Sepsis guideline 2026 may be written flow chart for MD Anaesthesia
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I now have all the data needed. Let me build a comprehensive, MD Anaesthesia-level sepsis flowchart as a well-formatted text document with visual ASCII flow structure.
SEPSIS MANAGEMENT FLOWCHART 2026
Based on SSC International Guidelines 2026 | For MD Anaesthesia
Reference: Prescott H, Antonelli M, Alhazzani W, et al. Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2026. Crit Care Med. 2026 Mar. doi:10.1097/CCM.0000000000007075 | Also: Barash Clinical Anesthesia 9e, Harrison's 22E
STEP 1 - RECOGNITION
┌─────────────────────────────────────────────────────────────┐
│ SUSPECT SEPSIS (Sepsis-3 Definition) │
│ │
│ SIRS + Suspected Infection + SOFA score ≥ 2 │
│ OR qSOFA ≥ 2: (RR ≥ 22, AMS, SBP ≤ 100 mmHg) │
└─────────────────────┬───────────────────────────────────────┘
│
▼
┌─────────────────────────────────────────────────────────────┐
│ SEPSIS CONFIRMED? │
└───────┬─────────────────────────────────┬───────────────────┘
│ YES │ Low probability,
▼ │ no shock
┌───────────────┐ ▼
│ Is there │ Defer antibiotics;
│ SHOCK? │ close monitoring;
│ SBP < 90 or │ re-evaluate q1h x 3h
│ MAP < 65 │
│ + Lactate │
│ > 2 mmol/L │
└───┬───────┬───┘
│ YES │ NO
▼ ▼
SEPTIC SEPSIS
SHOCK (w/o shock)
STEP 2 - IMMEDIATE ACTIONS (within FIRST HOUR - "Hour-1 Bundle")
┌─────────────────────────────────────────────────────────────────────────────┐
│ HOUR-1 BUNDLE │
├─────────────────────────────────────────────────────────────────────────────┤
│ □ Obtain BLOOD CULTURES x2 (aerobic + anaerobic) — ideally BEFORE │
│ antibiotics; do NOT delay antibiotics by > 45 min to get cultures │
│ │
│ □ Measure SERUM LACTATE (repeat if initial > 2 mmol/L) │
│ │
│ □ Administer BROAD-SPECTRUM ANTIBIOTICS: │
│ - Septic SHOCK → within 1 hr of recognition (STRONG) │
│ - Sepsis (no shock)→ within 1 hr (STRONG) │
│ - Low risk, no shock → defer; reassess at 3 hrs │
│ │
│ □ IV ACCESS: 2x large-bore peripheral IV or central venous catheter │
│ │
│ □ Start IV CRYSTALLOID RESUSCITATION: │
│ At least 30 mL/kg in first 3 hrs (conditional, low evidence) │
│ → Use BALANCED crystalloids (LR/PlasmaLyte) over 0.9% NaCl │
│ │
│ □ If MAP < 65 mmHg despite fluids → START VASOPRESSORS │
└─────────────────────────────────────────────────────────────────────────────┘
STEP 3 - ANTIBIOTIC STRATEGY
┌───────────────────────────────────────────────────────────────────────────┐
│ ANTIBIOTIC SELECTION │
├───────────────────────────────────────────────────────────────────────────┤
│ │
│ UNDIFFERENTIATED SEPSIS (source unknown): │
│ ┌─────────────────────────────────────────────────────────┐ │
│ │ No Pseudomonas risk: │ │
│ │ Ceftriaxone 2g IV q24h OR Cefotaxime 2g IV q8h │ │
│ │ │ │
│ │ Pseudomonas RISK (ICU-onset, structural lung disease): │ │
│ │ Piperacillin-Tazobactam 4.5g IV q6h │ │
│ │ OR Cefepime 2g IV q8h │ │
│ │ OR Meropenem/Imipenem (if carbapenem-resistant risk) │ │
│ │ │ │
│ │ MRSA RISK (frequent healthcare exposure, nosocomial): │ │
│ │ Add Vancomycin 25-30 mg/kg IV load OR Linezolid │ │
│ │ │ │
│ │ Candida RISK (recent abdominal surgery, TPN, liver │ │
│ │ failure, multi-site colonization): │ │
