西田 修

日本集中治療医学会臨床倫理委員会は,日本COVID-19対策ECMOnet(代表竹田晋浩)(日本集中治療医学会,日本呼吸療法医学会,日本救急医学会)ならびに厚生労働科学研究費補助金(新興・再興感染症及び予防接種政策推進研究事業)「新興・再興感染症のリスク評価と危機管理機能の実装のための研究」分担研究班と合同で,新型コロナウイルス感染症(coronavirus disease 2019,COVID-19)流行に際しての医療資源配分の観点からの治療の差し控え・中止の考え方を提言する。提言は,非常事態にあっても臨床倫理の原則を守りつつ,医療資源を公正に配分するために適切な議論を経て行われるべきことを骨子としている。(著者抄録)

Sepsis is a dysregulated immune response that leads to organ dysfunction and has high mortality rates despite recent therapeutic advancements. Accurate diagnosis and risk stratification are important for effective sepsis treatment; however, no decisive diagnostic or prognostic biomarkers are currently available. To understand whether microRNA (miRNA) might be useful biomarkers of sepsis, we aim to assess the diagnostic and prognostic accuracy of three miRNAs (122, 150, and 223) in sepsis patients via a meta-analysis of relevant published data. We will search electronic bibliographic databases (MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials) for pertinent retrospective and prospective studies in October 2019. Two reviewers will evaluate the collected titles, abstracts, and full articles, and extract the data. We will assess the included studies using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. If feasible, we will use bivariate random effects and hierarchical summary receiver operating characteristic (ROC) models to estimate summary ROCs, pooled sensitivity and specificity values, and the corresponding 95% confidence intervals. We will evaluate heterogeneity via clinical and methodological subgroup and sensitivity analyses. This systematic review will clarify the diagnostic and prognostic accuracy of select miRNAs in sepsis. It may also identify knowledge gaps in sepsis' diagnosis and prognosis.

PICS対策・生活の質改善検討委員会(Ad Hoc)は、本邦の診療現場におけるpost-intensive care syndrome(PICS)の実態を把握するために、日本集中治療医学会会員を対象とし、診療現場におけるPICSの実態調査を実施した。453名から回答を得た。PICSやABCDEFバンドルの認識度は約6割であった。実践しているPICS介入では、早期リハビリテーションが92%であった。しかしながら、ICU患者の退室時あるいは退院時の身体・認知・精神機能障害、QOLの評価は約1割程度にとどまっていた。また現時点では、PICS外来やPICSラウンドを全ての患者で行っていると回答した割合は1%未満であった。ICU患者の長期予後を改善するために、今後はさらなるPICSの認知・実態評価・予防・治療・フォローアップ・啓発活動を、システマティックに実臨床で展開していくことが重要と考えられる。(著者抄録)

Expanding elderly populations are a major social challenge in advanced countries worldwide and have led to a rapid increase in the number of elderly patients in intensive care units (ICUs). Innovative advances in medical technology have enabled lifesaving of patients in ICUs, but there remain various problems to improve their long-term prognoses. Post-intensive care syndrome (PICS) refers to physical, cognition, and mental impairments that occur during ICU stay, after ICU discharge or hospital discharge, as well as the long-term prognosis of ICU patients. Its concept also applies to pediatric patients (PICS-p) and the mental status of their family (PICS-F). Intensive care unit-acquired weakness, a syndrome characterized by acute symmetrical limb muscle weakness after ICU admission, belongs to physical impairments in three domains of PICS. Prevention of PICS requires performance of the ABCDEFGH bundle, which incorporates the prevention of delirium, early rehabilitation, family intervention, and follow-up from the time of ICU admission to the time of discharge. Diary, nutrition, nursing care, and environmental management for healing are also important in the prevention of PICS. This review outlines the pathophysiology, prevention, and future directions of PICS.

INTRODUCTION: The benefits and harm caused by anticoagulant treatments for sepsis induced disseminated intravascular coagulation (DIC) remain unclear. Therefore, we performed a network meta-analysis to assess the effect of available anticoagulant treatments on patient mortality, DIC resolution and the incidence of bleeding complication in patients with septic DIC. MATERIALS AND METHODS: We considered all studies from four recent systematic reviews and searched the PubMed, MEDLINE, and Cochrane databases for other studies that investigated anticoagulant treatment for septic DIC using antithrombin, thrombomodulin, heparin, or protease inhibitors in adult critically ill patients. These four anticoagulants and placebo were compared. The primary outcome in this study was patient mortality, and the secondary outcomes were the DIC resolution rate and incidence of bleeding complications. RESULTS: The network meta-analysis included 1340 patients from nine studies. There were no significant differences in the risks of mortality and bleeding complications among all direct comparisons and the network meta-analysis. Using a placebo was associated with a significantly lower rate of DIC resolution, compared to antithrombin in the direct comparison (odds ratio [OR]: 0.20, 95% credible interval [95% CrI]: 0.046-0.81) and in the network meta-analysis (OR: 0.20, 95% CrI: 0.043-0.84). CONCLUSIONS: Our study revealed no significant differences in the risks for mortality and bleeding complications when a placebo and all four anticoagulants were compared in septic DIC patients. The results also indicated that antithrombin was associated with a five-fold higher likelihood of DIC resolution, compared to placebo.

