A case of multiple organ injury resuscitated by collaboration of damage control surgery and interventional radiology in hybrid emergency room.

Background: Hybrid emergency room systems, namely hybrid ER (HER), enable us to perform computed tomography (CT), surgery, and interventional radiology (IVR) without patient transfer. HER significantly shortened the time to CT after arrival and allowed us to achieve early intervention, resulting in reduced mortality from exsanguination in patients with severe blunt trauma. Case Presentation: We encountered a patient diagnosed with left common iliac artery occlusion and dissection caused by blunt traumatic compressive abdominal injury with transection of the small intestine, kidney, and adrenal and pelvic ring fractures. Although the patient experienced cardiopulmonary arrest (CPA) immediately after CT, we performed damage control surgery (DCS) and IVR after temporary aortic occlusion in the HER and resuscitated the patient. Conclusion: The present case, in which rapid diagnosis and intervention were performed and the patient was successfully resuscitated, supports the efficacy of the HER system for managing severe blunt trauma.

Trends and characteristics of severe road traffic injuries in children: a nationwide cohort study in Japan.

PURPOSE: The purpose of this study was to evaluate temporal trends of characteristics of severe road traffic injuries in children and identify factors associated with mortality using a nationwide database in Japan. METHODS: We performed a retrospective analysis of Japan Trauma Data Bank (JTDB) from 2004 to 2018. We included patients with traffic injuries under the age of 18 who were hospitalized. The primary outcome was in-hospital mortality. We evaluated trends in characteristics and assessed factors associated with in-hospital mortality using a logistic regression analysis. RESULTS: A total of 4706 patients were analyzed. The most common mechanism of injury was bicycle crash (34.4%), followed by pedestrian (28.3%), and motorcycle crash (21.3%). The overall in-hospital mortality was 11.2%. We found decreasing trends in motorcycle crash and in-hospital mortality and increasing trends in rear passenger seats in cars over the 15-year period. The following factors were associated with in-hospital mortality: car crash (aOR 1.69, 95%CI 1.18-2.40), pedestrian (aOR 1.50, 95%CI 1.13-1.99), motorcycle crash (aOR 1.42, 95%CI 1.03-1.95) [bicycle crash as a reference]; concomitant injuries to head/neck (aOR 5.06, 95%CI 3.81-6.79), thorax (aOR 2.34, 95%CI 1.92-2.87), abdomen (aOR 1.74, 95%CI 1.29-2.33), pelvis/lower-extremity (aOR 1.57, 95%CI 1.23-2.00), spine (aOR 3.01, 95%CI 2.02-4.43); and 5-year increase in time period (aOR 0.80, 95%CI 0.70-0.91). CONCLUSIONS: We found decreasing trends in motorcycle crash and in-hospital mortality, increasing trends in rear passenger seats in cars over the 15-year period, and factors associated with in-hospital mortality such as type of mechanisms and concomitant injuries. Strengthening child road safety measures, particularly for rear passenger seats in vehicles, is imperative to enhance our dedication to injury prevention.

Anticoagulant therapies against sepsis-induced disseminated intravascular coagulation.

Disseminated intravascular coagulation (DIC) is a frequent but lethal complication in sepsis. Anticoagulant therapies, such as heparin, antithrombin, activated protein C, and recombinant human-soluble thrombomodulin, were expected to regulate the progression of coagulopathy in sepsis. Although a number of randomized controlled trials (RCTs) have evaluated the survival effects of these therapies over the past few decades, there remains no consistent evidence showing a significant survival benefit of anticoagulant therapies. Currently, anticoagulant therapies are not conducted as a standard treatment against sepsis in many countries and regions. However, most of these RCTs were performed overall in patients with sepsis but not in those with sepsis-induced DIC, who were theoretically the optimal target population of anticoagulants. Actually, multiple lines of evidence from observational studies and meta-analyses of the RCTs have suggested that anticoagulant therapies might reduce mortality only when used in septic DIC. In addition, the severity of illness is another essential factor that maximally affects the efficacy of the therapy. Therefore, to provide evidence on the true effect of anticoagulant therapies, the next RCTs must be designed to enroll only patients with sepsis-induced overt DIC and a high severity of illness. To prepare these future RCTs, a novel scientific infrastructure for accurate detection of patients who can receive maximal benefit from anticoagulant therapies also needs to be established.

