To perform blood purification therapy（BPT）, it is important to ensure that vascular access can be placed safely and used without interrupting treatment. To maintain stable vascular access for newborns it is necessary to master catheter puncturing and inserting techniques, to select an appropriate insertion site, adjust the tip position according to each neonatal patient, and manage catheter use appropriately. Among these, the selection of a dialysis catheter is extremely important. However, there is little data regarding the use of dialysis catheters in neonates. In the United States, it has been reported that using a 6Fr central venous catheter（CVC）in newborns, instead of a 7Fr dialysis catheter, reduces the incidence of complications and facilities a more stable dialysis process. In Europe, the conventional approach is to use 4-5Fr CVCs instead of dialysis catheters. In Japan, neonatal BPT can be safely performed with the use of 6Fr dialysis catheters, which are commercially available. However, smaller infants, weighing less than 2kg, require CVCs alternatives rather than dialysis catheters.

Multimodal approach (MMA) is reported to be useful to stabilize hemodynamics and fluid management during renal replacement therapy for critically ill patients. This method uses long-term dialysis and multiple dialysis techniques, such as high-sodium, low temperature, acetate-free, and high-calcium dialysates. From Schortgen’s report in 2000, MMA has been gradually developed and reported to improve prognosis. MMA may alleviate hemodynamic instability, which is a weak point of intermittent dialysis (IHD). Therefore, in selecting IHD or continuous renal replacement therapy (CRRT), it may be important to consider CRRT trauma in addition to hemodynamics changes. We utilized the MMA from 2019 in our intensive care unit. We used continuous intravenous NaCl infusion instead of high-sodium dialysate, considering a large sodium loss by fluid removal through ultrafiltration, and applying it to CRRT. We detected various clinical outcome improvements.

Presepsin (P-SEP) a sepsis biomarker developed in Japan, is covered by insurance, and widely used in clinical practice. It was considered that it should not be used alone as a diagnostic tool, and it was, accordingly, positioned as an auxiliary diagnostic marker. However, there have been several reports from Japan, in recent years, that P-SEP is more useful than other biomarkers in the prediction and monitoring of infections in various postoperative patients. Because sepsis is associated with organ damage such as acute kidney injury and disseminated intravascular coagulation that increases the mortality rate, P-SEP has been found to be useful in evaluating and monitoring the severity of sepsis cases. Additionally, it serves as a valuable criterion for antibiotic discontinuation. These findings are summarized in the following review.

Introduction: Nutritional therapy for critically ill patients receiving continuous renal replacement therapy (CRRT) should consider the hypermetabolic status and amino acid loss due to CRRT. Objective: We conducted this retrospective study to evaluate the effect of protein intake of ≥1.5 g/kg/day during CRRT. Methods: We compared the data of 52 patients who received ＜1.5 g protein/kg/day from day 7 to day 10 (group L) with the data of 53 patients who received ＞1.5 g protein/kg/day (group H). Results: The two groups did not differ in their baseline characteristics. The CRRT purification was significantly greater in the H group than in the L group. The amount of protein received was significantly higher in the H group than in the L group after the 4th day. On the 10th day, protein intake in the H group was 1.8 g/kg and that in the L group was 1.1 g/kg (p＜0.001). The sufficiency rate for target energy was significantly higher in the H group than in the L group on the 8th and 10th day. The serum albumin level was significantly higher in the H group than in the L group on the 14th and 21st day (p＜0.05). The functional independence measure effectiveness was significantly higher in the H group than in the L group (p＜0.01). Conclusions: Our results indicated that a high protein intake of ≥1.5 g/kg/day improved the actives of daily living.

We investigated the association between circuit clotting during continuous renal replacement therapy (CRRT) and blood coagulation-fibrinolysis system using fibrin monomer complex (FMC) and plasmin-α2-plasmin inhibitor complex (PIC). We retrospectively analyzed data of 53 patients who received CRRT between January 2016 and September 2023．Nafamostat mesilate was used as an anticoagulant. Patients were divided into two groups: the coagulation group, which included patients who required an unexpected exchange of CRRT circuit due to adverse coagulative events, and the non-coagulation group without circuit coagulation. Before CRRT initiation, FMC and PIC were significantly high in the coagulation group. Increase in FMC was independently significant by logistic analysis, and its cut-off value was 150μg/mL. In the non-coagulation group, FMC was positively correlated with PIC before CRRT initiation. In addition, the association between the changes in FMC and PIC as variations between data before CRRT and at day 2 after CRRT initiation showed that PIC was elevated in this group, which correlated with FMC levels. However, in the coagulation group, the change in PIC did not correlate with changes in FMC and plasminogen levels after CRRT initiation. Thus, we concluded that the coagulation group is in a hypercoagulable state before initiation of CRRT, and FMC ≧150μg/mL could be an indicator for circuit clotting. Furthermore, it is hypothesized that the coagulation and fibrinolysis systems would be interrupted, with the fibrinolysis system being suppressed in the coagulation group. Therefore, inhibition of anti-fibrinolytic pathway might be important for maintaining a non-clotting circulation in CRRT.