│ │ Add Echinocandin (Micafungin/Caspofungin) │ │
│ └─────────────────────────────────────────────────────────┘ │
│ │
│ ADMINISTRATION (SSC 2026 NEW): │
│ • Prolonged infusion of β-lactams RECOMMENDED (extended/continuous) │
│ after initial loading dose (vs bolus-only dosing) [STRONG, mod. evid.] │
│ • Procalcitonin: Do NOT use to START antibiotics; │
│ USE to guide DE-ESCALATION / STOPPING │
│ │
│ DE-ESCALATION (when culture + sensitivity available): │
│ Narrow spectrum → ALWAYS recommended [STRONG] │
│ Duration: Guided by clinical response + procalcitonin trend │
└───────────────────────────────────────────────────────────────────────────┘
STEP 4 - HEMODYNAMIC RESUSCITATION
┌─────────────────────────────────────────────────────────────────────────┐
│ FLUID RESUSCITATION │
├─────────────────────────────────────────────────────────────────────────┤
│ Initial: ≥ 30 mL/kg IV crystalloid in first 3 hrs │
│ After initial bolus: Reassess frequently using DYNAMIC MEASURES: │
│ • Pulse pressure variation (PPV) │
│ • Stroke volume variation (SVV) │
│ • Passive leg raise (PLR) + cardiac output │
│ • Mini fluid challenge (100-200 mL) + CO response │
│ │
│ Add ALBUMIN when large volumes of crystalloid required │
│ AVOID hetastarch/HES (STRONG recommendation) │
│ │
│ TARGET ENDPOINTS: │
│ ✓ MAP ≥ 65 mmHg │
│ ✓ Lactate clearance > 10% per 2 hrs (target < 2 mmol/L) │
│ ✓ UO ≥ 0.5 mL/kg/hr │
│ ✓ Improving mental status │
│ │
│ After acute resuscitation: ACTIVE FLUID REMOVAL suggested (de- │
│ resuscitation/conservative strategy) [NEW SSC 2026] │
└─────────────────────────────────────────────────────────────────────────┘
│
▼
┌─────────────────────────────────────────────────────────────────────────┐
│ VASOPRESSOR THERAPY │
├─────────────────────────────────────────────────────────────────────────┤
│ GOAL: MAP ≥ 65 mmHg │
│ │
│ 1st LINE: NOREPINEPHRINE (NE) - preferred in most patients │
│ (preferred if tachyarrhythmia or sinus tachycardia) │
│ │
│ Cardiac dysfunction present? │
│ ├─ Yes, + bradyarrhythmia → EPINEPHRINE 1st line │
│ └─ Yes, + tachyarrhythmia → NOREPINEPHRINE 1st line │
│ │
│ NE dose ≥ 0.25 μg/kg/min → ADD VASOPRESSIN 0.03-0.04 U/min │
│ (fixed rate; do NOT use vasopressin alone) │
│ │
│ Refractory shock (NE + Vasopressin inadequate) → ADD EPINEPHRINE │
│ │
│ Low CO states → Add DOBUTAMINE to NE │
│ OR switch to EPINEPHRINE monotherapy │
│ │
│ AVOID: Dopamine (except very select cases) │
│ AVOID: β-blockers for septic shock [NEW SSC 2026] │
│ AVOID: Levosimendan / Terlipressin │
└─────────────────────────────────────────────────────────────────────────┘
STEP 5 - CORTICOSTEROIDS
┌──────────────────────────────────────────────────────────────────────┐
│ IV CORTICOSTEROIDS │
├──────────────────────────────────────────────────────────────────────┤
│ INDICATION: Septic shock (conditional recommendation) │
│ │
│ WHEN TO START: Shock persisting despite adequate fluids │
│ and vasopressors (NE doses ≥ 0.2-0.3 μg/kg/min) │
│ │
│ DRUG: HYDROCORTISONE 200 mg/day IV │
│ • Intermittent: 50 mg IV q6h (preferred by 86% of SSC panel) │
│ • OR: 200 mg continuous infusion/24h │
│ │
│ DURATION: Until vasopressors are no longer required │
│ TAPER: Not required if shock resolving [SSC 2026 panel consensus] │
