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1 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.

2 UQ Centre for Clinical Research 2 COI 2012 11 6 3 4 6 1. 9 2. 14 3. 17 4. 36 5. 39 6. 48 7. 56 8.

3 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 sepsis septic 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)

4 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.

5 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;36:296 327. 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 Crit Care Med 1997;25:372-4.

6 6 Sepsis Registry EBM Sepsis Registry 1 2007 10 1 12 31 47 226 2 2009 10 1 2010 3 31 39 310 2000 PubMed Medline(Ovid) Cochran Database of Systematic Reviews sepsis severe sepsis septic shock Web RCT RCT RCT 13 CQ 3-5 1 CQ SSCG2008[1-3] 2011 [4]

7 A RCT B RCT C D 1 100 RCT 1000 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.

8 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.

9 SIRS infection-induced SIRS SIRS 4 2 1C 1 38 C 36 C 2 90 / 3 20 / PaCO2 32 Torr 4 12,000mm3 4,000mm3 band 10 1C (1C) 38 C 36 C 90/ 2SD 20 / 24 20mL/kg 120mg/dL WBC 12000/ L WBC 4000/ L 10% CRP * , IL-6 ( 1,000pg/mL*) 90mmHg 70mmHg 40mmHg SD 10 PaO2/FIO2 300 Cre PT-INR aPTT 60 100,000/ L T-Bil 4mg/dL 2mmol/L * 1989 Bone sepsis syndrome [1] 1991 Society of Critical Care Medicine (SCCM)

10 /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.