Adacolumn^®, a purifier for blood cell removal, is a blood purification column that was listed in Japanese insurance in 2000 for inducing remission in active ulcerative colitis. We participated in a clinical trial conducted to expand the indication of Adacolumn^® for the treatment of sepsis. Herein, we aimed to report on our experience using this device. Nine patients with sepsis were registered at our facility; two patients with worsening symptoms discontinued the trial midway. No serious adverse events were observed during administration. One patient experienced a decrease in blood pressure while administering Adacolumn^®. The APACHE Ⅱ score of the nine patients who had enrolled for the study was 29.4 ± 3.8; their SOFA score was 8.7 ± 1.1. On the 7th day of illness, seven out of the nine patients（two patients had discontinued the study）displayed a significant SOFA score of 4.0 ± 1.3. A decrease was confirmed（p＝0.0165）. Improvements were also confirmed by measuring other markers; however, because this study was a noninferiority study and the number of patients was small, it was challenging to determine whether the improvement in these values was because of the effects of Adacolumn^® based only on the results of this study.

Objective: We analyzed only the cases experienced at our facility from the multicenter trial data evaluating the safety and efficacy of granulocyte adsorption columns in septic patients. Methods: The study included patients diagnosed as sepsis and with an APACHE Ⅱ score ranging from 17-34．A total of five G-1 direct perfusion (G-1-DHP) procedures were performed within 3 days of intensive care unit (ICU) admission. The primary endpoint was the change in SOFA score from ICU admission to 7 days, and the safety endpoints were adverse events and mortality at 28 days. Results: The study included 20 patients, with a median age of 72.5 years (IQR 68.3-75.8) and a median APACHE Ⅱ score of 23.5 (IQR 20.0-28.8). G-1-DHP demonstrated effective adsorptive removal of granulocytes. The SOFA score significantly decreased from a median of 8 to 3 after 7 days (p＜0.01). No adverse events related to G-1 treatment were observed, and all patients survived for 28 days. Conclusion: G-1-DHP is a promising novel treatment for sepsis that may help prevent the progression of organ damage.

[Objective] This study aimed to determine the difference in filter lifetime (FLT) between AN69ST and PMMA membranes during continuous kidney replacement therapy (CKRT) with nafamostat mesylate (NM). [Subjects and Methods] The study included 45 septic patients admitted to our facility between December 2018 and February 2023 and underwent CKRT using AN69ST or PMMA membrane in the initial circuit. NM dosage, circuit activated clotting time (ACT), FLT, and the incidence of circuit clotting within 24 h were compared between the two groups. [Results] The study included 26 and 19 patients in the AN69ST and PMMA groups, respectively. The NM dosage was 30 (20-30) and 14 (8-20) mg/h and the ACT was 176 (147-198) and 241 (204-326) sec in the AN69ST and PMMA groups, respectively (p ＜ 0.01 for both). However, FLT was 16.4 (6.5-43.5) and 27.7 (14.5-35.8) h in the AN69ST and PMMA groups, respectively, with no significant difference between the two groups (p=0.69). Further, the incidence of circuit clotting within 24 h was 16 (61.5%) and 10 circuits (52.6%) in the AN69ST and PMMA groups, respectively, with no significant difference between the two groups (p=0.55). [Conclusion] We did not find any significant differences in FLT between the AN69ST and PMMA groups.