Early versus delayed vasopressor administration in patients with septic shock.

Aim: This study aimed to investigate the association of early vasopressor initiation with improved septic shock outcomes. Methods: This multicenter observational study was conducted in 17 intensive care units in Japan and included adult patients with sepsis admitted to the intensive care unit from July 2019 to August 2020 and treated with vasopressor therapy. Patients were divided into the early vasopressor group (≤1 h from sepsis recognition) and the delayed vasopressor group (>1 h). The impact of early vasopressor administration on risk-adjusted in-hospital mortality was estimated using logistic regression analyses adjusted by an inverse probability of treatment weighting analysis with propensity scoring. Results: Among the 97 patients, 67 received vasopressor therapy within 1 h from sepsis recognition and 30 received vasopressor after 1 h. In-hospital mortality was 32.8% in the early vasopressor group and 26.7% in the delayed vasopressor group (p = 0.543). The adjusted odds ratio for in-hospital mortality was 0.76 (95% confidence interval 0.17-3.29) when comparing patients in the early vasopressor with those in the delayed vasopressor group. The fit curve from the mixed-effects model showed a relatively lower trend toward an infusion volume over time in the early vasopressor group than in the delayed vasopressor group. Conclusion: Our study did not reach a definitive conclusion for early vasopressor administration. However, early vasopressor administration may help avoid volume overload in the long course of sepsis care.

Mortality analysis among sepsis patients in and out of intensive care units using the Japanese nationwide medical claims database: a study by the Japan Sepsis Alliance study group.

BACKGROUND: A substantial number of sepsis patients require specialized care, including multidisciplinary care, close monitoring, and artificial organ support in the intensive care unit (ICU). However, the efficacy of ICU management on clinical outcomes remains insufficiently researched. Therefore, we tested the hypothesis that ICU admission would increase the survival rate among sepsis patients. METHODS: We conducted a retrospective study using the nationwide medical claims database of sepsis patients in Japan from 2010 to 2017 with propensity score matching to adjust for baseline imbalances. Patients aged over 20 years, with a combined diagnosis of presumed serious infection and organ failure, were included in this study. The primary outcome studied was the in-hospital mortality among non-ICU and ICU patients. In addition to propensity score matching, we performed a multivariable logistic regression analysis for the primary outcome. As the treatment policy was not extracted from the database, we performed sensitivity analyses to determine mortality differences in adults (20 ≤ age ≤ 64), independent patients, patients without malignant tumors, based on the assumption that treatment intensity is likely to increase in those population. RESULTS: Among 1,167,901 sepsis patients (974,289 in non-ICU and 193,612 in ICU settings), the unadjusted in-hospital mortality was 22.5% among non-ICU patients and 26.2% among ICU patients (3.7% [95% CI 3.5-3.9]). After propensity score matching, the in-hospital mortality was 29.2% among non-ICU patients and 25.8% among ICU patients ([Formula: see text] 3.4% [95% CI [Formula: see text] 3.7 to [Formula: see text] 3.1]). In-hospital mortality with a multivariable regression analysis ([Formula: see text] 5.0% [95% CI [Formula: see text] 5.2 to [Formula: see text] 4.8]) was comparable with the results of the propensity score matching analysis. In the sensitivity analyses, the mortality differences between non-ICU and ICU in adults, independent patients, and patients without malignant tumors were [Formula: see text] 2.7% [95% CI [Formula: see text] 3.3 to [Formula: see text] 2.2], [Formula: see text] 5.8% [95% CI [Formula: see text] 6.4 to [Formula: see text] 5.2], and [Formula: see text] 1.3% [95% CI [Formula: see text] 1.7 to [Formula: see text] 1.0], respectively. CONCLUSIONS: Herein, using the nationwide medical claims database, we demonstrated that ICU admission was potentially associated with decreasing in-hospital mortality among sepsis patients. Further investigations are warranted to validate these results and elucidate the mechanisms favoring ICU management on clinical outcomes.

