Written and maintained by CASRAI Editorial Board
Last updated
This page describes clinical practice guidelines and operational protocols for researchers, clinical investigators, and healthcare teams; it does not provide individual medical advice.
Short answer (first 60 words)
The Surviving Sepsis Campaign guidelines provide an international, evidence-based consensus framework developed jointly by the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM). They standardize early recognition, protocolized fluid resuscitation, dynamic hemodynamic monitoring, rapid diagnostic microbiology, timely antimicrobial therapy, emergent source control, and post-intensive care rehabilitation to reduce sepsis-related mortality worldwide.
Definition and scope
The Surviving Sepsis Campaign (SSC) is an ongoing global initiative established in 2002 by SCCM and ESICM following the Barcelona Declaration. Its mandate is to reduce worldwide morbidity and mortality from sepsis and septic shock across emergency departments, acute hospital wards, and intensive care units. The guidelines provide graded recommendations that clinical departments, hospital laboratories, and quality improvement programs translate into standardized institutional protocols.
The scope encompasses adult and pediatric patients with sepsis (life-threatening organ dysfunction driven by a dysregulated host response to infection) and septic shock (sepsis with persistent cellular, metabolic, and circulatory abnormalities). The framework utilizes the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system:
- Strong Recommendations: Panel consensus confirms desirable effects clearly outweigh undesirable effects across virtually all clinical contexts (phrased as “we recommend”).
- Weak / Conditional Recommendations: Desirable effects probably outweigh undesirable consequences, but clinical variability or resources warrant bedside tailoring (phrased as “we suggest”).
- Best Practice Statements (BPS): Ungraded consensus representing uncontested ethical or practical imperatives where trials are unfeasible, such as pre-antimicrobial blood cultures and immediate source control.
How it works or how it is used in practice
In clinical practice, the Surviving Sepsis Campaign guidelines coordinate multidisciplinary care across core operational stages:
1. Structured Screening and Triage: The guidelines recommend hospital-wide performance improvement programs with routine screening for acutely ill patients. Institutions utilize early warning systems such as the National Early Warning Score (NEWS) or Modified Early Warning Score (MEWS). The guidelines explicitly recommend against using qSOFA as a standalone screening tool due to its lower sensitivity compared to formal multi-parameter scores.
2. Initial Resuscitation and Hemodynamic Targets: For patients with sepsis-induced hypoperfusion or septic shock, guidelines suggest administering at least 30 mL/kg of intravenous crystalloids within 3 hours. Balanced crystalloids (lactated Ringer’s or Plasma-Lyte) are suggested over 0.9% normal saline. The initial target mean arterial pressure (MAP) is 65 mm Hg. Ongoing fluid titration is guided by dynamic measures of fluid responsiveness (passive leg raise, stroke volume variation) rather than static venous pressures alone.
3. Vasoactive Support: Norepinephrine is the first-choice vasopressor. If target MAP remains unmet despite fluids and norepinephrine, adding vasopressin (titrated up to 0.03 units/min) is suggested over escalating norepinephrine alone. Epinephrine is an acceptable secondary agent, while dobutamine is added if persistent hypoperfusion indicates myocardial dysfunction.
4. Diagnostics and Antimicrobials: Blood cultures are drawn before starting antimicrobials without delaying therapy. For septic shock or probable sepsis, broad-spectrum intravenous antimicrobials must be administered immediately, ideally within 1 hour. For suspected sepsis without shock, a rapid diagnostic window of up to 3 hours is permitted before deciding on antimicrobial initiation.
5. Source Control and Post-ICU Care: Emergent anatomical source control (abscess drainage, debridement, catheter removal) is executed rapidly. Beyond acute stabilization, the guidelines emphasize post-intensive care syndrome (PICS) screening and structured rehabilitation.
Types or related concepts
The campaign encompasses adult guidelines, pediatric adaptations, operational bundles, and diagnostic criteria:
| Initiative or Component | Target Population / Scope | Primary Operational Mechanism | Distinguishing Guideline Role |
|---|---|---|---|
| Adult Guidelines (2021) | Hospitalized adults with sepsis or septic shock | Comprehensive 93-question GRADE panel recommendations | Sets core benchmarks (30 mL/kg fluids, norepinephrine first-line, 65 mm Hg MAP target). |
| Pediatric Guidelines (2020) | Infants and children with sepsis-associated organ dysfunction | Weight-adjusted fluid boluses (10–20 mL/kg up to 40–60 mL/kg) and age-specific thresholds | Allows epinephrine or norepinephrine as first-line inotropes/vasopressors tailored to pediatric physiology. |
| Hour-1 Resuscitation Bundle | Emergency and acute inpatient admissions | Five-element operational bundle initiated within 60 minutes | Translates guidelines into an operational checklist: lactate, blood cultures, antibiotics, fluids, vasopressors. |
| Best Practice Statements (BPS) | Universal clinical practice across all settings | Ungraded consensus statements for uncontested ethical/clinical imperatives | Mandates pre-antibiotic cultures, urgent source control, and multidisciplinary discharge coordination. |
| Sepsis-3 Diagnostic Criteria | Clinical and epidemiological surveillance | Acute change in total SOFA score of ≥ 2 points from baseline infection | Defines clinical organ dysfunction; distinct from SSC operational treatment guidelines. |
Where it matters for labs, clinics or supply decisions
Implementing the guidelines requires close operational alignment across diagnostic labs, pharmacies, and supply chains:
- Microbiology Protocols: Labs require drawing at least two sets of blood cultures (aerobic and anaerobic bottles) prior to antibiotic infusion: at least one peripheral draw and one through each vascular catheter placed over 48 hours. Proper skin antisepsis using antiseptic preparations (such as chlorhexidine gluconate in alcohol) prevents bottle contamination.
