The 2026 Surviving Sepsis Campaign Guidelines: The Dissenting Opinion

The 2026 Surviving Sepsis Campaign Guidelines: The Dissenting Opinion

Authors: Rory Spiegel, Korbin Haycock, Ashley Miller, Scott Weingart, Joshua Farkas, Ian Ajmo, Philippe Rola
Journal: American Journal of Emergency Medicine, 2026

Conclusions:

  • This is not a clinical trial or systematic review. It is a physician-authored critique of the 2026 Surviving Sepsis Campaign (SSC) guidelines, arguing that several high-impact recommendations remain more protocol-driven than evidence-driven.

  • The central argument is that sepsis is too heterogeneous for rigid, one-size-fits-all resuscitation bundles. The authors advocate individualized, physiology-based treatment rather than automatic adherence to fixed fluid, lactate, MAP, and antibiotic targets.

  • They specifically challenge:

    • routine 30 mL/kg crystalloid as a universal initial target;

    • using serial lactate reduction as a driver of further fluid administration;

    • treating fluid responsiveness as synonymous with benefit from additional fluid;

    • using MAP 65 mm Hg as an isolated resuscitation endpoint;

    • and requiring antibiotics within 1 hour for all patients with suspected sepsis without shock.

  • Their preferred framework emphasizes earlier vasopressors when appropriate, assessment of both fluid responsiveness and fluid tolerance, POCUS-guided hemodynamic evaluation, and broader markers of tissue perfusion rather than protocol completion alone.

  • The paper is deliberately a dissenting opinion. Its conclusions should therefore be interpreted as an evidence-informed critique of the SSC rather than a replacement guideline.

Practice Takeaways:

  • Do not equate “sepsis” with “needs 30 mL/kg.” Especially in patients with HF, renal failure, RV dysfunction, pulmonary hypertension, or clinical congestion, reassess physiology before continuing fluid.

  • Earlier vasopressors are increasingly defensible when hypotension appears predominantly vasodilatory rather than preload-responsive, particularly after an initial limited fluid challenge.

  • A positive passive leg raise is not a mandate to give fluid. Ask two separate questions: Will stroke volume rise? and Can this patient tolerate more preload without harm?

  • Use lactate as context, not a fluid prescription. A persistently elevated lactate should trigger diagnostic and physiologic reassessment—not automatic repeat boluses.

  • MAP 65 is a reasonable starting reference, not proof of adequate perfusion. Look at capillary refill, mentation, urine output, mottling, cardiac performance, and the underlying shock phenotype.

  • POCUS deserves a larger role than the SSC gives it. For ED physicians comfortable with bedside echo, integrating LV/RV function, venous congestion, pulmonary findings, and response to interventions fits well with the individualized approach advocated here.

  • Antibiotic urgency should track illness severity. Septic shock still warrants immediate appropriate antibiotics. In a stable patient with possible sepsis but substantial diagnostic uncertainty, the paper argues that forcing antibiotics within 60 minutes may create more harm than benefit.

  • The operational message is important: quality metrics should not substitute for bedside physiology. The authors are particularly concerned that guideline recommendations become performance measures such as SEP-1, where clinicians may feel pressured to satisfy time-based criteria rather than individualize care.

  • This is a provocative and clinically relevant critique, but it remains an opinion piece. It should push emergency physicians to interrogate rigid sepsis protocols rather than be interpreted as evidence that fluids, lactate, MAP targets, or early antibiotics are broadly unhelpful.

Results:

  • 30 mL/kg fluids

    • The SSC continues to suggest at least 30 mL/kg crystalloid within 3 hours for sepsis-induced hypoperfusion or septic shock, despite labeling the recommendation conditional with low-certainty evidence.

    • The authors argue that observational associations favoring 30 mL/kg are highly vulnerable to confounding by indication, since patients receiving less fluid often have heart failure, ESRD, frailty, or pulmonary edema.

    • In CLOVERS, restrictive fluids with earlier vasopressors versus a more liberal fluid strategy produced no difference in 90-day mortality.

    • CLASSIC similarly found no mortality difference between restrictive and liberal fluid strategies.

