Sepsis 2026: When Better Blood Pressure Isn't Enough | Part 3

Better blood pressure does not answer every question about perfusion. Part 3 of our Sepsis 2026 series examines initial fluids, MAP targets, arterial monitoring, dynamic assessment, lactate and capillary refill, vasopressors, cardiac dysfunction and inotropes. We connect SSC recommendations with the populations, outcomes and uncertainty in major trials, using original source figures and tables alongside clinical illustrations. Learn how to distinguish fluid responsiveness from fluid need and tolerance, interpret neutral strategy trials, and reassess the mechanism of persistent hypoperfusion. Recommendation strength, evidence certainty and later trial updates are identified separately. Presented by Stefan Porubcin, MD, PhD, Associate Professor of Internal Medicine. The Evidence Explained — Beyond the abstract. From trial to practice. CHAPTERS 00:00 The Evidence Explained 01:21 Practice Check: strength and certainty 01:59 The original hemodynamic map 02:36 Initial fluids and repeated reassessment 03:18 Choose an initial pressure target 03:36 An arterial line is a clinical decision 04:18 EVERDAC: a strategy with rescue monitoring 05:03 Fluid choice 05:49 Balanced fluids: the SMART sepsis analysis 06:39 Albumin: no routine survival benefit established 07:18 CLOVERS: what was actually randomized? 08:03 ARISE FLUIDS: early vasopressors or more fluid? 08:46 Will flow increase if we give fluid? 09:33 FRESH: fluid balance after dynamic assessment 10:22 Responsiveness, need, and tolerance 11:06 Lactate in clinical context 11:47 Capillary refill adds bedside information 12:34 ANDROMEDA-SHOCK-2: a treatment package 13:13 Return to the pressure branch 13:52 Norepinephrine and timely vascular access 15:05 Add vasopressin when norepinephrine escalates 15:53 VASSPR: a new timing trial 16:49 Epinephrine: escalation with context 17:30 Persistent hypoperfusion: look at the pump 18:20 What cardiac-output monitoring can resolve 18:55 Rescue therapies and evidence gaps 19:38 Beta blockade as septic-shock treatment 20:20 Back to our patient 21:03 What changes at the bedside? 21:56 Sources and scope PRIMARY GUIDELINE Prescott HC, Antonelli M, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026. Intensive Care Medicine. 2026;52:863–936. https://doi.org/10.1007/s00134-026-08... Methods supplement SDC1 and hemodynamic evidence supplement SDC5 accompany the guideline. SELECTED PRIMARY EVIDENCE EVERDAC — noninvasive versus invasive arterial-pressure monitoring in shock. NEJM. 2025. https://doi.org/10.1056/NEJMoa2502136 SMART sepsis secondary analysis — Balanced Crystalloids versus Saline in Sepsis. AJRCCM. 2019. https://doi.org/10.1164/rccm.201903-0... ALBIOS — Albumin Replacement in Patients with Severe Sepsis or Septic Shock. NEJM. 2014. https://doi.org/10.1056/NEJMoa1305727 CLOVERS — Shapiro NI, Douglas IS, Brower RG, et al. Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension. N Engl J Med. 2023;388:499–510. https://doi.org/10.1056/NEJMoa2212663 ARISE FLUIDS Investigators — early vasopressors versus more fluid in septic shock. NEJM. 2026. https://doi.org/10.1056/NEJMoa2516225 FRESH — Fluid Response Evaluation in Sepsis Hypotension and Shock: A Randomized Clinical Trial. Chest. 2020. https://doi.org/10.1016/j.chest.2020.... ANDROMEDA-SHOCK-2 — personalized hemodynamic resuscitation targeting capillary refill time. JAMA. 2025. https://doi.org/10.1001/jama.2025.20402 SOAP II — Comparison of Dopamine and Norepinephrine in the Treatment of Shock. NEJM. 2010. https://doi.org/10.1056/NEJMoa0907118 VASST — Vasopressin versus Norepinephrine Infusion in Patients with Septic Shock. NEJM. 2008. https://doi.org/10.1056/NEJMoa067373 VASSPR — vasopressin initiation timing in septic shock. JAMA. 2026. https://doi.org/10.1001/jama.2026.21333 STRESS-L — Landiolol and Organ Failure in Patients With Septic Shock. JAMA. 2023. https://doi.org/10.1001/jama.2023.20134 Educational analysis for clinicians. Decisions require the patient's circumstances, local resources and clinical judgment. Illustrative cases are not patient records. Selected primary studies and guideline supplements were reviewed; separate disclosure forms and all trial supplements were not comprehensively reviewed.