Impact of the COVID-19 pandemic on epidemiology, treatment, and outcome of major trauma in Japan in 2020: a retrospective observational nationwide registry-based study.

Aim: The nationwide impact of the coronavirus disease (COVID-19) pandemic on major trauma in Japan is unknown. The nationwide registry-based data of the Japanese Trauma Data Bank were analyzed to elucidate the impact of COVID-19 on the epidemiology, treatment, and outcomes of major trauma patients. Methods: Among patients transported directly from the injury site by ambulance with an Injury Severity Score of ≥16, we compared patients managed from April to December in 2019 to those managed from April to December in 2020. Results: In total, 9792 patients were included in this study (2019, n = 5194; 2020, n = 4598). There were no significant differences in age or sex, but there were significant differences between 2019 and 2020 in the rates of "self-injury (suicide)", "motor vehicle accident", "fall from height", "fall down", and "fall to the ground", which are factors associated with patient age. Injury severity in 2019 and 2020 did not differ to a statistically significant extent, but the rate of major spinal injury increased. The time of prehospital care significantly increased in 2020 compared to 2019. There was no noticeable change in hospital treatment or in-hospital mortality between 2019 and 2020. Conclusion: This study suggests that the COVID-19 pandemic might have altered the injuries of major trauma; however, medical services for major trauma were well supplied in Japan in 2020.

Characteristics and outcomes of severe sports-related injury in children and adults: a nationwide cohort study in Japan.

PURPOSE: Understanding epidemiological patterns in patients with severe sports-related injuries between children and adults is important for injury prevention. We ought to describe the characteristics and outcomes of patients with severe sports-related injuries and compare the characteristics between children and adults. METHODS: We conducted a retrospective analysis of the Japan Trauma Data Bank (JTDB). We included patients with sports-related injury and an ISS of at least 16, who were admitted between 2004 and 2018. We compared characteristics between children (< 18 years) and adults (≥ 18 years). We performed a multivariable logistic regression analysis to compare in-hospital mortality. RESULTS: We identified 1369 eligible patients (children, n = 326; adults, n = 1043). The most common season was April-June and July-September in children (28.5% and 27.9%) and January-March in adults (42.1%). Injuries to the head/neck (58.9% vs. 40.8%, p < 0.001) and abdomen (16.0% vs. 8.3%, p < 0.001) were significantly more frequent in children than adults, while injuries to the thorax (8.0% vs. 27.2%, p < 0.001), pelvis/lower extremity (0.6% vs. 6.0%, p < 0.001), and spine (23.9% vs. 35.3%, p < 0.001) were less frequent in children. We did not observe a statistically significant difference in in-hospital mortality between children and adults. CONCLUSIONS: We conducted a comprehensive analysis of severe sports-related injuries using a nationwide trauma database and demonstrated different patterns of severe sports-related injuries in children and adults.

Residual persistence of cytotoxicity lymphocytes and regulatory T cells in patients with severe coronavirus disease 2019 over a 1-year recovery process.

Aim: To clarify the immune cellular changes in critically ill patients recovering from coronavirus disease 2019 (COVID-19). Methods: The immune response of peripheral blood mononuclear cells from patients with severe COVID-19 in different stages of recovery (3, 6, and 12 months from hospitalization) was evaluated by single-cell mass cytometry. Immunological changes in patients were compared with those in age-matched healthy donors. Results: Three patients with severe COVID-19 were compared with four healthy donors. In the patients, there was an increase in the cell density of CD4- and CD8-positive T lymphocytes, and B cells, over the course of the recovery period. CD4- and CD8-positive T lymphocytes expressing T-bet and granzyme B (Gzm B) in patients were abundant during all recovery periods. The level of regulatory T cells remained high throughout the year. The levels of natural killer (NK) cells in patients were higher than in those in the healthy donors, and the frequency of CD16+ NK cells expressing Gzm B increased throughout the year. Conclusion: Patients recovering from severe COVID-19 showed persistence of cytotoxic lymphocytes, NK cells, and regulatory T cells throughout the posthospitalization year of recovery.