│ │
│ NOTE: Fludrocortisone NOT routinely added (63% panel members) │
│ NOTE: Antipyretics for fever NOT recommended to improve outcomes │
│ [SSC 2026 NEW - Conditional against antipyretics] │
└──────────────────────────────────────────────────────────────────────┘
STEP 6 - RESPIRATORY SUPPORT (Anaesthesia-Critical Component)
┌─────────────────────────────────────────────────────────────────────────┐
│ RESPIRATORY MANAGEMENT │
├─────────────────────────────────────────────────────────────────────────┤
│ MONITORING: SpO2 or SaO2 + clinical assessment [SSC 2026] │
│ │
│ STEP-UP APPROACH: │
│ │
│ Hypoxemia (SpO2 < 94%): │
│ ┌────────────────────────────────────────────────────────────────┐ │
│ │ 1. Supplemental O2 via nasal cannula/face mask │ │
│ │ ↓ if inadequate │ │
│ │ 2. HIGH-FLOW NASAL CANNULA (HFNC) [SSC 2026 - SUGGESTED │ │
│ │ over conventional O2 AND over NIV] - PREFERRED INITIAL │ │
│ │ ↓ if HFNC inadequate or contraindicated │ │
│ │ 3. NIV/CPAP (if tolerated, not preferred over HFNC) │ │
│ │ ↓ if failing (ROX index < 4.88, rising RR, AMS) │ │
│ │ 4. INTUBATION + MECHANICAL VENTILATION │ │
│ └────────────────────────────────────────────────────────────────┘ │
│ │
│ MECHANICAL VENTILATION TARGETS: │
│ ┌────────────────────────────────────────────────────────────────┐ │
│ │ Sepsis-induced hypoxemic RF (no ARDS): │ │
│ │ TV: 6-8 mL/kg IBW (NOT < 6 mL/kg unless ARDS develops) │ │
│ │ │ │
│ │ ARDS (Berlin criteria - PaO2/FiO2 < 300): │ │
│ │ TV: 6 mL/kg IBW [STRONG] │ │
│ │ Plateau pressure: ≤ 30 cmH2O [STRONG] │ │
│ │ PEEP: Titrate to FiO2 (using PEEP-FiO2 table) │ │
│ │ Moderate-severe ARDS (P/F < 150): │ │
│ │ → PRONE POSITIONING ≥ 12 hrs/day [STRONG] │ │
│ │ → NMB (cisatracurium) during prone - intermittent bolus │ │
│ │ preferred over continuous infusion │ │
│ │ → ECMO if refractory respiratory failure [SUGGESTED] │ │
│ │ Head of bed elevation: 30-45° unless contraindicated │ │
│ └────────────────────────────────────────────────────────────────┘ │
│ │
│ WEANING: Spontaneous breathing trial (SBT) protocol daily │
│ SEDATION: Target lightest sedation; daily sedation interruptions │
│ Avoid PAC (pulmonary artery catheter) routinely │
└─────────────────────────────────────────────────────────────────────────┘
STEP 7 - SOURCE CONTROL
┌──────────────────────────────────────────────────────────────────┐
│ SOURCE CONTROL │
├──────────────────────────────────────────────────────────────────┤
│ Identify focus: Imaging (CT/US) URGENTLY │
│ │
│ Common sources requiring control: │
│ • Intra-abdominal abscess → Drainage (percutaneous or surgical) │
│ • Bowel perforation → Emergency laparotomy │
│ • Cholangitis → ERCP/biliary decompression │
│ • Pyelonephritis → Ureteral stenting / nephrostomy │
│ • Necrotizing fasciitis → Urgent surgical debridement │
│ • Infected prosthesis/device → Remove as soon as possible │
│ • Infected IV catheters → Remove/replace │
│ │
│ TIMING: As soon as anatomically feasible │
│ PRINCIPLE: Least invasive approach first, when effective │
└──────────────────────────────────────────────────────────────────┘
STEP 8 - ADDITIONAL SUPPORTIVE THERAPIES
┌─────────────────────────────────────────────────────────────────────┐
