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Fluid Resuscitation in Septic Shock (Adults)

Fluid Resuscitation in Septic Shock (Adults): Adult Sepsis With Hypotension or Hypoperfusion → Caution: High Risk of Fluid Overload → Caution: Pregnant ...

Pathway Overview

16 steps

Algorithm Steps

16 total

  1. 01Start

    Adult Sepsis With Hypotension or Hypoperfusion

    Adults only. Hypotension (MAP <65 mmHg or systolic BP <90 mmHg), raised lactate (>2 mmol/L), or clinical hypoperfusion (mottled skin, slow capillary refill, confusion, low urine output). Start resuscitation at once.

    • Adults only. Children: use a paediatric sepsis pathway
    • Individualise the initial volume for every patient; reassess often to avoid under- or over-resuscitation
    • Hypotension or lactate ≥4 mmol/L: highest risk; get senior or ICU review now
    • Measure lactate and capillary refill within 1 hour; monitor BP, heart rate, respiratory rate and conscious state at least hourly
    • Take cultures and give antimicrobials without delay
  2. 02Warning

    Caution: High Risk of Fluid Overload

    Severe LV or RV dysfunction, severe aortic stenosis, dialysis-dependent kidney failure, or pulmonary oedema: still give fluid, but in smaller boluses and reassess after each.

    • Give 250–500 mL crystalloid per bolus, then reassess
    • Stop fluid if SpO2 falls, work of breathing rises or new crackles appear
    • Start norepinephrine early; do not wait for the full 30 mL/kg
  3. 03Warning

    Caution: Pregnant or Postpartum

    Do not give a fixed 30 mL/kg. Pre-eclampsia raises the risk of pulmonary oedema. Involve obstetrics and ICU, and use the obstetric sepsis pathway.

    • Give 500 mL crystalloid boluses; reassess after each
    • Ward: up to 20 mL/kg (max 2 L), then ICU or HDU review before more fluid
    • After 20 weeks: left lateral tilt or manual uterine displacement
  4. 04Action

    Give at Least 30 mL/kg IV Crystalloid Within 3 Hours

    Give as boluses and reassess after each. SSC 2026: conditional suggestion, low certainty. Adjust the volume to the patient.

    • Use actual body weight. BMI >30 kg/m²: adjusted or ideal body weight may be used
    • Hypotension persists after initial fluid: start norepinephrine (noradrenaline); a peripheral line is acceptable
    • Unstable shock (very low BP, mottled or ashen skin, altered mentation): start norepinephrine at the same time as fluid
    • MAP target 65 mmHg; age ≥65 years: 60–65 mmHg
  5. 05Action

    Fluid Type: Balanced Crystalloid (Not in Head Injury)

    Suggest balanced crystalloid over 0.9% saline. Traumatic brain injury: use 0.9% saline and do not give albumin.

    • Compound sodium lactate (Hartmann's) or Plasma-Lyte 148; 0.9% saline is acceptable
    • Do not use starch (HES); avoid gelatin
    • Crystalloid alone is preferred over added albumin
    • Albumin may suit patients with cirrhosis or after large crystalloid volumes (not in brain injury)
  6. 06Decision

    Hypotension or Hypoperfusion Persists After Initial Fluid?

    Reassess after each bolus: MAP, heart rate, capillary refill, mentation, urine output, lactate trend.

  7. If Yes
    1. 07Action

      Persistent Hypoperfusion: Look for the Cause

      Hypoperfusion or hypotension persists after initial fluid. Start norepinephrine now if MAP is below target.

      • Check source control (drain, debride or remove infected device)
      • Consider other causes of shock: cardiac, bleeding, obstruction (PE, tamponade)
      • Echocardiography if available: LV or RV dysfunction
      • Consider an arterial line; repeat lactate
    2. 08Action

      Persistent Hypoperfusion: Test Fluid Responsiveness

      Use dynamic measures, not examination or static measures (such as CVP) alone.

      • Passive leg raise or a fluid challenge with stroke volume or pulse pressure response
      • Stroke volume or pulse pressure variation (valid only with controlled ventilation and a regular rhythm)
      • Trend capillary refill time and lactate
    3. 09Decision

      Fluid Responsive?

      Stroke volume or pulse pressure rises after passive leg raise or a fluid challenge.

    4. If Yes
      1. 10Decision

        Fluid Responsive: Signs of Fluid Overload?

        A positive test does not mean the patient needs fluid. Overload: new hypoxaemia, crackles, rising oxygen need, worsening oedema or raised abdominal pressure.