    • In ARISE-FLUID, initial resuscitation volumes were approximately 25 mL/kg versus 38 mL/kg. Mortality did not differ, while pulmonary edema was less frequent with the lower-fluid/earlier-vasopressor strategy: 0.6% vs 5.0%; RR 0.12, 95% CI 0.03–0.39; P<0.001.

    • The authors favor abandoning an empiric weight-based prescription in favor of fluid decisions based on comorbidities, hemodynamics, size, and fluid tolerance.

  • Lactate

    • The SSC now suggests serial lactate measurements but explicitly cautions against continuing fluids until lactate normalizes.

    • The authors view this as progress but argue that lactate remains overinterpreted as a marker of hypovolemia or tissue hypoxia.

    • They emphasize that septic hyperlactatemia may reflect adrenergic stimulation and inflammatory metabolism rather than inadequate preload.

    • A persistently elevated lactate should prompt reassessment of the entire clinical picture—including source control and antibiotic adequacy—rather than another reflexive fluid bolus.

  • Fluid responsiveness versus fluid tolerance

    • The SSC suggests dynamic measures such as passive leg raise, stroke volume, pulse pressure variation, and related measures rather than static examination alone.

    • The authors argue that this answers only whether cardiac output can increase with preload—not whether administering fluid will actually help the patient.

    • A patient can be fluid responsive while simultaneously developing venous congestion, RV dilation, pulmonary edema, or tissue edema.

    • They argue that assessment should incorporate both fluid responsiveness and fluid tolerance, ideally including POCUS and evaluation of forward flow and venous congestion.

  • MAP targets

    • The SSC recommends an initial MAP target of approximately 65 mm Hg.

    • The authors do not argue that hypotension should be ignored; rather, they object to treating MAP as a stand-alone surrogate for perfusion.

    • Trials comparing empirically higher MAP targets with approximately 65 mm Hg have not shown clear benefit, and one cited trial suggested possible harm in older patients.

    • They advocate integrating MAP with capillary refill, mottling, cardiac output, and the presumed hemodynamic mechanism of shock.

  • Antibiotic timing

    • The SSC recommends antibiotics immediately, ideally within 1 hour, even for probable or definite sepsis without shock.

    • The authors agree that timely antibiotics are critical in septic shock, where delays have repeatedly been associated with increased mortality.

    • They argue that the evidence is much weaker for a strict 1-hour requirement in sepsis without shock.

    • A prehospital antibiotic RCT involving 2,698 patients achieved antibiotics 93 minutes earlier without a mortality difference.

    • Another randomized trial of 872 patients delivered antibiotics 73 minutes earlier with a rapid 1-hour bundle and again found no mortality benefit.

    • The authors cite meta-analysis data suggesting no mortality difference when antibiotics in sepsis without shock are administered within 3 hours rather than within 1 hour.

    • Their concern is that indiscriminate 1-hour antibiotic metrics may encourage false-positive sepsis diagnoses, premature diagnostic closure, unnecessary broad-spectrum exposure, reduced culture yield, and antimicrobial stewardship problems.

Methods:

  • Narrative commentary and evidence-based critique of selected recommendations from the 2026 Surviving Sepsis Campaign guidelines.

  • The authors focus on recommendations with major bedside and quality-metric implications, particularly:

    • initial fluid volume;

    • lactate-guided resuscitation;

    • dynamic measures of fluid responsiveness;

    • MAP targets;

    • antibiotic timing;

    • and bundle-driven quality measures.

  • They support their arguments using previously published randomized trials, observational studies, systematic reviews, physiologic literature, and other guidelines.

  • This paper did not perform a new systematic literature search, meta-analysis, or original patient-level study, so there are no primary outcomes or independently generated effect estimates.

Spiegel R, Haycock K, Miller A, Weingart S, Farkas J, Ajmo I, Rola P. The 2026 Surviving Sepsis Campaign Guidelines: The dissenting opinion. Am J Emerg Med. 2026 Sep 15;110:411-415. doi: 10.1016/j.ajem.2026.09.025. Epub ahead of print. PMID: 42767105. 

Back to blog