Search

Abstract The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

OBJECTIVES:. Although multiple organ dysfunction syndrome (MODS) is the main cause of death in patients with heat-related illnesses, its underlying pathophysiological mechanism remains elusive. Complement activation is considered one of the main causes of MODS in patients with sepsis and trauma. Considering the pathophysiological similarity of heat related-illnesses with sepsis and trauma, the complement system might be activated in patients with heat-related illnesses as well. Our aim was to investigate whether excessive complement activation occurs in patients with heat-related illnesses. DESIGN:. Prospective observational study. SETTING:. Emergency department in the university hospital. PATIENTS:. Thirty-two patients with heat-related illnesses and 15 age-matched healthy controls were enrolled in this study. INTERVENTIONS:. Blood samples were collected from the study subjects for the measurement of complement factors. MEASUREMENTS AND MAIN RESULTS:. Complement component 3a (C3a), complement component 5a (C5a), C5b-9, complement factor B (Ba), Factor H, and soluble CD59 in plasma were measured. The levels of C3a, C5a, C5b-9, and Ba significantly increased in patients with heat-related illnesses on day 0 compared with those in the healthy controls. Soluble CD59 was significantly high in patients with heat-related illnesses on day 0 and showed a correlation with the severity of the condition (Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, and staging scores), Japanese Association for Acute Medicine disseminated intravascular coagulation scores, and the coagulation system (prothrombin time and fibrin degradation products). CONCLUSIONS:. The complement system was activated in patients with heat-related illnesses, suggesting that it is one of the causes of MODS. Soluble CD59 may be a potent biomarker for the severity of heat-related illnesses.

Abstract Background The effect of corticosteroid treatment on survival outcome in early acute respiratory distress syndrome (ARDS) is still debated. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the efficacy of prolonged corticosteroid therapy in early ARDS. Methods We assessed the MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science databases from inception to August 1, 2020. We included RCTs that compared prolonged corticosteroid therapy with control treatment wherein the intervention was started within 72 h of ARDS diagnosis. Two investigators independently screened the citations and conducted the data extraction. The primary outcomes were all-cause 28- or 30-day mortality and 60-day mortality. Several endpoints such as ventilator-free days and adverse events were set as the secondary outcomes. DerSimonian-Laird random-effects models were used to report pooled odds ratios (ORs). Results Among the 4 RCTs included, all referred to the all-cause 28- or 30-day mortality. In the corticosteroid group, 108 of 385 patients (28.1%) died, while 139 of 357 (38.9%) died in the control group (pooled OR, 0.61; 95% confidence interval [CI], 0.44–0.85). Three RCTs mentioned the all-cause 60-day mortality. In the corticosteroid group, 78 of 300 patients (26.0%) died, while 101 of 265 (38.1%) died in the control group (pooled OR, 0.57; 95% CI, 0.40–0.83). For secondary outcomes, corticosteroid treatment versus control significantly prolonged the ventilator-free days (4 RCTs: mean difference, 3.74; 95% CI, 1.53–5.95) but caused hyperglycemia (3 RCTs: pooled OR, 1.52; 95% CI, 1.04–2.21). Conclusions Prolonged corticosteroid treatment in early ARDS improved the survival outcomes. Trial registration PROSPERO, CRD42020195969

Abstract Background We assessed the effect of liberal versus restrictive red blood cell transfusion strategy on survival outcome in sepsis or septic shock by systematically reviewing the literature and synthesizing evidence from randomized controlled trials (RCTs). Methods We searched the MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science databases. We included RCTs that compared mortality between a liberal transfusion strategy with a hemoglobin threshold of 9 or 10 g/dL and a restrictive transfusion strategy with a hemoglobin threshold of 7 g/dL in adults with sepsis or septic shock. Two investigators independently screened citations and conducted data extraction. The primary outcome was 28- or 30-day mortality. Secondary outcomes were 60- and 90-day mortality, use of life support at 28 days of admission, and number of patients transfused during their intensive care unit stay. DerSimonian-Laird random-effects models were used to report pooled odds ratios (ORs). Results A total of 1516 patients from three RCTs were included; 749 were randomly assigned to the liberal transfusion group and 767 to the restrictive strategy group. Within 28–30 days, 273 patients (36.4%) died in the liberal transfusion group, while 278 (36.2%) died in the restrictive transfusion group (pooled OR, 0.99; 95% confidence interval [CI], 0.67–1.46). For the primary outcome, heterogeneity was observed among the studies (I 2 = 61.0%, χ 2 = 5.13, p = 0.08). For secondary outcomes, only two RCTs were included. There were no significant differences in secondary outcomes between the two groups. Conclusions We could not show any difference in 28- or 30-day mortality between the liberal and restrictive transfusion strategies in sepsis or septic shock patients by meta-analysis of RCTs. Our results should be interpreted with caution due to the existence of heterogeneity. As sepsis complicates a potentially wide range of underlying diseases, further trials in carefully selected populations are anticipated. Trial registration This present study was registered in the PROSPERO database (CRD42018108578).

Abstract Aim The objective of this study is to identify the risk factors for cancellation after dispatch of rapid response cars (RRC) for prehospital emergency care. Methods We retrospectively extracted data from all RRC cases dispatched from our hospital between April 2017 and March 2019. A total of 1,440 cases were included in our study and divided into either the “cancelled” group (n = 723) or the “treated” group (n = 717), based on the occurrence of cancellation. The variables obtained from the request calls for RRC included patient characteristics, distance from the hospital to the scene, and reasons for RRC request. The variables were compared between the two groups and logistic regression analysis was carried out to identify the risk factors for RRC cancellation. Results Multivariable analysis showed that distance from the hospital to the scene (odds ratio [OR] 1.25; 95% confidence interval (CI), 1.21–1.28), suspicion of cardiopulmonary arrest with no witness information (OR 7.61; 95% CI, 4.13–14.00), dyspnea (OR 2.22; 95% CI, 1.19–4.11), and suicide by hanging (OR 3.49; 95% CI, 1.37–8.89) were independent risk factors for cancellation. Conclusions In our study, a greater distance from the hospital to the scene, suspicion of cardiopulmonary arrest with no witness information, dyspnea, and suicide by hanging were identified as independent risk factors for cancellation after dispatch of RRC. Evaluating the risk factors for cancellation at individual facilities could help hospitals adjust their dispatch criteria to allocate limited medical resources more effectively.

A 79-year-old female with diabetes mellitus had general fatigue, a high fever and vomiting. A CT revealed acute emphysematous pyelonephritis (EPN). A nephrectomy was performed on the 2 nd hospital day. The results of the blood culture showed the presence of Citrobacter freundii infection. The patient′s post-operative course was uneventful. This case is the second reported case of EPN induced by Citrobacter freundii. Bacteremia induced by Citrobacter freundii infection typically results in a high mortality rate. In this case, the early diagnosis of the EPN using CT and immediate medical treatment, including urgent elective nephrectomy, were key to the favorable outcome.