Give me a consisis answer for dnb anaesthesia exam question surviving sepsis guidelines
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I now have enough content from the SSC 2026 guidelines to provide a comprehensive DNB-focused answer. Let me compile this.
Surviving Sepsis Campaign (SSC) Guidelines 2026 - DNB Anaesthesia Exam Summary
Source: SSC International Guidelines for Management of Sepsis and Septic Shock 2026 (Prescott et al., Critical Care Medicine, April 2026; simultaneous publication in Intensive Care Medicine)
Definitions (Sepsis-3)
- Sepsis: Life-threatening acute organ dysfunction due to infection
- Septic Shock: Subset of sepsis with circulatory dysfunction conferring higher mortality risk (vasopressor requirement to maintain MAP ≥65 mmHg + serum lactate >2 mmol/L despite adequate fluid resuscitation)
- Sepsis terminology: Definite / Probable / Possible / Unlikely sepsis - clinicians must assess likelihood category as it drives antibiotic timing decisions
SCREENING & EARLY MANAGEMENT
| # | Recommendation | Strength |
|---|---|---|
| 1 | Use a performance improvement program for sepsis (screening + SOPs + QI strategies) | Strong |
| 2 | Use a "code sepsis" or "sepsis huddle" multidisciplinary protocol | Conditional |
| 3 | Use a standard sepsis screening tool for acutely ill patients in ambulance/flight | Conditional |
| 4 | Use NEWS, NEWS2, MEWS, or SIRS over qSOFA as single in-hospital screening tool | Strong |
| 5 | Sepsis is a clinical diagnosis - do not rule in/out with a single biomarker | Good practice |
| 8 | Measure blood lactate in possible/probable/definite sepsis or septic shock | Conditional |
| 9 | Sepsis/septic shock = medical emergency; resuscitation begins immediately | Good practice |
| 15 | Admit to ICU within 6 hours if ICU admission required | Conditional |
INFECTION
Antibiotics - Timing
| Scenario | Timing | Strength |
|---|---|---|
| Possible/probable/definite septic shock | Within 1 hour | Strong |
| Probable/definite sepsis without shock | Within 1 hour | Strong |
| Possible sepsis without shock | Rapid assessment of infectious vs. non-infectious cause; if concern persists → antibiotics within 3 hours | Conditional |
| Low likelihood of infection, no shock | Defer antibiotics, monitor closely | Conditional |
| Prehospital (septic shock, >60 min to hospital) | Give antibiotics in ambulance/flight | Conditional |
Blood Cultures
| # | Recommendation | Strength |
|---|---|---|
| 7 | Collect blood cultures before antibiotics (where possible, without delaying therapy) | Good practice |
Antibiotic Management
| # | Recommendation | Strength |
|---|---|---|
| 22 | Use clinical evaluation alone (not procalcitonin) to decide whether to START antibiotics | Conditional |
| 23 | Rapidly evaluate for source requiring source control | Good practice |
| 24 | Early source control within 6 hours of diagnosis | Conditional |
| 25 | Use broad-spectrum empiric therapy covering likely pathogens | Strong |
| 26 | Include MDR coverage if risk factors for MDR pathogen present | Conditional |
| 27 | Avoid empiric antifungal therapy routinely (consider in high-risk cases) | Conditional |
| 33 | Use prolonged infusion of beta-lactams (after loading dose) | Strong |
| 36 | De-escalate antibiotics when microbiological diagnosis + susceptibility available | Strong |
| 39 | Use shorter over longer antibiotic duration with adequate source control | Conditional |
| 40 | Use procalcitonin + clinical evaluation to decide when to STOP antibiotics | Conditional |
| 41 | In ventilated patients in units with low MDR prevalence: use selective decontamination of the digestive tract (SDD) | Conditional |
HEMODYNAMIC MANAGEMENT
Fluids
| # | Recommendation | Strength |
|---|---|---|
| 10 | At least 30 mL/kg IV crystalloid in first 3 hours for sepsis-induced hypoperfusion/shock (use ABW if BMI>30) | Conditional |
| 11 | Initial crystalloid bolus, then vasopressors if hypotension persists (concurrent vasopressor for unstable shock) | Conditional |
| 43 | Crystalloids first-line for resuscitation | Strong |
| 44 | Balanced crystalloids over 0.9% saline (exception: traumatic brain injury → use saline) | Conditional |
| 45 | Crystalloids alone over crystalloids + albumin; albumin may be used after large crystalloid volumes or in cirrhosis | Conditional |
| 46 | No starches | Strong |
| 47 | No gelatin | Conditional |
| 48 | After initial 30 mL/kg, either liberal or restrictive strategy acceptable; individualize | Conditional |
| 49 | Use dynamic measures (PLR, fluid bolus with SV/SVV/PP/PPV response) to guide further resuscitation | Conditional |
| 51 | Use serial lactate measurements to guide resuscitation (target ≥10% reduction every 2 hrs) | Conditional |
| 89 | After acute resuscitation phase, use active fluid removal (diuretics ± ultrafiltration) | Conditional |