Temporal trends of medical cost and cost-effectiveness in sepsis patients: a Japanese nationwide medical claims database.

BACKGROUND: Sepsis is the leading cause of death worldwide. Although the mortality of sepsis patients has been decreasing over the past decade, the trend of medical costs and cost-effectiveness for sepsis treatment remains insufficiently determined. METHODS: We conducted a retrospective study using the nationwide medical claims database of sepsis patients in Japan between 2010 and 2017. After selecting sepsis patients with a combined diagnosis of presumed serious infection and organ failure, patients over the age of 20 were included in this study. We investigated the annual trend of medical costs during the study period. The primary outcome was the annual trend of the effective cost per survivor, calculated from the gross medical cost and number of survivors per year. Subsequently, we performed subgroup and multiple regression analyses to evaluate the association between the annual trend and medical costs. RESULTS: Among 50,490,128 adult patients with claims, a total of 1,276,678 patients with sepsis were selected from the database. Yearly gross medical costs to treat sepsis gradually increased over the decade from $3.04 billion in 2010 to $4.38 billion in 2017, whereas the total medical cost per hospitalization declined (rate = - $1075/year, p < 0.0001). While the survival rate of sepsis patients improved during the study period, the effective cost per survivor significantly decreased (rate = - $1806/year [95% CI - $2432 to - $1179], p = 0.001). In the subgroup analysis, the trend of decreasing medical cost per hospitalization remained consistent among the subpopulation of age, sex, and site of infection. After adjusting for age, sex (male), number of chronic diseases, site of infection, intensive care unit (ICU) admission, surgery, and length of hospital stay, the admission year was significantly associated with reduced medical costs. CONCLUSIONS: We demonstrated an improvement in annual cost-effectiveness in patients with sepsis between 2010 and 2017. The annual trend of reduced costs was consistent after adjustment with the confounders altering hospital expenses.

Assessing the impact of the national traffic safety campaign: a nationwide cohort study in Japan.

OBJECTIVES: This study aimed to examine the difference in mortality from serious road traffic injuries during the National Traffic Safety Campaign compared with other periods and identify the common mechanisms of injury by age group in Japan. DESIGN: A retrospective review of Japan Trauma Data Bank (JTDB). SETTING: A total of 280 participating major emergency institutions across Japan. PARTICIPANTS: Patients with road traffic injuries registered in JTDB between 2004 and 2018 were recruited in the study. We included patients injured by traffic crashes during the National Traffic Safety Campaigns and controls using a double control method. The National Traffic Safety Campaign comprises 10 consecutive days in spring and fall (20 days in each year), and controls was the same calendar days 2 weeks before and after the days in the National Traffic Safety Campaigns (40 days in each year) to control for weekday, seasonal and yearly trends. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was in-hospital mortality. The secondary outcome was the incidences of severe traffic injury. RESULTS: Among 126 857 patients recorded as road traffic injuries in JTDB, we identified 6181 patients (21 cases per day) with injuries occurring during the National Traffic Safety Campaigns and 12 382 controls (21 cases per day). The overall in-hospital mortality was 11.4%. We did not observe a significant difference in in-hospital mortality between the groups (11.8% vs 11.1%) with an adjusted OR of 1.05 (95% CI 0.95 to 1.16). The most common mechanism of injury in each age group was bicycle crash among children, motorcycle crash among adults and pedestrian among the elderly. CONCLUSIONS: We found no change in the incidence of severe traffic injury or in-hospital mortality during the National Traffic Safety Campaign in Japan. Serious road trauma was high for bicycles among children, motorcycles among adults and pedestrian among the elderly.

Relationship between in-hospital mortality and abdominal angiography among patients with blunt liver injuries: a propensity score-matching from a nationwide trauma registry of Japan.

