The Japanese Guidelines for the Management of Sepsis

Sepsis Registry

1

Sepsis Registry

Royal Brisbane and Women's Hospital, Department of Intensive Care

Medicine The University of Queensland, UQ Centre for Clinical Research

2

COI

http://www.jsicm.org/pdf/COI..pdf

2012 11 6

3

4

6

1. 9

2. 14

3. 17

4. 36

5. 39

6. 48

7. 56

8. 60

9. 72

10. DIC 79

11. 88

12. 100

13. 106

109

4

Surviving Sepsis Campaign guidelines (SSCG) critical care

2004 [1]

2008 [2] 2

2012 Society of Critical Care Medicine, Annual Meeting

2008

SSCG randomized controlled

trial: RCT severe sepsisseptic shock

SSCG

[3,4]

innate immunity cytokine

RCT

RCT

SSCG RCT

sepsis

humoral mediator continuous

hemodiafiltration (CHDF) SSCG

proinflammatory cytokine high mobility group box 1 protein (HMGB1)

severe sepsis, septic shock

RCT

critical care RCT

[5]Sepsis Registry

severe sepsis, septic shock

SSCG

infection-induced

SIRS severe sepsis, septic shock

[6]SSCG 2

severe sepsis, septic shock sepsis

2

critical care sepsis severe sepsis

5

1. Dellinger RP, Cartlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for

management of severe sepsis and septic shock. Crit Care Med 2004;32:858-72.

2. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International guidelines

for management of severe sepsis and septic shock: 2008. Crit Care Med 2008;36:296327.

3. Revise Surviving Sepsis Campaign Guidelines

2008;5:301-11.

4. Surviving Sepsis Campaign Guidelines

2009;43:161-5.

5. Vincent JL. We should abandon randomized controlled trials in the intensive care unit. Crit

Care Med 2010;38:S534-8.

6. Vincent JL. Dear SIRS, I'm sorry to say that I don't like you... Crit Care Med 1997;25:372-4.

6

Sepsis Registry

EBM

Sepsis Registry 1

2007 10 1 12 31 47 226 2

2009 10 1 2010 3 31 39 310

2000 PubMedMedline(Ovid)Cochran Database

of Systematic Reviews sepsissevere sepsisseptic shock

Web

RCT

RCT RCT

13

CQ

3-5

1

CQ

SSCG2008[1-3]

2011 [4]

A RCT

B RCT

C

D

1 100 RCT1000

7

RCT Sepsis

Registry

SSCG2008 GRADE

2

2

GRADE A

A

GRADE B

A

GRADE C

B

GRADE D

C

CQ

answer: A 2 GRADE

3

4

8

*

1. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International guidelines

for management of severe sepsis and septic shock: 2008. Crit Care Med 2008;36:296-327.

2. GRADE working group. Grading quality of evidence and strength of recommendations. BMJ

2004;328:1490-8.

3. Guyatt G, Gutterman D, Baumann MH, et al. Grading strength of recommendations and quality

of evidence in clinical guidelines: report from an American College of Chest Physicians task

force. Chest 2006;129:174-81.

4.

2011 2012;29:75-120.

9

CQ1

A1

sepsis

systemic inflammatory response syndrome: SIRS infection-induced

SIRS SIRS 4 2

1C

1 3836

2 90 /

3 20 / PaCO232Torr

4 12,000mm3 4,000mm3

band10

1C

(1C)

38

36

90/2SD

20 /

24 20mL/kg

120mg/dL

WBC12000/L

WBC4000/L

10%

CRP 2.0mg/dL*

0.5ng/mL, 2.0ng/mL

IL-6 ( 1,000pg/mL*)

90mmHg 70mmHg

40mmHg SD

10

PaO2/FIO2300

0.5mL/kg/hr

Cre 0.5mg/dL

PT-INR1.5 aPTT60

100,000/L

T-Bil4mg/dL

2mmol/L

*

1989 Bone sepsis syndrome [1]

1991 Society of Critical Care Medicine (SCCM)/American College of

Chest Physicians (ACCP)1992

[2]

SIRS

10

SCCM/ESICM/ACCP/ATS/SIS 2003

[3]infection-induced SIRS

Weiss

[4] 2003

1992

1992

( Clostridium difficile

)2003

CDC[5]International Sepsis

Forum (ISF)[6]

1. Bone RC, Fisher Jr CJ, Clemmer TP, et al. Sepsis syndrome: A valid clinical entity. Crit Care

Med 1989;17:389-93.