│ ADDITIONAL SUPPORTIVE MEASURES (SSC 2026) │
├──────────────────────┬──────────────────────────────────────────────┤
│ GLYCEMIC CONTROL │ Start insulin at glucose ≥ 180 mg/dL │
│ │ Target: 144-180 mg/dL [STRONG] │
├──────────────────────┼──────────────────────────────────────────────┤
│ TRANSFUSION │ Hb threshold: 7 g/dL (restrictive) │
│ │ Exception: CAD, active hemorrhage → 9 g/dL │
├──────────────────────┼──────────────────────────────────────────────┤
│ RENAL PROTECTION │ RRT if AKI: CRRT preferred in hemodynamic │
│ │ instability; IHD acceptable if stable │
│ │ Bicarbonate if pH < 7.2 + AKI │
├──────────────────────┼──────────────────────────────────────────────┤
│ GI PROPHYLAXIS │ PPI (stress ulcer prophylaxis) in patients │
│ │ with GI bleeding risk factors [SUGGESTED] │
│ │ Probiotics → NOT recommended [SSC 2026 NEW] │
├──────────────────────┼──────────────────────────────────────────────┤
│ DVT PROPHYLAXIS │ LMWH preferred over UFH │
│ │ Mechanical prophylaxis if anticoag. CI │
├──────────────────────┼──────────────────────────────────────────────┤
│ NUTRITION │ Early enteral nutrition (within 24-48 hrs) │
│ │ Avoid early parenteral nutrition if EN │
│ │ possible │
├──────────────────────┼──────────────────────────────────────────────┤
│ IV VITAMIN C │ NOT routinely recommended [SSC 2026] │
├──────────────────────┼──────────────────────────────────────────────┤
│ IV IMMUNOGLOBULINS │ NOT recommended [SSC 2026] │
├──────────────────────┼──────────────────────────────────────────────┤
│ BLOOD PURIFICATION │ NOT recommended (incl. Polymyxin B │
│ │ hemoperfusion) [SSC 2026 - STRONG against] │
├──────────────────────┼──────────────────────────────────────────────┤
│ ICU ADMISSION │ Within 6 hours of diagnosis │
└──────────────────────┴──────────────────────────────────────────────┘
STEP 9 - MONITORING TARGETS & REASSESSMENT
┌──────────────────────────────────────────────────────────────────────┐
│ MONITORING TARGETS (Ongoing Assessment) │
├─────────────────────────┬────────────────────────────────────────────┤
│ Hemodynamic │ MAP ≥ 65 mmHg │
│ │ HR 60-100 bpm │
│ │ CVP 8-12 mmHg (mechanically ventilated: │
│ │ 12-15 mmHg) — if measured │
├─────────────────────────┼────────────────────────────────────────────┤
│ Perfusion │ Lactate < 2 mmol/L │
│ │ ScvO2 ≥ 70% (SvO2 ≥ 65%) │
│ │ UO ≥ 0.5 mL/kg/hr │
├─────────────────────────┼────────────────────────────────────────────┤
│ Respiratory │ SpO2 94-98% (non-ARDS) │
│ │ Plateau pressure ≤ 30 cmH2O │
│ │ Driving pressure ≤ 15 cmH2O │
├─────────────────────────┼────────────────────────────────────────────┤
│ Metabolic │ Glucose 144-180 mg/dL │
│ │ pH > 7.2 (consider bicarb if pH < 7.2 │
│ │ + AKI) │
├─────────────────────────┼────────────────────────────────────────────┤
│ Labs (q6-8h initially) │ ABG, BMP, LFTs, CBC, Coags, Procalcitonin│
│ │ Serial lactate q2h until < 2 mmol/L │
└─────────────────────────┴────────────────────────────────────────────┘
SIMPLIFIED MASTER FLOWCHART (Quick Reference)
SUSPECT SEPSIS (SOFA ≥2 + infection)
│
▼
┌─────────────────────────────┐
│ HOUR-1 BUNDLE │
│ • Blood cultures x2 │
│ • Lactate │
│ • IV access │
│ • Broad-spectrum ABx │
│ • 30 mL/kg crystalloid │
└──────────┬──────────────────┘
│
▼
MAP < 65 mmHg?