AIM: To assess relationships between abdominal angiography and outcomes in adults with blunt liver injuries. METHODS: A retrospective observational study carried out from January 2004 to December 2018. Adult blunt-trauma patients with AAST grade Ⅲ-Ⅴ were analyzed with in-hospital mortality as the primary outcome using propensity-score-(PS) matching to seek associations with abdominal angiography findings. RESULTS: A total of 1,821 patients were included, of which 854 had available abdominal angiography data (AA+) and 967 did not (AA-). From these, 562 patients were selected from each group by propensity score matching. In-hospital mortality was found to be lower in the AA+ than in the AA- group (15.1% [87/562] versus 25.4% [143/562]; odds ratio 0.544, 95% confidence interval 0.398-0.739). CONCLUSION: Abdominal angiography is shown to be of benefit for adult patients with blunt liver injury in terms of their lower in-hospital mortality.

Characteristics and outcomes of pediatric blunt renal trauma: a nationwide cohort study in Japan.

PURPOSE: The aim of this study was to describe epidemiologic features of pediatric blunt renal trauma. METHODS: We performed a retrospective analysis using the Japan Trauma Data Bank over 15 years. We included patients younger than 18 years with blunt renal trauma. We analyzed temporal trends and variations across age groups in patient characteristics, intervention, and in-hospital mortality. We also assessed factors associated with in-hospital mortality. RESULTS: We identified 435 pediatric patients with blunt renal trauma. Their median age was 14 years and median Injury Severity Score (ISS) was 17. The most common mechanism of injury was traffic accident in all age groups. Nephrectomy was performed in 3.2%, and the overall in-hospital mortality was 4.6%, both of which showed decreasing trends. The most common mechanism of injury by age group was a pedestrian accident in infants/toddlers/preschoolers (43.5%), pedestrian accident in middle childhood (18.5%), bicycle accident in young teens (24.7%), and motorcycle accident in teenagers (41.2%). Sports-related injury was common in young teens (23.3%) and teenagers (15.2%). Factors such as ISS, shock, concomitant injury, and nephrectomy were associated with high in-hospital mortality. CONCLUSIONS: We described decreasing trends in nephrectomy and in-hospital mortality in pediatric blunt renal trauma and found traffic accident and sports-related injury were common in the pediatric population in Japan.

Patient age affects sex-based differences in post-traumatic mortality: a national trauma registry study in Japan.

PURPOSE: Sex-based differences in post-traumatic mortality have been widely discussed for quite some time. We hypothesized that age-related pathophysiologic changes would affect sex-based differences in post-traumatic mortality and aimed to verify the hypothesis using a nationwide trauma registry in Japan. METHODS: This was a retrospective analysis of trauma patients registered in The Japanese Trauma Data Bank. We stratified the study population into the following three subsets based on age: (1) pediatric subset (age ≤ 14), (2) adult subset (age 15-50) and (3) senior adult subset (age ≥ 51). We evaluated both sex-based differences in mortality in each subset separately using multivariate logistic regression analysis and the two-way interaction effect for predicted survival between the continuous increase of age and the sexes using a nonlinear multivariate regression model. RESULTS: We included 122,819 trauma patients who fulfilled the inclusion criteria and classified them into the 3 subsets according to age. Male patients were more likely to die compared to female patients only in the senior adult subset (adjusted odds ratio: 1.26; 95% confidence interval: 1.18-1.36), whereas there were no statistically significant differences in the other two subsets. Furthermore, non-linear logistic regression analysis revealed that predicted survival probability in male patients decreased more sharply in accordance with the increase of age compared to that in female patients (p for interaction: 0.051). CONCLUSION: Age-related change in post-traumatic mortality was significantly different between males and females, and male patients had a relatively higher risk of death in the older population.

Effect of fluid administration on scene to traffic accident patients by EMS personnel: a propensity score-matched study using population-based ambulance records and nationwide trauma registry in Japan.

