Novel coronavirus infection (COVID-19) causes not only severe pneumonia, but also renal dysfunction and neuromuscular manifestation. Although COVID-19 medication treatment recommendations are now more precise, rhabdomyolysis instances still uncommon and there is no approved treatment for them. A woman in her 60s had COVID-19 four days before admission. She had worsening dyspnea and weakness with CK 49,920 IU/L and Cr 4.01 mg/dL and was admitted with a diagnosis of COVID-19 with rhabdomyolysis and acute kidney injury (AKI). She continued oliguria, and was resuscitated with a crystalloid solution. She performed renal replacement therapy（RRT） on day 2 and was intubated due to worsening respiratory status on day 3. However, she was discontinued RRT on day 9, and underwent extubation on day 13. She was moved to a rehabilitation facility on day 104 because she needed extensive rehabilitation for the significant motor dysfunction. Here, we demonstrate a case that early combined RRT with ventilator management for COVID-19 with rhabdomyolysis resulting in AKI, that could prevent long-term oxygen therapy and maintenance dialysis.

A personal reverse osmosis machine and a personal dialysis machine are used for intermittent hemodialysis in the intensive care unit. At our hospital, water spouted from a personal dialysis machine due to a connection error in the pipes during preparation for treatment, and an accident occurred in which chlorine gas was generated due to a mixture of chlorine-based and acidic cleaning agents. After that, countermeasures were taken to minimize damage and prevent the subsequent generation of chlorine gas. After this experience, we became keenly aware that there are many causes of major accidents hidden behind treatment procedures. Therefore, when deciding and reviewing operations, it is necessary to consider all possibilities and implement multiple safety measures.

In our ICU, we hold multi-disciplinary conferences every morning, confirm and share our patient’s pathology and treatment policy, and conduct multi-disciplinary team medical care. In recent years, as end-of-life care has attracted more attention from society, various organizations and academic societies have issued guidelines and proposals for end-of-life care. Among the severely ill patients treated in the ICU, there are cases that are judged to be “terminal,” with no prospect of survival, despite appropriate treatment. For these cases, we refer to guidelines and recommendations for end-of-life care, and hold thorough discussions in our multi-disciplinary team conferences based on the patient’s pathology and background to make careful and objective decisions about treatment. In addition, there are many cases in which the patients are unable to make decisions by themselves regarding their treatment, and must entrust decision-making to a family member or the like. For patients who are indicated for blood purification therapy, we “forgo” blood purification therapy after sufficient discussion and consensus building with them, their family or the like. The current novel coronavirus pandemic has created new problems, such as reduced opportunities and time for discussion with their family or others due to visitation restrictions.

Case: A man in his 60s with COVID-19 required mechanical ventilation on day 8 of the illness. On day 12, the P/F ratio reached 120, and veno-venous ECMO （VV-ECMO） was started. His creatinine level increased to 1.45 mg/dL, and high-volume continuous hemofiltration was initiated. On day 19, he developed severe diarrhea, with losses exceeding 2,000 g/day, and metabolic acidosis (pH 7.19). The renal failure worsened (creatinine 1.78 mg/dL). It was difficult to maintain pH when PaCO₂ exceeded 50 mmHg. NaHCO₃ (bicarbonate 35 mEq/L) was added to the replenisher to raise the bicarbonate level to 40 mEq/L, and continuous renal replacement therapy was initiated. The bicarbonate level increased to 27 mEq/L and pH improved to 7.34. However, NaHCO₃ supplementation was discontinued owing to an increased serum sodium level, and metabolic acidosis worsened. Therefore, the same dosage was reinitiated to maintain the pH, and weaning from VV-ECMO was started. VV-ECMO was stopped on day 41. Conclusion: Addition of NaHCO₃ to the dialysate to facilitate prolonged VV-ECMO withdrawal in severe metabolic acidosis can be performed safely. It does not require intravenous access and the risk of infection is lower than with conventional intravenous infusion.

Crush syndrome is one of the emergency medical conditions which is encountered during and after natural disasters. This condition can be managed with dialysis. Circumstances during and after mass disasters are chaotic. There is a lack of medical resources such as equipment, medical supplies and medical staff. Close clinical monitoring of patients is often impossible. Therefore, we have modified the manual for the management of crush syndrome patients, keeping in mind the equipment and drugs available in a dialysis unit, in accordance with the findings of international review papers. The scale of damage that can occur as a consequence of any disaster, natural or man-made, is very unpredictable. It is necessary to establish good protocols for the management of mass disasters, as embodied in Standard Operating Procedures (SOPs). The emergency backup system must be constantly put to the test, and regular disaster management training must be imparted to all personnel involved. It is imperative that an excellent communication network be established between all hospital personnel during any emergency situation. The emergency contact details of all essential personnel must be readily available to everyone concerned.

A 24-hour on duty system was introduced when our hospital moved to a new location. The entire staff, regardless of gender, take turns performing duty operations. In addition, the person on duty is now responsible for acute blood purification operations in the event of an emergency. However, some female CEs (Clinical Engineers) working in clinical settings, including acute blood purification operations, experience difficulty balancing life and work, and end up temporarily leaving the scene. None of the female CEs at this hospital, have taken advantage of maternity or paternity leave and then returned to work, so we do not have any experience in this matter. Consequently, if someone temporarily leaves the worksite due to a life event or other reason in the future, continuing operations with such a vacancy is considered difficult since a backup system has not been established. In addition, since this will lead to a decrease in organizational strength, a review of the system is needed. In order to create an environment where female CEs can continue working, construction and review not only of its organization, but also its support system at facilities and in society as a whole are needed.

