In summary, qSOFA should not be used as a single screening tool for sepsis. NEWS, MEWS, or SIRS may be more beneficial at this time.

2. Lactate clearance and capillary refill time (CRT)

Most institutions are beginning to transition to electronic health record-generated order sets for sepsis when it is suspected by the practitioner; however, the “necessary” labs to obtain have varied by clinical center. Specifically, lactate clearance has been a debatable topic since its inception. The SSC guidelines for 2021 weakly recommended measuring blood lactate and, if elevated (defined as ≥4 mmol/L), guiding resuscitation by a decrease in its value over time.⁷ The ANDROMEDA-SHOCK study evaluated whether targeting resuscitation towards a CRT versus lactate clearance led to a reduced mortality at 28 days; ultimately, there was no detectable difference. The CRT group’s mortality rate was 34.9 percent versus 43.4 percent in the lactate group.⁹ A concern raised with both strategies was whether volume overload and its early recognition was key to preventing further complications as a result of over-resuscitation. ACEP’s own clinical policy does not recommend the use of serum lactate levels to guide ongoing IV fluid resuscitation, as it has not been found to be an accurate marker of ongoing fluid needs.¹⁰

In summary, there is no good “endpoint” guiding resuscitation in septic shock, but CRT or lactate clearance can be considered.

3. Intravenous fluids

One of the greatest controversies in the care of sepsis has been intravenous fluid management during the acute stages of septic shock. For patients in septic shock or exhibiting signs of hypoperfusion, SSC guidelines weakly recommend at least 30 mL/kg of intravenous crystalloid within the first three hours of resuscitation.⁷ The current fluid recommendation is a balanced crystalloid, with lactated ringers being superior to normal saline.⁵ The CLOVERS trial investigated conventional fluid resuscitation versus early vasopressor use and intravenous fluid restriction, with the conventional group receiving approximately 3.8 L and the fluid restriction group receiving 1.8 L. Researchers concluded that at 90 days, mortality and adverse events of the aforementioned volumes were similar between the two groups.¹¹ Notably, ACEP’s clinical policy does not endorse an empirical fluid bolus but, rather, individualized fluid resuscitation needs for each patient.¹⁰ The judicious amount of intravenous fluids cited by the SSC should also be liberalized for patients with clinical findings of volume overload or a known reduced ejection fraction.

In summary, the current recommendation is 30 mL/kg of lactated ringers within the first three hours of resuscitation, with the caveat of utilizing clinical judgment to prevent fluid overload.