Acute kidney injury (AKI) is a syndrome which has a broad range of etiologic factors depending on different clinical settings. Because AKI has significant impacts on prognosis in any clinical settings, early detection and intervention are necessary to improve the outcomes of AKI patients. This clinical guideline for AKI was developed by a multidisciplinary approach with nephrology, intensive care medicine, blood purification, and pediatrics. Of note, clinical practice for AKI management which was widely performed in Japan was also evaluated with comprehensive literature search.

Acute kidney injury (AKI) is a syndrome which has a broad range of etiologic factors depending on different clinical settings. Because AKI has significant impacts on prognosis in any clinical settings, early detection and intervention are necessary to improve the outcomes of AKI patients. This clinical guideline for AKI was developed by a multidisciplinary approach with nephrology, intensive care medicine, blood purification, and pediatrics. Of note, clinical practice for AKI management which was widely performed in Japan was also evaluated with comprehensive literature search.

PURPOSE: To observe arterial oxygen in relation to fraction of inspired oxygen (FIO2) during mechanical ventilation (MV). MATERIALS AND METHODS: In this multicenter prospective observational study, we included adult patients required MV for >48h during the period from March to May 2015. We obtained FIO2, PaO2 and SaO2 from commencement of MV until the 7th day of MV in the ICU. RESULTS: We included 454 patients from 28 ICUs in this study. The median APACHE II score was 22. Median values of FIO2, PaO2 and SaO2 were 0.40, 96mmHg and 98%. After day two, patients spent most of their time with a FIO2 between 0.3 and 0.49 with median PaO2 of approximately 90mmHg and SaO2 of 97%. PaO2 was ≥100mmHg during 47.2% of the study period and was ≥130mmHg during 18.4% of the study period. FIO2 was more likely decreased when PaO2 was ≥130mmHg or SaO2 was ≥99% with a FIO2 of 0.5 or greater. When FIO2 was <0.5, however, FIO2 was less likely decreased regardless of the value of PaO2 and SaO2. CONCLUSIONS: In our multicenter prospective study, we found that hyperoxemia was common and that hyperoxemia was not corrected.

日本版敗血症診療ガイドライン(J-SSCG)2016作成特別委員会は、J-SSCG2016の普及状況をモニタリングすることと、今後のガイドライン改訂における改善点を明らかにすることを目的に、日本集中治療医学会、日本救急医学会の両学会員を対象とし、J-SSCG2016の使用に関する実態調査を実施した。610名から回答を得た。回答者の86%でJ-SSCG2016が活用されており、50〜75%程度の敗血症患者でガイドラインに準じた治療が行われていた。また、回答者の83%が診療の標準化、51%が教育の向上にJ-SSCG2016が役立つと評価した。一方、ガイドラインの存在意義、作成工程や発行・公開方法、両学会員以外の一般医療従事者における普及に関する問題を指摘する意見もあった。本調査結果を今後のJ-SSCG改訂に活かし、より実用的なガイドラインとして発展させていくことが重要と考えられる。(著者抄録)

日本版敗血症診療ガイドライン(J-SSCG)2016作成特別委員会は、J-SSCG2016の普及状況をモニタリングすることと、今後のガイドライン改訂における改善点を明らかにすることを目的に、日本集中治療医学会、日本救急医学会の両学会員を対象とし、J-SSCG2016の使用に関する実態調査を実施した。610名から回答を得た。回答者の86%でJ-SSCG2016が活用されており、50〜75%程度の敗血症患者でガイドラインに準じた治療が行われていた。また、回答者の83%が診療の標準化、51%が教育の向上にJ-SSCG2016が役立つと評価した。一方、ガイドラインの存在意義、作成工程や発行・公開方法、両学会員以外の一般医療従事者における普及に関する問題を指摘する意見もあった。本調査結果を今後のJ-SSCG改訂に活かし、より実用的なガイドラインとして発展させていくことが重要と考えられる。(著者抄録)

