Sepsis 2026: What Should You Add and Avoid? | Part 5

The antibiotics are running and source control is addressed—but the patient is still in shock. What should you add? The final part of our Sepsis 2026 series examines adjunctive and supportive therapies in adults. We connect Surviving Sepsis Campaign recommendations 79–99 with the major trials: corticosteroids, fever control, vitamin C, blood purification, prevention of complications, fluid removal, transfusion, nutrition, glucose management and kidney support. We distinguish recommendation strength from certainty of evidence, faster shock resolution from survival, and a treatment indication from a numerical target. BICARICU-2 and TIGRIS are discussed as later evidence updates, separately from the guideline recommendations. Their populations, outcomes and limitations matter. Presented by Stefan Porubcin, MD, PhD. The Evidence Explained — Beyond the abstract. From trial to practice. CHAPTERS 00:00 Opening 00:30 The guideline and this final chapter 00:46 Corticosteroids and the major trials 02:50 Applying the steroid evidence 03:30 Fever and outcome-driven suppression 04:08 Vitamin C and LOVIT 05:05 IVIG and vitamin D 05:38 Blood purification 06:27 TIGRIS later evidence update 07:30 XueBiJing and jurisdiction 08:09 GI bleeding prevention and REVISE 09:21 Probiotics 09:58 Fluid removal after resuscitation 10:46 Transfusion and TRISS 11:23 Early enteral nutrition 11:40 When to start insulin 12:10 Kidney support and STARRT-AKI 13:26 Bicarbonate indications 14:15 BICARICU-2 later evidence update 15:12 Venous thromboembolism prevention 15:48 Putting the recommendations together 16:31 Sources and clinical context SOURCES Prescott HC, Antonelli M, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026. Intensive Care Med. 2026;52:863–936. https://doi.org/10.1007/s00134-026-08... Venkatesh B, et al. Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. N Engl J Med. 2018;378:797–808. https://doi.org/10.1056/NEJMoa1705835 Annane D, et al. Hydrocortisone plus Fludrocortisone for Adults with Septic Shock. N Engl J Med. 2018;378:809–818. https://doi.org/10.1056/NEJMoa1705716 Lamontagne F, et al. Intravenous Vitamin C in Adults with Sepsis in the Intensive Care Unit. N Engl J Med. 2022;386:2387–2398. https://doi.org/10.1056/NEJMoa2200644 Cook D, et al. Stress Ulcer Prophylaxis during Invasive Mechanical Ventilation. N Engl J Med. 2024;391:9–19. https://doi.org/10.1056/NEJMoa2404245 Holst LB, et al. Lower versus Higher Hemoglobin Threshold for Transfusion in Septic Shock. N Engl J Med. 2014;371:1381–1391. https://doi.org/10.1056/NEJMoa1406617 STARRT-AKI Investigators. Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury. N Engl J Med. 2020;383:240–251. https://doi.org/10.1056/NEJMoa2000741 Jung B, et al. Sodium Bicarbonate for Severe Metabolic Acidemia and Acute Kidney Injury: The BICARICU-2 Randomized Clinical Trial. JAMA. Published online October 29, 2025. https://doi.org/10.1001/jama.2025.20231 Neyra JA, et al. Polymyxin B haemoadsorption in endotoxic septic shock (Tigris): a multicentre, open-label, Bayesian, randomised, controlled, phase 3 trial. Lancet Respir Med. 2026;14:443–452. https://doi.org/10.1016/S2213-2600(26... Educational analysis for clinicians. Clinical decisions require individual assessment and applicable local practice. Conceptual medical illustrations are teaching aids, not patient records. #Sepsis #CriticalCare #EvidenceBasedMedicine