- Lactate Turnaround: Initial blood lactate > 2 mmol/L triggers protocolized resuscitation, requiring rapid laboratory or point-of-care turnaround and serial re-testing within 2 to 4 hours to verify metabolic clearance.
- Biomarker Stewardship: Guidelines advise against using procalcitonin to guide initial antimicrobial initiation. However, laboratory procalcitonin testing supports decisions to safely discontinue antimicrobials when infection resolution is uncertain.
- Fluid and Infusion Logistics: Formularies stock balanced crystalloids as the primary emergency fluid. Units require reliable intravenous infusion supplies, pressure infusors, and dedicated lines for continuous vasopressor titration.
Common misunderstandings
Clinical teams navigate several common misconceptions regarding guideline application:
- Hour-1 Initiation vs. Completion: The Hour-1 bundle mandates that resuscitation and diagnostic steps be actively initiated within 60 minutes of triage, not that all fluid infusions and therapies be completed within that hour.
- qSOFA vs. Full Diagnostic Scoring: qSOFA assesses altered mentation, respiratory rate ≥ 22/min, and systolic blood pressure ≤ 100 mm Hg. Because of its limited sensitivity, guidelines advise against using qSOFA alone as a screening tool or replacement for comprehensive SOFA and qSOFA scores.
- Fixed Formulas vs. Dynamic Physiology: The 30 mL/kg fluid recommendation is an initial resuscitation target, not a continuous formula. Subsequent volume must be tailored to dynamic fluid responsiveness to prevent pulmonary edema.
- Universal One-Hour Antibiotics: While septic shock demands immediate broad-spectrum antibiotics within 1 hour, possible sepsis without shock allows up to 3 hours of diagnostic evaluation to prevent antimicrobial overuse.
Frequently asked questions
What is the difference between Surviving Sepsis Campaign guidelines and Sepsis-3 definitions?
Sepsis-3 establishes diagnostic criteria, defining sepsis as infection-induced organ dysfunction with a SOFA score increase ≥ 2. The Surviving Sepsis Campaign guidelines deliver actionable management protocols instructing clinicians how to screen, resuscitate, and treat affected patients.
Why did the guidelines shift from static CVP targets to dynamic measures?
Static measures like central venous pressure (CVP 8–12 mm Hg) correlate poorly with fluid responsiveness. The modern guidelines favor dynamic measures—such as passive leg raising and stroke volume variation—which evaluate real-time changes in cardiac preload.
What are the five core components of the Hour-1 bundle?
The Hour-1 bundle requires initiating five actions within 60 minutes: (1) measure lactate level; (2) obtain blood cultures prior to antibiotics; (3) administer broad-spectrum antimicrobials; (4) begin 30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L; and (5) apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mm Hg.
How do adult and pediatric resuscitation guidelines differ?
Adult guidelines recommend an initial 30 mL/kg fluid bolus and designate norepinephrine as the first-choice vasopressor. Pediatric guidelines use incremental fluid boluses of 10–20 mL/kg (up to 40–60 mL/kg) and support either epinephrine or norepinephrine as initial first-line inotropic/vasopressor support.
Can procalcitonin replace blood cultures according to the guidelines?
No. Blood cultures remain a mandatory Best Practice Statement before antibiotic initiation. Procalcitonin serves solely as a secondary stewardship tool to guide antimicrobial discontinuation, never replacing microbiological cultures.
Sources
- Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Critical Care Medicine. 2021;49(11):e1063–e1143. doi:10.1097/CCM.0000000000005337. URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8486643/ (Read 2026-11-08).
- Weiss SL, Peters MJ, Alhazzani W, et al. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatric Critical Care Medicine. 2020;21(2):e52–e106. doi:10.1097/PCC.0000000000002198. URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7095013/ (Read 2026-11-08).
- Society of Critical Care Medicine (SCCM). Surviving Sepsis Campaign: Adult Patients Resources and Guidelines. URL: https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/Adult-Patients (Read 2026-11-08).