2. Members of the American College of Chest Physicians/ Society of Critical Care Medicine

11

consensus conference committee. American College of Chest Physicians/ Society of Critical

Care Medicine Consensus Conference: Definitions for sepsis and organ failure and guidelines

for the use of innovative therapies in sepsis. Crit CareMed 1992;20:864-74.

3. Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International

Sepsis Definitions Conference. Crit Care Med 2003;31:1250-6.

4. Weiss M, Huber-Lang M, Taenzer M, et al. Different patient case mix by applying the

2003SCCM/ESICM/ACCP/ATS/SIS sepsis definitions instead of the 1992ACCP/SCCM

sepsis definitions in surgical patients: a retrospective observational study. BMC Med Inform

Decis Mak 2009;9:25.

5. Garner JS, Jarvis WR, Emori TG, et al. CDC definitions for nosocomial infections, 1988. Am J

Infect Control 1988;16:128-40.

6. Calandra T, Cohen J, for the International Sepsis Forum Definition of Infection in the ICU

Consensus Conference. The international sepsis forum consensus conference on definitions

of infection in the intensive care unit. Crit Care Med 2005;33:1538-48.

CQ2severe sepsis

septic shock

A2

(1C)

SOFA

1C

90mmHg 40mmHg

1C

1992 severe sepsisseptic shock

[1,2]2003

Marshall MODS [3]

ESICM SOFA [4]

Rivers early

goal-directed therapy[5]Bernard C [6]Annane

[7]

1. Moreno RP, Metnitz B, Adler L, et al. Sepsis mortality prediction based on predisposition,

infection and response. Intensive Care Med 2008;34:496-504.

2. Silva E, Pedro MdeA, Sogayar AC, et al. Brazilian sepsis epidemiological study (BASES study).

Crit Care 2004;8:R251-60.

3. Marshall JC, Cook DJ, Christou NV, et al. Multiple organ dysfunction score: a reliable

descriptor of a complex clinical outcome. Crit Care Med 1995;23:1638-52.

12

4. Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ Failure Assessment)

score to describe organ dysfunction/failure. Intensive Care Med 1996;22:707-10.

5. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe

sepsis and septic shock. N Engl J Med 2001;345:1368-77.

6. Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and safety of recombinant human

activated protein C for severe sepsis. N Engl J Med 2001;344:699-709.

7. Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of

hydrocortisone and fludrocortisones on mortality in patients with septic shock. JAMA

2002;288:862-71.

CQ3

A3CRPIL-6

(1C)

170

[1,2]

CRP

IL-6

6SIRS

IL-6 6 CRP PCT

IL-6IL-6 2448

IL-6 SIRS IL-6

[3-5]

[6] 2006

[7]

CRPPCTIL-6

IL-6

FDA endotoxin activity assay (EAA)

[8]

1. Pierrakos C, Vincent JL. Sepsis biomarkers: a review. Crit Care 2010;14:R15.

2. Van den Bruel A, Thompson MJ, Haj-Hassan T, et al. Diagnostic value of laboratory tests in identifying serious infections in febrile children: systematic review. BMJ 2011;342:d3082.

3. Oda S, Hirasawa H, Shiga H, et al. Sequential measurement of IL-6 blood levels in patients

13

with systemic inflammatory response syndrome (SIRS)/ sepsis. Cytokine 2005;29:169-75.

4. Abe R, Oda S, Sadahiro T, et al. Gram-negative bacteremia induces greater magnitude of inflammatory response than Gram-positive bacteremia. Critical Care 2010;14:R27.

5. Herzum I, Renz H. Inflammatory markers in SIRS, sepsis and septic shock. Curr Med Chem 2008;15:581-7.

6. Luzzani A, Polati E, Dorizzi R, et al. Comparison of procalcitonin and C-reactive protein as markers of sepsis. Crit Care Med 2003;31:1737-41.

7. Tang BMP, Eslick GD, Craig JC, et al. Accuracy of procalcitonin for sepsis diagnosis in critically ill patients: systematic review and meta-analysis. Lancet Infect Dis 2007;7:2107.

8. Marshall JC, Foster D, Vincent JL, et al. Diagnostic and prognostic implications of endotoxemia in critical illness: Results of the MEDIC study. J Infect Dis 2004;190:527-34.

SCCM: Society of Critical Care Medicine

ACCP: American College of Chest Physicians

ESICM: European Society of Intensive Care Medicine

ATS: American Thoracic Society

SIS: Surgical Infection Society

CDC: Center for Disease Control and Prevention

MODS: multiple organ dysfunction score

SOFA: sequential organ failure assessment

14

CQ1?

A1

1D

(1D)

/

[1]

bronchoalveolar

lavage fluid: BALF