Reviewing The Latest Surviving Sepsis Guidelines Updates By Dr Brit Long From EM Quick Hits 36 March 2022

In this post, I review the 2021 Surviving Sepsis Guidelines Update podcast notes By Dr Brit Long From EM Quick Hits 36. This section of the podcast is from 0:38 – 11:58. This is the link to the complete podcast.

A. EM Quick Hits 36 – Surviving Sepsis, Angle Closure Glaucoma, Bougies, Frostbite, Hot/Altered Patient, Central Cord Syndrome. Emergency Medicine Cases. March 2022. 3-6-2022.

Here are the notes from the above section of the podcast.

Surviving Sepsis Campaign: 2021 Updates relevant to EM

Screening for Sepsis

  • New guidelines recommend against using qSOFA as a single screening agent
  • Commentary: NEWS score is likely a better single screening tool that is easy to use and can be done at triage


  • Fluids
    • Guidelines now only suggest rather than recommend using 30 cc/kg of IV crystalloid within the first 30 minutes of resuscitation
    • Balanced crystalloids such as Plasmalyte and Lactated Ringer’s recommended as a first line over normal saline
  • Vasopressors
    • In most patients, norepinephrine is the first-line vasopressor, followed by vasopressin, then epinephrine
    • In patients with cardiac dysfunction, use norepinephrine as first line then dobutamine or epinephrine alone
    • In septic shock resistant to vasopressors, guidelines now support using IV hydrocortisone
  • Monitoring resuscitation
    • Use dynamic parameters (e.g. passive leg raise, stroke volume/pulse pressure variation, ultrasound) rather than using static parameters
    • Point-of-care ultrasound can be used to assess volume status (IVC, B-lines, cardiac activity)
    • For patients in septic shock, target a MAP of 65 mmHg
    • Adjunctive markers: use capillary refill, lactate to guide resuscitation
  • Antimicrobial therapy
    • In patients with possible sepsis without shock, consider investigating for other causes for up to 3 hours before starting antimicrobial therapy (adjusted from 1 hour from previous guidelines)
    • Choice of antimicrobials in the empiric phase
      • High risk of multi-drug resistant organisms: 2 agents with gram negative coverage
      • Low risk of multi-drug resistant organisms: 1 agent with gram negative coverage
      • High risk of MRSA: provide coverage for MRSA (eg. vancomycin)
      • No risk factors for MRSA: no routine MRSA coverage
  • Other
    • IV vitamin C is not recommended in septic shock

Airway and ventilation

  • High-flow nasal cannula (HFNC): in sepsis-induced hypoxemic respiratory failure, HFNC is recommended over non-invasive positive pressure ventilation
  • Intubation: low tidal volume strategy and upper plateau pressure of 30 cm H2O; in ARDS, consider using higher PEEP
  • V-V ECMO can be considered if conventional mechanical ventilation fails

Episode 122 Sepsis and Septic Shock – What Matters from EM Cases Course with Sara Gray


  1. Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-e1143.
  2. Evans L, Rhodes A, Alhazzani W, et al. Executive Summary: Surviving Sepsis Campaign: International Guidelines for the Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021 Nov 1;49(11):1974-1982.
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