/ \
YES NO
│ │
▼ ▼
START NE Ongoing
(+ consider monitoring
vasopressin & source
if NE≥0.25) control
│
▼
NE ≥ 0.25 μg/kg/min?
│
YES
│
▼
Add VASOPRESSIN 0.03 U/min
│
▼
Still in shock?
│
YES
│
▼
Add EPINEPHRINE / DOBUTAMINE (if low CO)
+ HYDROCORTISONE 200 mg/day
│
▼
VENTILATION:
• Hypoxemia → HFNC first
• If intubated: TV 6-8 mL/kg IBW
• ARDS: TV 6 mL/kg + Prone ≥12h
│
▼
SOURCE CONTROL
+ Antibiotic DE-ESCALATION
when culture results available
│
▼
SUPPORTIVE CARE
(Glucose, DVT, nutrition,
stress ulcer PPI, RRT if needed)
│
▼
ICU within 6 hours
Goals of care / palliative
discussion with family
KEY SSC 2026 UPDATES (New vs 2021 - High-Yield for Exam)
| Topic | 2021 | 2026 Update |
|---|---|---|
| Antibiotics in ambulance | Not addressed | Suggested if transport >60 min to hospital (NEW) |
| β-lactam administration | Standard bolus | Prolonged infusion RECOMMENDED (NEW - STRONG) |
| HFNC vs NIV | Suggested HFNC | HFNC preferred over NIV and alternating HFNC/NIV |
| TV (no ARDS) | 6 mL/kg | 6-8 mL/kg IBW (not < 6 unless ARDS develops) |
| Vasopressors + cardiac dysfunction | NE 1st line | NE or Epi depending on heart rate (bradycardia → Epi) |
| β-blockers | No recommendation | Suggested AGAINST in septic shock (NEW) |
| Antipyretics | No recommendation | Suggested AGAINST for outcome benefit (NEW) |
| Active fluid removal | Not addressed | Suggested post-acute phase (de-resuscitation) (NEW) |
| Probiotics | No recommendation | Suggested AGAINST (NEW) |
| Blood purification/Polymyxin B | Not recommended | Strongly AGAINST (NEW - STRONG) |
| Vitamin C IV | Suggested against | Confirmed NOT recommended |
| Immunoglobulins IV | Not recommended | Confirmed NOT recommended |
| De-escalation | Recommended | Strongly RECOMMENDED when culture available |
DEFINITIONS (Sepsis-3, 2016 - Still Current)
| Term | Definition |
|---|---|
| Infection | Suspected or confirmed microbial pathology |
| Sepsis | Life-threatening organ dysfunction due to dysregulated host response to infection; SOFA score ≥ 2 from baseline |
| Septic Shock | Sepsis + vasopressor requirement to maintain MAP ≥ 65 mmHg AND serum lactate > 2 mmol/L despite adequate fluid resuscitation |
| qSOFA | Screening tool: RR ≥ 22/min + AMS + SBP ≤ 100 mmHg (≥ 2 = high risk) |
SOURCES
- SSC 2026: Prescott H, Antonelli M, Alhazzani W, et al. Surviving Sepsis Campaign International Guidelines for Management of Sepsis and Septic Shock 2026. Crit Care Med & Intensive Care Med. Published March 23, 2026. doi:10.1097/CCM.0000000000007075
- Barash Clinical Anesthesia 9e, Table 57-4 - Management of Sepsis and Septic Shock (p. 4831-4832)
- Harrison's Principles of Internal Medicine 22E (2025) - Initial Sepsis Management, Ch. 315
- S3 Guideline Sepsis Update 2025 (German, PMID: 40824313)
- ESICM Circulatory Shock Guidelines 2025 (PMID: 41236566)
This flowchart covers all 9 key management phases of sepsis based on the most current SSC 2026 guidelines (published March 23, 2026 - the latest available), integrated with anaesthesia-specific content from Barash and Harrison's. The SSC 2026 contains 129 statements with 46 new recommendations compared to the 2021 version. The key new aspects most relevant to an MD Anaesthesia exam are the prolonged β-lactam infusion (now a strong recommendation), HFNC preference over NIV, the NE-or-Epi choice based on cardiac rhythm in shock with cardiac dysfunction, de-resuscitation after acute phase, and the strong recommendation against blood purification devices.
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