We assessed the effects of heat on the extracorporeal circuit in neonatal acute blood purification therapy. We perfused the circuit with blood heated to 36.0 ℃ at 25 ℃ and 27 ℃ room temperatures and measured the temperatures of the venous chamber and patient connections. Thereafter, an incubator was used to measure the temperatures by varying the lengths of the indwelling circuit in the incubator in the open/closed mode. Hence, the temperature decreased gradually from the venous chamber to the patient connection at both 25 ℃ and 27 ℃, but was less at 27 ℃. Generally, the incubator is used to increase the temperature gradually from the venous chamber to the patient connection, with this temperature being the highest at 35.8 ℃ and the indwelling circuit being 80 cm wide in the open mode. These findings suggest that heating the extracorporeal circuits is affected by the environmental and patient’s conditions, including the room temperature, incubator mode, and the indwelling circuit length.

Continuous hemodiafiltration（CHDF）using a cytokine-adsorbing polymethyl methacrylate (PMMA) membrane has been reported to be effective in controlling hypercytokinemia after infection. In this study, we evaluated the efficacy of hemodiafiltration/hemodialysis using a PMMA membrane（PMMA-HDF/HD）. From January 2021 to March 2022, PMMA-HDF/HD was performed in 10 patients with sepsis and high interleukin-6（IL-6）levels (six men/four women, mean age 73.6 ± 14.3 years). IL-6 levels and white blood cell counts significantly decreased after performing PMMA-HDF/HD, and all the patients survived. PMMA-HDF/HD can be used for acute blood purification from the early infection stage because it can provide a treatment regimen close to CHDF in the intensive care unit even in the dialysis room by changing the dialysis conditions, and can therefore, be considered to contribute to the prevention of disease progression.

Patients with acute kidney injury, and patients on maintenance dialysis, requiring intensive care unit（ICU）admission have a considerably poor prognosis; however, this is more dependent on the comorbidities and illness severity than on the renal failure itself. Clinical practice guidelines on shared decision-making for appropriate initiation and withdrawal from dialysis recommend considering a time-limited trial for patients requiring dialysis. However, the recommendation is for patients with uncertain prognoses or if consensus regarding the usefulness of dialysis cannot be obtained. This has been performed in select patients in the ICU. Ideally, intensivists and nephrologists should collaborate in a time-limited trial of dialysis using each other’s strengths. In patients of prolonged ICU stay, difficult withdrawal from continuous renal replacement therapy, and ethically conflicted cases, we actively hold conferences using the Jonsen’s four topics approach with multiple disciplines, including intensivists and nephrologists, to help determine the best treatment strategy. We intend to introduce our dialysis approach for patients with terminal illnesses in the ICU, based on our experience.

Dialysis patients are at high risk for severe illness due to coronavirus disease 2019 (COVID-19). Therefore, all dialysis patients with COVID-19 must be hospitalized for treatment. However, in Tokyo, only a limited number of hospitals can accept dialysis patients with COVID-19, many of whom were unable to be hospitalized when the number of new COVID-19 positive patients rapidly increased. Therefore, in December 2021, the Tokyo Metropolitan Government opened several temporary medical facilities (Oxygen and Medical Care Stations) to provide medical care such as oxygen administration and neutralizing antibody therapy to patients with mild to moderate COVID-19. Among them, one facility was available for hemodialysis treatment. The present study investigated the outcomes for hemodialysis patients with COVID-19 who were admitted to this facility between January 1 and August 31, 2022. The number of hospitalized hemodialysis patients was 211 (mean age 65.1 years). The neutralizing antibody sotrovimab and the antiviral agent molnupiravir were mainly administered at this facility. Ninety-two percent of these patients were discharged home, 6.2％ were transferred to an acute care hospital due to exacerbation, and 1 patient died. This facility contributed to shortening hospitalization waiting lists for hemodialysis patients with COVID-19 and alleviating the tight supply of hospital beds in Tokyo. In addition, treatment for COVID-19 helped to prevent exacerbation. Thus, operation of the facility was effective.

In continuous blood purification (CBP), which is carried out in intensive care unit (ICU) day and night for extended periods, safety management must always be aware of the risks related to extracorporeal circulation, and in addition to hardware safety measures such as the inclusion of safety functions to equipment, software safety measures such as operational systems, education, and interprofessional care are also essential in CBP risk management. In addition to hardware safety measures such as the addition of safety functions to devices, software safety precautions such as operational systems, education, and interprofessional care are also important. At our hospital, a safety system has been built through proactive team medicine intervention, including resident clinical engineer who work in the ICU around the clock and are involved in their various specialties. However, an analysis of the incidents that happened at our hospital showed that one of the background factors was a lack of cooperation and communication due to a clear division of roles, that risk management in CBP needs interprofessional care from multiple perspectives, and that information sharing and communication among the various professions are essential to prevent lack of cooperation. To avoid a lack of coordination, information sharing and communication among the different professions were considered vital.