The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), as revised from J-SSCG 2016, was created to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. 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 (CQs) were extracted regardless of the presence or absence of evidence. 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. 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. 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.

In 2016, the international definition and diagnosis of sepsis was newly published as Sepsis-3. The Japanese Sepsis Practice Guidelines (J-SSCG) and the Surviving Sepsis Campaign guidelines (SSCG) adopted the same definition of sepsis according to Sepsis-3. Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. In out-of-hospital, emergency department, or general hospital ward settings, adult patients with suspected infection is rapidly identified by quick SOFA (qSOFA): respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100mmHg or less. In intensive care unit, organ dysfunction is detected by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more. Septic shock is defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock is clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65mmHg or greater and serum lactate level greater than 2mmol/L (＞18mg/dL) in the absence of hypovolemia. However, qSOFA has low sensitivity in the diagnosis of sepsis. SSCG2021 recommends not to use qSOFA alone as a screening tool for sepsis and septic shock. It is necessary to evaluate the timing of qSOFA and iterative evaluation of qSOFA in sepsis evaluation. Regarding the possibility of an increase in the mortality such as in-hospital death in sepsis, the therapeutic management need to be improved in infection and multiple organ management.

The approach for the source of infection is an important factor in sepsis. Since the diagnostic imaging is essential, the appropriate imaging in accordance with the suspected source should be selected in the case of sepsis patients with unknown source of infection. The drainage approaches are considered when the source of infection is revealed, whereas the early and invasive approaches are not necessarily recommended for infectious pancreatic necrosis. In the context of the development of less invasive therapy such as the endoscopic drainage and percutaneous drainage, the “step─up approach” which becomes incrementally more invasive according to the treatment effect should be considered.

The pathogenesis of septic shock includes not only a relative decrease in intravascular volume associated with vasodilatation and vascular permeability, but may also be mixed with sepsis induced myocardial dysfunction. Since it is necessary to accurately assess the pathophysiology and select an appropriate treatment for each individual case, the J-SSCG 2020 recommends that when a septic patient is encountered, a simple cardiac and vascular echocardiography should first be performed to assess preload and cardiac function. For decreased in intravascular volume, initial fluid resuscitation is recommended, noradrenaline is administered if it is determined that the patient is in shock due to vasodilation, and if blood pressure still cannot be maintained, additional vasopressin is recommended. On the other hand, if cardiac dysfunction is detected by echocardiography, inotropic drugs are necessary, β1 receptor blockers are recommended for tachyarrhythmias, and indications for assisted circulation are being considered for severe cardiac dysfunction. This paper will discuss the CQ/Answer and medical treatment flow presented by the J-SSCG 2020 regarding initial resuscitation and inotropes for patients with septic shock.

Today’s developments in emergency and intensive care medicine have dramatically improved the short-term outcomes of critically ill patients, but this has led to an increasing number of patients suffering from various sequelae even after ICU discharge, a situation that cannot be ignored. In 2012, the Society of Critical Care Medicine proposed the concept of ICU-acquired weakness (ICU-AW) and post-intensive care syndrome (PICS), which led to various reports on PICS/ICU-AW. It has been suggested that PICS and ICU-AW are also closely involved in septic patients and are covered as independent chapters in The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020. In this review, PICS and ICU-AW are first outlined, and then the clinical questions addressed in the guidelines are explained.

The causes of acute brain dysfunction in sepsis can be divided into 1. narrowly-defined sepsis-associated acute brain dysfunction (SABD), 2. broadly-defined SABD, and 3. new neurological disease complications. Narrowly-defined SABD results from the direct effect of inflammatory mediators on the brain. Broadly-defined SABD is caused indirectly by sepsis-associated damage to organs other than the brain or by drugs. Narrowly-defined SABD is the most frequent sepsis-related organ disorder, affecting up to 70％ of patients with sepsis and often occurring before other organs are affected. The symptoms of narrowly-defined SABD are non-specific and a diagnosis by exclusion, taking into account the medical history, is important. 1. is mainly treated with sepsis, while 2. and 3. may require additional treatment or an early change in treatment.

While short–term vital prognosis of patients undergoing intensive care has improved in recent years, issues such as PICS (Post intensive care syndrome), adjustment of the care environment, and relationships among medical staff, patients, and their families are coming to light. “Patient–and Family–Centered Care” was positioned to handle content relating to the mental state of patients and their families, and the care environment and decision–making support in the ICU. CQ20–1: What are methods for providing information regarding PICS and PICS–F to patients and their families？ CQ20–2: Should ICU diaries be kept by patients with sepsis or those undergoing intensive care？ CQ20–3: Should physical restraints be avoided during intensive care？ CQ20–4: Should ventilation support or non–pharmacological sleep management be provided for sleep care？ CQ20–5: Should family visiting restrictions be relaxed for the ICU？ CQ20–6: What are methods for supporting decision–making which respects the value systems and ways of thinking in the patient？ There are some with poor levels of evidence; however, these are extremely important areas that can improve the quality of future sepsis treatment and intensive care.