Vasopressors
| # | Recommendation | Strength |
|---|---|---|
| 12 | Start vasopressors peripherally rather than waiting for central access | Conditional |
| 13 | MAP target 65 mmHg (initial) | Strong |
| 14 | In patients ≥65 years: MAP target 60-65 mmHg acceptable | Conditional |
| 53 | Norepinephrine first-line over dopamine, epinephrine, selepressin | Strong |
| 55 | Norepinephrine first-line over vasopressin or angiotensin II | Conditional |
| 56 | Add vasopressin when norepinephrine doses escalating | Conditional |
| 57 | Add epinephrine if inadequate MAP despite norepinephrine + vasopressin | Conditional |
| 58 | In cardiac dysfunction with septic shock: either norepinephrine or epinephrine (NE preferred if tachyarrhythmia; epinephrine if bradyarrhythmia) | Conditional |
| 60 | Add inotropes (dobutamine or epinephrine) if cardiac dysfunction + persistent hypoperfusion despite adequate fluids and MAP | Conditional |
| 62 | No levosimendan | Conditional (against) |
| 79 | Use IV corticosteroids in septic shock (hydrocortisone 200 mg/day) | Conditional |
RESPIRATORY SUPPORT
| # | Recommendation | Strength |
|---|---|---|
| 65 | Measure oxygenation by SpO2 or ABG + clinical assessment (ABG is gold standard; SpO2 less accurate in shock, dark skin, sat <90% or >97%) | Conditional |
| 66 | Target either higher (SpO2 ≥96%) or lower (SpO2 ~90-93%) oxygen levels based on patient factors | Conditional |
| 67 | HFNC over conventional oxygen therapy in acute hypoxemic respiratory failure (PaO2/FiO2 <200) | Conditional |
| 68 | HFNC as initial therapy over NIPPV | Conditional |
| 70 | Trial of awake proning in non-intubated patients | Conditional |
Invasive Ventilation (mechanically ventilated)
- Use lung-protective ventilation principles consistent with ARDS management
ADJUNCTIVE & SUPPORTIVE THERAPIES
| Therapy | Recommendation | Notes |
|---|---|---|
| Corticosteroids (rec 79) | Suggest USE in septic shock | Hydrocortisone 200 mg/day; reduces time to shock reversal |
| Antipyretics (rec 80) | Suggest AGAINST for clinical outcome improvement | OK for symptom control |
| IV Vitamin C (rec 81) | Suggest AGAINST | No mortality benefit in low-bias trials |
| IVIG (rec 82) | Suggest AGAINST | |
| Blood purification (rec 83, 84) | Suggest AGAINST (hemoperfusion, high-dose hemofiltration, plasma exchange, polymyxin B) | |
| Vitamin D (rec 85) | Suggest AGAINST (for sepsis treatment) | VIOLET trial: possible harm |
| Stress ulcer prophylaxis (rec 87) | Suggest USE (PPI) if GI bleeding risk factors present | |
| Probiotics (rec 88) | Suggest AGAINST | |
| Blood transfusion (rec 90) | Restrictive strategy | Strong recommendation |
| Enteral nutrition (rec 91) | Early (within 72 hr) | Conditional |
| Insulin therapy (rec 92) | Start at glucose ≥180 mg/dL (10 mmol/L) | Strong |
| RRT (rec 93, 94) | No RRT without definitive indication; if indicated: continuous or intermittent | Conditional |
| Sodium bicarbonate (rec 95, 96) | Avoid for hemodynamic improvement; consider if pH ≤7.2 + AKI stage 2-3 | Conditional |
| VTE prophylaxis (rec 97-99) | LMWH preferred over UFH; pharmacologic alone over combined mechanical | Strong |
GOALS OF CARE
- Discuss goals of care and prognosis with patients/families early (within 72 hours) - Conditional
- Health systems should ensure discharge patients have opportunity to complete advance directives
KEY "NEW" POINTS IN SSC 2026 (vs. 2021)
- qSOFA downgraded - use NEWS/NEWS2/MEWS/SIRS instead for in-hospital screening (now a strong recommendation)
- Prehospital antibiotics: new recommendation - give if septic shock + >60 min to hospital
- SDD: New conditional recommendation in favour (low MDR prevalence settings)
- HFNC: Preferred over conventional O2 and over NIPPV (new recommendations)
- Awake proning: New conditional suggestion for non-intubated patients
- MAP 60-65 mmHg acceptable in elderly ≥65 yrs (new conditional)
- Peripheral vasopressors: Explicitly suggested over waiting for central access
- Prolonged infusion of beta-lactams: Upgraded to strong recommendation
- Active fluid removal after acute phase: New conditional suggestion
- Antipyretics, Vitamin D, Probiotics: New recommendations against for clinical outcome improvement
- Code sepsis / sepsis huddle: New conditional recommendation
- Stress ulcer prophylaxis: Updated with REVISE trial data (PPI preferred over H2-blockers)
Exam tip for DNB: The "Hour-1 bundle" concept is embedded here - blood cultures, lactate, antibiotics within 1 hour, IV fluids 30 mL/kg, vasopressors targeting MAP ≥65 mmHg form the core rapid management framework. The 2026 update is notable for explicitly addressing prehospital management, HFNC, and moving away from qSOFA as a screening tool.
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