INTRODUCTION: We examined the effectiveness of early rehabilitation for the prevention of postintensive care syndrome (PICS), characterised by an impaired physical, cognitive or mental health status, among survivors of critical illness. METHODS: We performed a systematic literature search of several databases (Medline, Embase and Cochrane Central Register of Controlled Trials) and a manual search to identify randomised controlled trials (RCTs) comparing the effectiveness of early rehabilitation versus no early rehabilitation or standard care for the prevention of PICS. The primary outcomes were short-term physical-related, cognitive-related and mental health-related outcomes assessed during hospitalisation. The secondary outcomes were the standardised, long-term health-related quality of life scores (EuroQol 5 Dimension (EQ5D) and the Medical Outcomes Study 36-Item Short Form Health Survey Physical Function Scale (SF-36 PF)). We used the Grading of Recommendations Assessment, Development and Evaluation approach to rate the quality of evidence (QoE). RESULTS: Six RCTs selected from 5105 screened abstracts were included. Early rehabilitation significantly improved short-term physical-related outcomes, as indicated by an increased Medical Research Council scale score (standardised mean difference (SMD): 0.38, 95% CI 0.10 to 0.66, p=0.009) (QoE: low) and a decreased incidence of intensive care unit-acquired weakness (OR 0.42, 95% CI 0.22 to 0.82, p=0.01, QoE: low), compared with standard care or no early rehabilitation. However, the two groups did not differ in terms of cognitive-related delirium-free days (SMD: -0.02, 95% CI -0.23 to 0.20, QoE: low) and the mental health-related Hospital Anxiety and Depression Scale score (OR: 0.79, 95% CI 0.29 to 2.12, QoE: low). Early rehabilitation did not improve the long-term outcomes of PICS as characterised by EQ5D and SF-36 PF. CONCLUSIONS: Early rehabilitation improved only short-term physical-related outcomes in patients with critical illness. Additional large RCTs are needed.

Background and purpose: The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 and published in the Journal of JSICM, [2017; Volume 24 (supplement 2)] 10.3918/jsicm.24S0001 and Journal of Japanese Association for Acute Medicine [2017; Volume 28, (supplement 1)] http://onlinelibrary.wiley.com/doi/10.1002/jja2.2017.28.issue-S1/issuetoc.This abridged English edition of the J-SSCG 2016 was produced with permission from the Japanese Association of Acute Medicine and the Japanese Society for Intensive Care Medicine. Methods: Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ) and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (> 66.6%) majority vote of each of the 19 committee members. Results: A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation, and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty-seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for five CQs. Conclusions: Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.

Background and Purpose: The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 in Japanese. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. Methods: Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ), and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (>66.6%) majority vote of each of the 19 committee members. Results: A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for 5 CQs. Conclusions: Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.

INTRODUCTION: Postintensive care syndrome (PICS) is defined as a new or worsening impairment in cognition, mental health and physical function after critical illness. There is little evidence regarding treatment of patients with PICS; new directions for effective treatment strategies are urgently needed. Early physiotherapy may prevent or reverse some physical impairments in patients with PICS, but no systematic reviews have investigated the effectiveness of early rehabilitation on PICS-related outcomes. The purpose of this systematic review is to evaluate whether early rehabilitative interventions in critically ill patients can prevent PICS and decrease mortality. METHODS: We will conduct a systematic review and meta-analysis of early rehabilitation for the prevention of PICS in critically ill adults. We will search PubMed, EMBASE and the Cochrane Central Register of Controlled Trials for published randomised controlled trials. We will screen search results and assess study selection, data extraction and risk of bias in duplicate, resolving disagreements by consensus. We will pool data from clinically homogeneous studies using a random-effects meta-analysis; assess heterogeneity of effects using the χ2 test of homogeneity; and quantify any observed heterogeneity using the I2 statistic. We will use the Grading of Recommendations Assessment, Development and Evaluation approach to rate the quality of evidence. DISCUSSION: This systematic review will present evidence on the prevention of PICS in critically ill patients with early rehabilitation. ETHICS: Ethics approval is not required. DISSEMINATION: The results will be disseminated via peer-reviewed journal publication, conference presentation(s) and publications for patient information. TRIAL REGISTRATION NUMBER: CRD42016039759.

近年、集中治療領域での早期リハビリテーションが注目されているが、わが国の集中治療領域で行われている早期リハビリテーションは経験的に行われていることが多く、その内容や体制は施設により大きな違いがある。早期リハビリテーションへの期待が高まり、今後より高度急性期の病床機能の明確化が進む中で、集中治療領域での早期リハビリテーションの確立や標準化は喫緊の課題である。この度、日本集中治療医学会の早期リハビリテーション検討委員会では、「集中治療における早期リハビリテーション〜根拠に基づくエキスパートコンセンサス〜」を作成した。このエキスパートコンセンサスでは、早期リハビリテーションの定義や早期リハビリテーションの効果、さらには早期リハビリテーションの禁忌や開始基準・中止基準、早期リハビリテーションの体制について解説する。(著者抄録)