Surviving Sepsis Campaign

How do we make this a more global issue? We are doing this at an institutional level in terms of educating families and patients what PIX-P is, but at a global level.

And I'm thinking about, you know, the surviving sepsis campaign.

You know, there are a lot more patients who are critically ill who suffer from this than, you know, those who have sepsis.

How do we get there? How do we educate about this globally?

So that once we start to generate the evidence base, that will help expedite and understand, you know, what does PICS-P look like in that context and thinking about wider social determinants of health that may be very different to the high resource contexts.

So I think that's really important and we really need to continue to move as a global collective in generating a universal evidence base as opposed to just one that's polarised to one end or the other.

I think the other thing is around how do we integrate this as an agenda on other things? And so, you know, as you know, because you were the methodologist that led the section for the Surviving Sepsis Campaign book, it's about how do we integrate this within society? other guidelines which were global and which are extensively used um so i think i think that's a way in which we can get pixp onto um the you know profile rays and onto the agenda and into people's understanding psyche and hopefully that will then proliferate down into education training and practice but i don't think it's a single you know We'll do this.

And then it becomes embedded that we have to sort of divide and conquer with PIXP.

What about the evidence? Well, there's been a whole bunch of studies and guidelines on norepinephrine.

The Surviving Sepsis Campaign, which is one of the guidelines we look to for septic shock data, recommends norepinephrine as a first-line vasopressor in septic shock.

This is fairly universal.

We are not personally aware of any guidelines that suggest something other than norepinephrine as a first-line vasopressor in septic shock.

did publish their trial design just to gain commentary on whether or not it would be feasible to evaluate a restrictive versus liberal fluid management approach in emergency department patients.

And then moving forward into 2022 and 2023, those are two trials I would like to briefly touch on a bit further that ultimately led up to our recent guideline update, the Surviving Sepsis Campaign.

So in 2022,

there was the classic trial.

This also did not find, or the investigators also did not find, that there was a difference when it came to mortality between these two groups.

And they particularly looked at the time before discharge home by day 90.

So with all that being said, looking at those few different trials I mentioned up until the recent publication of the surviving sepsis campaign update earlier this year, we do know a few different things.

So the timing of fluid resuscitation, we can all agree upon.

What about the evidence? Well, there's been a whole bunch of studies and guidelines on norepinephrine.

The Surviving Sepsis Campaign, which is one of the guidelines we look to for septic shock data, recommends norepinephrine as a first-line vasopressor in septic shock.

This is fairly universal.

We are not personally aware of any guidelines that suggest something other than norepinephrine as a first-line vasopressor in septic shock.

Bradycardia with hypotension might be a nice drug, but remember this is at those low doses, right? Because you just want that beta-1 effect somewhere on that 0.01 to 0.05 micrograms per kilogram per minute.

And then sometimes post-cardiopulmonary bypass, it's used because it has that inotropic with that beta-1 effect and that vasoconstrictive alpha-1 effect as a vasopressor.

What evidence and guidelines do we have on epinephrine? Well, the Surviving Sepsis Campaign recommends epinephrine as a second or third line agent for septic shock after you've already started norepinephrine and vasopressin.

It can cause tachycardia, tachydysrhythmias, elevated lactate levels, all reasons that it is not first line in the eyes of the striving sepsis campaign.

That hypothesis has been supported by physiologic data by some adult studies, although pediatric evidence before prompt bolus was limited and inconsistent.

The 2026 Surviving Sepsis Campaign pediatric guidelines recommended crystalloids over albumin for initial resuscitation and conditionally suggest balanced or buffered crystalloids over 0.9% saline in children with septic shock who require fluid boluses.

Importantly, that recommendation is based on very low certainty evidence.

Balance options, again, include lactated ringers, Hartman's solution, or plasmalite.

At the same time, the largest pediatric randomized trial now shows no improvement in major kidney or mortality outcomes compared with normal saline.

So if you use saline at your local hospital, that's okay too.

The 2026 Surviving Sepsis Campaign still conditionally favors balanced crystalloids, but that recommendation is based on very low certainty evidence.

So prompt bolus adds important randomized data suggesting that for most children with septic shock, either crystalloid strategy is reasonable.