Measure lactate, take blood cultures, give antibiotics, give at least 30 mL/kg crystalloid for hypotension or lactate ≥ 4, and start noradrenaline if MAP stays < 65, all begun within the first hour (SSC 2026).
At the bedside
Timed steps- 1
Airway, breathing, oxygen
0 minOxygen to SpO2 92-96%. Call senior help early if GCS ≤ 8, high work of breathing, or failing SpO2.
- 2
Two large-bore IV cannulae and labs
0-10 minLactate, blood cultures (2 sets from separate sites, ~10 mL per bottle; 1 set is acceptable where resources are limited), CBC, creatinine, bilirubin, coagulation, glucose, ABG/VBG, and site-specific cultures.
- 3
Antibiotics
≤ 1 hBroad-spectrum IV antibiotics within 1 h for shock or probable sepsis; do not wait for imaging. See the antibiotics topic.
- 4
Fluids: at least 30 mL/kg balanced crystalloid
0-3 hFor hypotension or lactate ≥ 4 (consider for lactate 2-4): 250-500 mL boluses over 10-15 min, reassessing after each (pulse, BP, capillary refill, lungs, POCUS). 70 kg = 2.1 L. Use actual weight; adjusted or ideal weight if BMI > 30. Stop early for crackles, rising oxygen need or no response. Balanced crystalloid over 0.9% saline (except saline in head injury). No starches or gelatin.
- 5
Noradrenaline for MAP < 65
EarlySSC 2026: bolus first, then noradrenaline if hypotension persists. In unstable shock (very low BP, mottling, ashen or cyanosed, altered mentation) start noradrenaline alongside fluid. Start peripherally through a good proximal cannula rather than wait for a central line. Target MAP 65 (keep within ~5 mmHg); aged ≥ 65: MAP 60-65.
- 6
Repeat lactate and reassess perfusion
2-4 hRepeat lactate if the first was > 2 and use the trend to guide resuscitation (SSC 2026). After the first bolus, individualise fluid: do not keep giving fluid until lactate is normal. Capillary refill time (check every 30 min) is a useful extra target (ANDROMEDA-SHOCK).
- 7
Dynamic fluid assessment
≤ 6 hGive more fluid only if fluid responsive (passive leg raise, pulse pressure or stroke volume variation, VTI change). After 30 mL/kg with ongoing hypoperfusion, a liberal or a restrictive strategy is equally acceptable (SSC 2026). Use crystalloid alone, not added albumin; albumin only case by case (after large crystalloid volumes, or cirrhosis), never in head injury.
- 8
Plan
6 hSource control plan, ICU admission within 6 h if needed, urinary catheter with hourly output, VTE prophylaxis (LMWH preferred), stress ulcer prophylaxis if at risk. Arterial line if on moderate-high or rising vasopressor doses, several vasopressors, frequent ABGs or unreliable cuff readings; otherwise cuff BP is acceptable (SSC 2026).
Initial resuscitation fluid
Balanced crystalloid (Ringer's lactate / Plasma-Lyte)
- Dose
- At least 30 mL/kg within 3 h, as 250-500 mL boluses with reassessment
- Range
- 20–30 mL/kg
- Target
- MAP ≥ 65, capillary refill ≤ 3 s, falling lactate, urine ≥ 0.5 mL/kg/h
- Worked example
- 70 kg → 2.1 L total: give 500 mL over 15 min, reassess, repeat.
SSC 2026: calculate on actual body weight, or adjusted or ideal body weight if BMI > 30; use actual weight in thin or underweight patients to avoid overload. Balanced crystalloid is suggested over 0.9% saline, except saline for sepsis with traumatic brain injury. Ringer's lactate is safe in liver disease and hyperkalaemia.
First-line vasopressor
Noradrenaline (norepinephrine)
- Dose
- 0.05-0.1 mcg/kg/min, titrate every 5-10 min
- Range
- 0.05–0.5 mcg/kg/min
- Preparation
- 4 mg in 50 mL NS (80 mcg/mL) or 8 mg in 50 mL (160 mcg/mL)
- Target
- MAP 65 mmHg (range ~65-70); 60-65 mmHg if aged ≥ 65
- Worked example
- 70 kg at 0.1 mcg/kg/min with 80 mcg/mL: 0.1 × 70 × 60 ÷ 80 = 5.25 mL/h
Hour-1 bundle elements
| Element | Detail | SSC 2026 strength |
|---|---|---|
| Measure lactate | Re-measure if > 2 mmol/L; use the trend to guide resuscitation | Conditional (measure lactate; serial lactate to guide resuscitation) |
| Blood cultures before antibiotics | As soon as possible, ideally before antibiotics; never delay antibiotics | Strong, low certainty (new in 2026) |
| Broad-spectrum antibiotics | Immediately, ideally ≤ 1 h for any septic shock or probable sepsis | Strong |
| ≥ 30 mL/kg crystalloid | For hypotension or hypoperfusion, within 3 h; reassess often | Conditional, low certainty |
| Vasopressor | Noradrenaline for MAP < 65 after the first bolus (with fluid if unstable); peripheral start is fine | Strong (noradrenaline over dopamine or adrenaline; MAP 65 target) |
SSC 2026 vs SSC 2021: what changes at the bedside
| Topic | SSC 2021 | SSC 2026 |
|---|---|---|
| Albumin | Suggested when large crystalloid volumes were given | Crystalloid alone suggested over added albumin; albumin case by case (large volumes, cirrhosis); avoid in head injury |
| MAP target | 65 mmHg | 65 mmHg, kept within ~5 mmHg; 60-65 mmHg suggested if aged ≥ 65 (new) |
| Fluid after 30 mL/kg | Insufficient evidence on restrictive vs liberal | Either liberal or restrictive, chosen for the patient and setting |
| Fluid volume in obesity | Not specified | Adjusted or ideal body weight if BMI > 30 |
| Fluid then vasopressor | Not addressed | Bolus first, vasopressor if still hypotensive; both together in unstable shock (new) |
| Gelatin | Crystalloid suggested over gelatin | Suggest against gelatin |
| Arterial line | Not addressed | Invasive or cuff BP both acceptable; arterial line for high, rising or multiple vasopressors (new) |
| Fluid removal | Insufficient evidence | Active fluid removal (diuretics, then ultrafiltration) suggested once the acute phase is over (new) |
| Fever | Not addressed | Suggest against antipyretics or cooling just to improve outcome; treating discomfort is fine (new) |
Only practice-relevant differences are listed. Strength and certainty are in the consultant notes.
