta-analysis found probably no effect of albumin on prioritized patient-centered outcomes. Given the lack of proven benefit and increased costs, the 2026 guidance has been updated to suggest crystalloids alone over supplemental albumin. We have included a remark to denote specific clinical contexts where albumin may be appropriate on a case-by-case basis. SSC = Surviving Sepsis Campaign. There are eight statements for which the guidance is consistent with 2021, but the certainty of evidence and/or strength of recommendation has changed. These are presented in Table 3. TABLE 3. - Statements With a Change in Strength of Recommendation or Certainty of Evidence Statements Change in Certainty or Strength 33. For adults with sepsis or septic shock, we “recommend” using prolonged infusion of beta-lactams for maintenance (after an initial loading dose) over bolus administration.(strong recommendation, moderate certainty evidence) Upgraded from a conditional to strong recommendation. 36. For adults with sepsis or septic shock, we “recommend” de-escalation of antimicrobial therapy over no de-escalation when a confirmed microbiological diagnosis and susceptibility profile is available.(strong recommendation, very low certainty evidence) Remark: De-escalation involves discontinuing unnecessary antimicrobial therapy or narrowing the spectrum of antimicrobial agents where appropriate. Upgraded from a conditional to strong recommendation. 44. For adults with sepsis or septic shock undergoing initial resuscitation, we “suggest” using balanced crystalloids over 0.9% saline.(conditional recommendation, moderate certainty evidence). Remark: For patients with sepsis and traumatic brain injury, we suggest using 0.9% saline. Upgraded from low to moderate certainty evidence. 49. For adults with sepsis or septic shock, we “suggest” using dynamic measures to guide initial fluid resuscitation over physical examination or static measures alone.(conditional recommendation, low certainty evidence) Remark: Dynamic measures include response to a passive leg raise or a fluid bolus using stroke volume, stroke volume variation, pulse pressure, or pulse pressure variation. Upgraded from very low to low certainty evidence. 55. For adults with septic shock, we “suggest” using norepinephrine as the first-line agent over vasopressin or angiotensin II.(conditional recommendation)Vasopressin. Low certainty evidence.Angiotensin II. Very low certainty evidence. Downgraded from strong to conditional recommendation. (Note: Use of norepinephrine as the first-line agent over dopamine, epinephrine, or selepressin remains a strong recommendation.) 57. For adults with septic shock and inadequate MAP levels despite norepinephrine and vasopressin, we “suggest” adding epinephrine.(conditional recommendation, very low certainty evidence). Remark: In settings where vasopressin is not available, epinephrine can be added to norepinephrine alone. Downgraded from low to very low certainty evidence. 61. For adults with septic shock with persistent hypoperfusion and cardiac dysfunction despite adequate fluid resuscitation and arterial blood pressure, we “suggest” adding dobutamine to norepinephrine or using epinephrine alone.(conditional recommendation, very low certainty evidence). Remark: Data were insufficient to make a recommendation for dobutamine vs. milrinone. Downgraded from low to very low certainty evidence. 79. For adults with septic shock, we “suggest” using IV corticosteroids.(conditional recommendation, low certainty evidence) Downgraded from moderate to low certainty evidence. WHAT IS THE SAME FROM 2021 The 2026 SSC guidelines contain 44 statements that were carried over directly from the 2021 SSC guidelines without un updated evidence synthesis (based on panel assessment that sufficient new evidence to justify a change in recommendation was unlikely). Statements carried over without an updated evidence synthesis are clearly denoted. The 2026 SSC guidelines additionally contain 39 statements that were revisited from 2021 SSC guidelines, of which 7 are unchanged and 29 are consistent with the 2021 recommendations but have revised wording and/or a new remark to refine or clarify guidance. Table 4 highlights recommendations that are consistent with the 2021 SSC guidelines. TABLE 4. - Abridged Rationale for Selected Statements that are Consistent With 2021 Surviving Sepsis Campaign Guidelines Selected Statements That are Consistent With 2021 Abridged Rationale 9. Sepsis and septic shock are medical emergencies; treatment and resuscitation should begin immediately.