Surgical Source Control in Adult Sepsis (SSC 2026): Adult with sepsis: find and control the source → Do not delay source control for prolonged stabilisa...
Pathway Overview
20 steps
20 total
Adults with sepsis or septic shock and a possible focus that needs a procedure. Children: use paediatric sepsis guidance. Give antibiotics now, ideally within 1 h, and resuscitate; do not wait for imaging or the procedure.
Aim for source control ideally within 6 h of the diagnosis (SSC 2026). In septic shock, resuscitate during the procedure, not only before it.
Ask about pain site, recent surgery, lines, drains, catheters and implants. Examine all lines, wounds and skin. Image by the likely site. Pregnant or postpartum: do not withhold needed imaging (ultrasound or MRI first if they answer the question) and involve obstetrics for retained products or chorioamnionitis.
Collection or obstruction, dead tissue, infected device, perforation or ischaemic bowel, or no source that needs a procedure.
Abscess (abdomen, pelvis, liver, soft tissue), empyema, septic joint, infected obstructed kidney or cholangitis. Cystic liver lesion with rural or overseas exposure: exclude a hydatid cyst before drainage (anaphylaxis risk).
Infected or suspected infected pancreatic or peripancreatic necrosis follows a different timing from all other sources.
Stable: give antibiotics that reach the necrosis and delay any drainage or necrosectomy, preferably 4 weeks, until the collection is walled off. Early open necrosectomy increases mortality.
These change how and where the procedure is done. They must not delay emergency surgery for a life-threatening source.
Choose the least invasive option that will control the source: percutaneous or endoscopic in preference to open surgery when it can work. Consider stability, anatomy and local expertise.
Examples: image-guided abscess drain, ERCP for cholangitis, nephrostomy or stent for an obstructed kidney, chest drain for empyema.
Continue resuscitation and antibiotics. Send samples for culture and narrow antibiotics to the results. With adequate source control, prefer a shorter antibiotic course.
Look at fever, haemodynamics, lactate, organ function and drain output.
Continue antibiotics for a short course guided by the source and clinical response. Monitor for recurrence.
Suspect inadequate source control or a second source. Repeat imaging, review drains, and discuss repeat drainage or surgery with the senior surgeon now.
For perforation, bowel ischaemia, necrotising infection, diffuse peritonitis, failed drainage, or when no other option is available in time. Remove dead tissue and control contamination.
Not pancreatic necrosis: aim for source control as early as possible, ideally within 6 h of diagnosis. Resuscitate during and after the procedure.
Necrotising soft tissue infection (including Fournier's gangrene) or gas gangrene: emergency surgical debridement now. Exception: infected pancreatic necrosis is not debrided early (see timing step).
Free perforation with generalised peritonitis, non-viable bowel or uncontained leak: surgery now (repair, resection or diversion). Unstable: damage control laparotomy. Stable with a contained leak or localised abscess: percutaneous drainage may be enough.
Remove an intravascular access device that may be the source promptly, after other vascular access is in place. Do not remove the only access in septic shock before new access works.
Continue antibiotics and resuscitation. Re-examine and re-image if the patient does not improve or a source becomes likely.
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (adults)
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
Contraindicated Populations
Applicable Regions
AU: Follow local sepsis pathways (for example the Victorian Adult Sepsis Pathway) and Therapeutic Guidelines: Antibiotic for drug choice. Rural and remote sites: early retrieval for source control that cannot be done locally.
Global: Surviving Sepsis Campaign 2026 adult guidelines (SCCM/ESICM).
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The Surgical Source Control in Adult Sepsis (SSC 2026) is a emergency clinical algorithm for General Surgery. 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 (adults).
This algorithm is based on Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (adults) (DOI: 10.1097/CCM.0000000000007075).
Known limitations include: Timing target (ideally within 6 h) is a conditional recommendation on very low certainty evidence; senior surgical judgement decides; Infected pancreatic necrosis follows a delayed step-up approach and needs pancreatic-centre input; Choice of procedure depends on local interventional, endoscopic and surgical expertise; Adults only; children follow the SSC 2026 paediatric guideline; Does not give antibiotic choices or doses; use local sepsis and antibiotic guidelines. Individual patient factors may require deviation from these recommendations.
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