Calculators for this topic
References
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First-hour resuscitation loop
Step 1 of ~6
Lactate + blood cultures ×2 + labs
Based on Prescott HC, Antonelli M, Alhazzani W, et al; Levy MM, Evans LE, Rhodes A. Educational use; follow local protocol.
Pathophysiology
Early septic hypotension combines venodilatation (less stressed volume), capillary leak, arterial vasoplegia and sometimes septic cardiomyopathy. Fluid restores stressed volume briefly, but much leaks out within an hour. Vasopressors restore venous tone and recruit unstressed volume, which is why early noradrenaline often reduces total fluid needs.
Evidence
- EGDT trials (ProCESS, ARISE, ProMISe; PRISM meta-analysis 2017): protocolised ScvO2-targeted care gave no benefit over usual early care. Early antibiotics and fluids are the active ingredients.
- 30 mL/kg: SSC 2026 still suggests at least 30 mL/kg of IV crystalloid in the first 3 h (conditional, low certainty), with frequent reassessment and adjusted or ideal body weight if BMI > 30. This differs from ESICM guidance ('up to 30 mL/kg'); SSC notes fluid harm in trials usually came with far larger volumes (> 50 mL/kg).
- Fluid then vasopressor (new, conditional, very low certainty): crystalloid bolus first, then a vasopressor if hypotension persists; concurrent vasopressor in unstable shock case by case. CLOVERS found no difference between early-vasopressor and liberal-fluid strategies; five RCTs are ongoing.
- CLASSIC (2022) and CLOVERS (2023): restrictive vs liberal fluid after initial resuscitation showed no mortality difference. SSC 2026 now suggests either strategy (conditional, low certainty), based on the patient (e.g. heart failure) and the setting (monitored beds for vasopressors).
- Active fluid removal (new): once the acute phase is over (no rising or ongoing high-dose vasopressor, no ongoing volume need), SSC 2026 suggests diuretics and, if needed, ultrafiltration (conditional, very low certainty).
- Balanced crystalloids are suggested over 0.9% saline (SSC 2026, conditional, moderate certainty; SMART: fewer major adverse kidney events), except 0.9% saline in sepsis with traumatic brain injury. Starches: recommend against (strong). Gelatin: suggest against.
- ANDROMEDA-SHOCK (2019): capillary refill-targeted resuscitation was not inferior (trend to benefit) to lactate-targeted resuscitation.
- MAP 65: SEPSISPAM found no benefit from 80-85 mmHg overall; chronic hypertensives needed less RRT at the higher target. SSC 2026 keeps the strong recommendation for 65 mmHg and adds that a range (within ~5 mmHg) is needed in practice.
- Age ≥ 65 (new, conditional, low certainty): SSC 2026 suggests MAP 60-65 mmHg. In its meta-analysis of patients ≥ 65, a lower target reduced mortality (RR 0.89, 95% CI 0.81-0.98); the 65 trial (2020) showed less vasopressor exposure with similar mortality.
- Albumin (changed in 2026): SSC 2021 suggested albumin after large crystalloid volumes. An updated meta-analysis (6 RCTs, 4,383 patients) found probably no effect on outcomes, so SSC 2026 suggests crystalloids alone over added albumin (conditional, moderate certainty). ALBIOS showed no overall mortality benefit.
- Monitoring (new): invasive or non-invasive BP both acceptable (conditional, very low certainty); EVERDAC (published after the guideline) found a non-invasive-first strategy non-inferior.
Controversies
- Fixed 30 mL/kg vs individualised fluid: SSC 2026 keeps 'at least 30 mL/kg' while ESICM says 'up to 30 mL/kg'; many intensivists give 1-2 L, then switch to dynamic measures.
- Peripheral noradrenaline: SSC 2026 still suggests starting peripherally rather than delaying (conditional, very low certainty) but sets no safe dose, duration or cannula size. Pooled complication rate ~6%. In the panel, about half use peripheral vasopressors for up to 6 h. Check the site hourly; use cautiously if frequent checks are not possible.
- Lactate clearance targets (e.g. 10-20% per 2 h) are used locally but not mandated.
🇮🇳 India notes
- Ringer's lactate is the cheapest balanced fluid and widely stocked; Plasma-Lyte costs more.
- In dengue shock, follow WHO and national dengue fluid protocols, not 30 mL/kg (module 25).
- Where arterial lines are unavailable, use non-invasive BP every 5-15 min, capillary refill and hourly urine output.
- Albumin is costly in India; the 2026 change towards crystalloid alone also saves money. Keep albumin for cirrhosis or after very large volumes.
References
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Test yourself
Module quiz · score 70% to complete the module
Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.