(good practice statement) This good practice statement was carried over directly from 2021. Sepsis is a leading cause of global mortality, contributing to an estimated 13.7 million deaths annually. In-hospital mortality is higher for patients with sepsis than patients with ST-elevation myocardial infarction. Prompt recognition and treatment reduce mortality. 10. For adults with sepsis-induced hypoperfusion or septic shock, we “suggest” administering at least 30 mL/kg of IV crystalloid in the first 3 hr. (conditional recommendation, low certainty evidence). Remark: Consideration should be given to individual patient characteristics and when initial fluid Remark: should ongoing and patients to of or Remark: fluid volume should be based on or by or in patients with This recommendation is unchanged from 2021. were added to clarify the of ongoing consideration of and for patients with high fluid resuscitation is for the of sepsis-induced tissue hypoperfusion in sepsis and septic shock. evidence in support of 30 mL/kg from observational studies and includes studies 30 mL/kg as of a of care are no new data suggesting a change is needed from prior SSC guidelines. Fluid overload with volumes 30 However, in patients at higher risk of from volume dynamic assessment to guide fluid resuscitation can prior to 30 mL/kg recommendation regarding dynamic measures to guide resuscitation, discussed For adults with possible, probable, or definite septic shock, we “recommend” administering antimicrobial therapy within 1 hr of recommendation, very low certainty evidence) These recommendations are unchanged from 2021 from wording changes for administration of appropriate antimicrobials is the initial intervention to reduce mortality in patients with sepsis or septic shock, with fluid resuscitation. Given the high risk of with septic shock and the more consistent and of antimicrobial timing and short-term mortality in patients with septic shock, the panel issued a strong recommendation to administer antimicrobials in adults with possible, probable, and definite septic shock and in adults with probable or definite sepsis. For adults with possible sepsis without shock, where the diagnosis of infection is the panel issued a conditional recommendation for a 3 assessment of and of This assessment may include additional history, clinical and testing to antimicrobials should be should be as as infection appears to be the of the and after no more than 3 hr if a for infection For adults with probable or definite sepsis without shock, we “recommend” administering antimicrobial therapy within 1 hr of recognition recommendation, very low certainty evidence) For adults with possible sepsis without shock, we “suggest” a course of and if for infection the administration of antimicrobial therapy within 3 hr from the time when sepsis was first recommendation, very low certainty of evidence) 49. For adults with sepsis or septic shock, we “suggest” using dynamic measures to guide fluid resuscitation over physical examination or static measures alone.(conditional recommendation, low certainty evidence) Remark: Dynamic measures include response to a passive leg raise or a fluid bolus using stroke volume, stroke volume variation, pulse pressure, or pulse pressure variation. This recommendation is unchanged from 2021. with sepsis or septic shock require additional IV fluid an initial 30 mL/kg fluid resuscitation. However, additional resuscitation fluid be balanced against the risk of fluid and associated with fluid or fluid administration the initial resuscitation phase should be by assessment of volume organ and fluid In a meta-analysis done for these SSC guidelines, fluid management by dynamic measures mortality and may in a in SSC = Surviving Sepsis Campaign. This executive summary describes the of the 2026 SSC guidelines and highlights selected new, and unchanged statements that are relevant to The guidelines document all 129 statements and narratives for all statements by a new or updated evidence

  PublisherDOI

Frequent coauthors

• Michael O’Connor

  University of Chicago

  51 shared

• Pierre Tissières

  Centre National de la Recherche Scientifique

  38 shared

• Matthew D. McEvoy

  35 shared

• Mitchell M. Levy

  Brown University

  33 shared

• Vivek K. Moitra

  Columbia University Irving Medical Center

  32 shared

• Andrew Rhodes

  25 shared

• Clifford S. Deutschman

  Northwell Health

  25 shared

• Richard I. Cook

  The University of Texas Health Science Center at Houston

  25 shared

Labs

• Mark E. NunnallyPI