PURPOSE: The aim of this study was to assess the effect of fluid administration by emergency life-saving technicians (ELST) on the prognosis of traffic accident patients by using a propensity score (PS)-matching method. METHODS: The study included traffic accident patients registered in the JTDB database from January 2016 to December 2017. The main outcome was hospital mortality, and the secondary outcome was cardiopulmonary arrest on hospital arrival (CPAOA). To reduce potential confounding effects in the comparisons between two groups, we estimated a propensity score (PS) by fitting a logistic regression model that was adjusted for 17 variables before the implementation of fluid administration by ELST at the scene. RESULTS: During the study period, 10,908 traffic accident patients were registered in the JTDB database, and we included 3502 patients in this study. Of these patients, 142 were administered fluid by ELST and 3360 were not administered fluid by ELST. After PS matching, 141 patients were selected from each group. In the PS-matched model, fluid administration by ELST at the scene was not associated with discharge to death (crude OR: 0.859 [95% CI, 0.500-1.475]; p = 0.582). However, the fluid group showed statistically better outcome for CPAOA than the no fluid group in the multiple logistic regression model (adjusted OR: 0.231 [95% CI, 0.055-0.967]; p = 0.045). CONCLUSION: In this study, fluid administration to traffic accident patients by ELST was associated not with hospital mortality but with a lower proportion of CPAOA.

Pathophysiology of Coagulopathy Induced by Traumatic Brain Injury Is Identical to That of Disseminated Intravascular Coagulation With Hyperfibrinolysis.

Background: Traumatic brain injury (TBI)-associated coagulopathy is a widely recognized risk factor for secondary brain damage and contributes to poor clinical outcomes. Various theories, including disseminated intravascular coagulation (DIC), have been proposed regarding its pathomechanisms; no consensus has been reached thus far. This study aimed to elucidate the pathophysiology of TBI-induced coagulopathy by comparing coagulofibrinolytic changes in isolated TBI (iTBI) to those in non-TBI, to determine the associated factors, and identify the clinical significance of DIC diagnosis in patients with iTBI. Methods: This secondary multicenter, prospective study assessed patients with severe trauma. iTBI was defined as Abbreviated Injury Scale (AIS) scores ≥4 in the head and neck, and ≤2 in other body parts. Non-TBI was defined as AIS scores ≥4 in single body parts other than the head and neck, and the absence of AIS scores ≥3 in any other trauma-affected parts. Specific biomarkers for thrombin and plasmin generation, anticoagulation, and fibrinolysis inhibition were measured at the presentation to the emergency department (0 h) and 3 h after arrival. Results: We analyzed 34 iTBI and 40 non-TBI patients. Baseline characteristics, transfusion requirements and in-hospital mortality did not significantly differ between groups. The changes in coagulation/fibrinolysis-related biomarkers were similar. Lactate levels in the iTBI group positively correlated with DIC scores (rho = -0.441, p = 0.017), but not with blood pressure (rho = -0.098, p = 0.614). Multiple logistic regression analyses revealed that the injury severity score was an independent predictor of DIC development in patients with iTBI (odds ratio = 1.237, p = 0.018). Patients with iTBI were further subdivided into two groups: DIC (n = 15) and non-DIC (n = 19) groups. Marked thrombin and plasmin generation were observed in all patients with iTBI, especially those with DIC. Patients with iTBI and DIC had higher requirements for massive transfusion and emergency surgery, and higher in-hospital mortality than those without DIC. Furthermore, DIC development significantly correlated with poor hospital survival; DIC scores at 0 h were predictive of in-hospital mortality. Conclusions: Coagulofibrinolytic changes in iTBI and non-TBI patients were identical, and consistent with the pathophysiology of DIC. DIC diagnosis in the early phase of TBI is key in predicting the outcomes of severe TBI.

Impact of medical reimbursement revision on ambulance transport of self-inflicted injury patients: a nationwide study in Japan.