      2. If Yes
        1. 11Action

          Overloaded: Stop Fluid, Start or Increase Norepinephrine

          Fluid responsive but overloaded: give no more fluid. Norepinephrine is first line; target MAP 65 mmHg (age ≥65 years: 60–65 mmHg).

          • Escalate vasopressors as in the 'Not Fluid Responsive' step
          • Seek ICU review
          • After the acute phase: consider active fluid removal (diuretics)
        2. 12Outcome

          Ongoing Septic Shock: ICU Care

          Continue vasopressors and reassess fluid status often. After the acute phase, consider active fluid removal.

        If No
        1. 13Action

          Fluid Responsive, No Overload: Give Further Bolus

          Give a further balanced crystalloid bolus and reassess. SSC 2026: a liberal or a restrictive strategy is acceptable; individualise.

          • 250–500 mL bolus, then reassess perfusion
          • Stop when no longer fluid responsive or overload appears
          • Do not give fluid only to make lactate normal
          • Head injury: use 0.9% saline
          • Heart failure, dialysis or pregnancy: smaller boluses, lower threshold for norepinephrine
        2. Path rejoins step 06Shared downstream outcome
      If No
      1. 14Action

        Not Fluid Responsive: Start or Increase Vasopressors

        Norepinephrine is first line. Do not delay for a central line. Target MAP 65 mmHg (age ≥65 years: 60–65 mmHg).

        • Norepinephrine dose rising: add vasopressin
        • MAP still low on norepinephrine and vasopressin: add epinephrine (adrenaline)
        • Norepinephrine need persists: IV hydrocortisone, with or without fludrocortisone
        • Cardiac dysfunction with hypoperfusion: add dobutamine or use epinephrine
        • Doses: see septic shock vasopressor pathway or local ICU protocol
      2. Path rejoins step 12Shared downstream outcome
    If No
    1. 15Action

      Perfusion Restored: Stop Routine Fluid

      MAP at target, lactate falling, capillary refill and mentation improving. Give more fluid only if hypoperfusion returns.

      • Keep monitoring BP, heart rate, urine output and lactate
      • Continue antimicrobials and source control
      • Check fluid balance each day
      • After the acute phase: consider active fluid removal if overloaded
    2. 16Outcome

      Adequately Resuscitated

      Perfusion restored. Avoid further fluid unless hypoperfusion returns. Check fluid balance daily.

Guideline Source

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026

DOI: 10.1097/CCM.0000000000007075View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Adults only. Children and neonates need a paediatric sepsis pathway.
  • The 30 mL/kg volume is a conditional, low-certainty suggestion. Individualise it in heart failure, severe aortic stenosis, dialysis or pulmonary oedema.
  • Pregnancy: only a brief caution is given; use the obstetric sepsis pathway. Does not cover burns, or cardiogenic, haemorrhagic or obstructive shock.
  • Vasopressor and corticosteroid doses are not given here; see the septic shock vasopressor pathway.
  • Local protocols may differ.

Contraindicated Populations

pediatricneonatal

Applicable Regions

USEUGlobalAU

AU: Balanced crystalloids available: compound sodium lactate (Hartmann's) and Plasma-Lyte 148. The ANZ PLUS trial (2022) found no mortality difference between Plasma-Lyte 148 and 0.9% saline.

Global: Surviving Sepsis Campaign 2026 adult guidelines (SCCM/ESICM).

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Fluid Resuscitation in Septic Shock (Adults)?

The Fluid Resuscitation in Septic Shock (Adults) is a management clinical algorithm for Critical Care. It provides a structured decision tree to guide clinical decision-making, based on Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026.

What guideline is the Fluid Resuscitation in Septic Shock (Adults) based on?

This algorithm is based on Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (DOI: 10.1097/CCM.0000000000007075).

What are the limitations of the Fluid Resuscitation in Septic Shock (Adults)?

Known limitations include: Adults only. Children and neonates need a paediatric sepsis pathway.; The 30 mL/kg volume is a conditional, low-certainty suggestion. Individualise it in heart failure, severe aortic stenosis, dialysis or pulmonary oedema.; Pregnancy: only a brief caution is given; use the obstetric sepsis pathway. Does not cover burns, or cardiogenic, haemorrhagic or obstructive shock.; Vasopressor and corticosteroid doses are not given here; see the septic shock vasopressor pathway.; Local protocols may differ.. Individual patient factors may require deviation from these recommendations.

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