AIM: Self-inflicted injury, as one reason to visit the emergency department, is an important issue in emergency medicine around the world. However, the impact of changes in social systems, such as medical reimbursement revision, on ambulance transport for self-inflicted injury remains unclear. The aim of this study was to assess the impact of medical reimbursement revision on the emergency transport of self-inflicted injury patients using nationwide ambulance records. METHODS: This was a retrospective observational study from April 2012 to March 2016. We analyzed nationwide ambulance records in Japan, and included self-inflicted injury, drug poisoning, and drug overdose patients transported to hospitals by ambulance. The primary outcome of this study was age-adjusted number of self-inflicted injury patients transported by ambulance in each month per 1 million standard populations. To assess the impact of the medical reimbursement revision in 2014, we calculated the R 2, regression coefficients and 95% confidence interval (CI) using interrupted time series analysis. RESULTS: This study included 148,873 patients. The R 2 for the interrupted time series model was 0.821. The regression coefficient for the time trend before the medical reimbursement revision was 0.167 (95% CI, 0.090 to 0.244; p < 0.001), that for the time trend after the medical reimbursement revision was -0.226 (95% CI, -0.327 to -0.125, p < 0.001), and that of the medical reimbursement revision was -2.165 (95% CI, -3.730 to -0.601, p = 0.008). CONCLUSION: In Japan, the medical reimbursement revision in April 2014 helped to decrease the number of self-inflicted injury patients transported to hospitals by ambulance.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020).

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.

Relationship between the prehospital quick Sequential Organ Failure Assessment and prognosis in patients with sepsis or suspected sepsis: a population-based ORION registry.

AIM: The quick Sequential Organ Failure Assessment (qSOFA) was proposed for use as a simple screening tool for sepsis. In this study, we evaluated the relationship between the prehospital use of qSOFA and prognosis in patients with sepsis or suspected sepsis using the population-based Osaka Emergency Information Research Intelligent Operation Network (ORION) registry, which compiles prehospital ambulance data and in-hospital information. METHODS: The study enrolled 437,974 patients in the ORION registry from January 1 to December 31, 2016. We selected hospitalized patients with sepsis or suspected sepsis using the appropriate codes from the International Classification of Diseases revision 10. We excluded patients with: (i) missing data (outcome, Japan Coma Scale, respiratory rate, and blood pressure); (ii) respiratory rate ≥60/min; and (iii) blood pressure ≥250 mmHg. These measures were evaluated by ambulance personnel when they first contacted the patient in the prehospital setting. The primary end-point was discharge to death. RESULTS: In total, 12,646 patients (median age, 78 [interquartile range, 65-85] years; male, n = 6,760 [53.5%]) were eligible for our analysis. In a multivariable logistic regression analysis adjusted for confounding factors, the proportion of patients discharged to death was significantly higher for those evaluated as qSOFA positive (≥2 points) than qSOFA negative (≤1 point) (265/2,250 [11.78%] vs. 415/10,396 [3.99%]; adjusted odds ratio 2.91; 95% confidence interval, 2.47-3.43; P < 0.0001). The specificity and sensitivity were 83.4% and 39.0%, respectively, and the area under the receiver operating characteristic curve for qSOFA positive was 0.61. CONCLUSIONS: The qSOFA evaluated by ambulance personnel in the prehospital setting was significantly associated with prognosis in patients with sepsis or suspected sepsis.

Effect of Earlier Door-to-CT and Door-to-Bleeding Control in Severe Blunt Trauma: A Retrospective Cohort Study.

Blunt trauma is a potentially life-threatening injury that requires prompt diagnostic examination and therapeutic intervention. Nevertheless, how impactful a rapid response time is on mortality or functional outcomes has not been well-investigated. This study aimed to evaluate effects of earlier door-to-computed tomography time (D2CT) and door-to-bleeding control time (D2BC) on clinical outcomes in severe blunt trauma. This was a single-center, retrospective cohort study of patients with severe blunt trauma (Injury Severity Score > 16). To assess the effect of earlier D2CT and D2BC on clinical outcomes, we conducted multivariable regression analyses with a consideration for nonlinear associations. Among 671 patients with severe blunt trauma who underwent CT scanning, 163 patients received an emergency bleeding control procedure. The median D2CT and D2BC were 19 min and 57 min, respectively. In a Cox proportional hazard regression model, earlier D2CT was not associated with improved 28-day mortality (p = 0.30), but it was significantly associated with decreased mortality from exsanguination (p = 0.003). Earlier D2BC was significantly associated with improved 28-day mortality (p = 0.026). In conclusion, earlier time to a hemostatic procedure was independently associated with decreased mortality. Meanwhile, time benefits of earlier CT examination were not observed for overall survival but were observed for decreased mortality from exsanguination.