There is very little information on pharmacokinetics during sustained low-efficiency diafiltration (SLED-f), and no dosage standard for vancomycin (VCM) has been established. This report describes a case in which blood VCM levels were measured before and after SLED-f to determine VCM clearance. The patient was on maintenance dialysis for end-stage renal failure and was rushed to our hospital because of respiratory distress and swelling of the entire face. Pulmonary edema was observed and sepsis associated with left orbital cellulitis was diagnosed. Two grams of VCM (28 mg/kg) was administered as the initial dose, and SLED-f was performed 30 min after the end of administration. The SLED-f hemofilter membrane material was polymethyl methacrylate (1.8 m²), with settings of blood flow rate 200 mL/min, dialysate flow rate 2 L/h, filtration flow rate 2.9 L/h, and replacement flow rate 2.5 L/h. Dialysis time was 6 h. The blood VCM levels immediately before the start of SLED-f and 1 h after the end of SLED-f were 63.3 μg/mL and 22.0 μg/mL, respectively. VCM clearance calculated from the obtained VCM concentration was 5.56 L/h, equivalent to normal renal function. This study reported only one case, and further data accumulation is required to clarify the relationship between SLED-f dialysis and VCM clearance and to accumulate useful information for dosing regimens.

Acute infectious purpura fulminans (AIPF) causes various infections and has a high mortality rate. Due to its rapid progress, AIPF requires early intervention mainly with systemic management. We experienced a case of AIPF triggered by toxic shock syndrome (TSS), in which we achieved a good outcome with multidisciplinary treatment including hemocatharsis therapy, which has rarely been reported in Japan. A female patient in her 40s consulted her local doctor with a chief complaint of fever and hypogastric pain. She was diagnosed with septic shock due to urogenital infection and referred to our hospital for intensive care management. We suspected menstrual TSS based on her medical history and various examinations and physical findings, and several treatments were initiated. A finding of systemic purpura after hospitalization suggested AIPF, and CBP with PMX-DHP and CAH were administered. Shock resolved after treatment with PMX-DHP. Given that TSS is a factor in AIPF, we believe that inflammation control by continuous and rapid hemocatharsis therapy may be a useful therapeutic option.

Hemofeel^TMSNV (SNV) is a hemofilter for continuous renal replacement therapy (CRRT). SNV contains a highly permeable polysulfone hollow fiber membrane with hydrophilic polymer (NV polymer) to improve biocompatibility. In this report, we compared the characteristics of SNV with those of a conventional filter, and found that SNV showed lower protein and platelet adhesion to the surface of the hollow fiber membrane and improved performance in maintaining solute removal and water permeability over a long period of time. Therefore, SNV shows potential to become an appropriate filter for CRRT to achieve planned treatment time and prolong the filter life-span.

The external jugular vein is rarely used as an emergency vascular access during emergency blood purification. Being a superficial blood vessel, the external jugular vein’s course can be visually confirmed, facilitating an easy puncture. Direct puncturing into the external jugular vein allows for rapid vascular access. The right external jugular vein is recommended for hemodialysis catheter placement. For a non-cuffed catheter, the puncture should occur 1 to 2 cm away from the right external jugular vein, whereas for a tunneled cuffed hemodialysis catheter, the puncture should be slightly toward the clavicle. In the case of tunneled cuffed hemodialysis catheters, a 1-cm wide incision at the puncture site is necessary, and the site should be thoroughly detached to ease subsequent dilatation and catheter placement. In both cases, careful body positioning prevents guidewires from straying into the catheter, and the infection rate is likely low for tunneled cuffed hemodialysis catheters because the exit site is positioned in the anterior thoracic region. The external jugular vein can be safely secured with a relatively straightforward technique and is considered a useful alternative for emergency vascular access.

Recently, prevention of post intensive care syndrome (PICS) in the intensive care field has been attracting attention, and early mobilization has been shown to be one of the strategies. Continuous blood purification (CBP) is often selected for critically ill patients who require acute blood purification therapy in the ICU due to hemodynamic instability, but the implementation rate of rehabilitation is low for CBP patients. reported to be low. Although our hospital recognizes the need for interventions to reduce prolonged immobility during CBP, it has been difficult to leave the bed during CBP for risk management reasons. However, by making physical therapists full-time, they participate in multidisciplinary conferences, coordinate schedules with other professions, set goals and share problems, etc., and by intervening with multiple professions, sufficient risk management can be achieved.

In the intensive care unit (ICU), medical care for the most critically ill patients is provided collaboratively by a multidisciplinary team with specialized expertise. Pharmacists working in the ICU must leverage their knowledge as pharmaceutical experts to contribute to the improvement of the quality of pharmacotherapy for patients. In the ICU, blood purification therapy is frequently performed for patients with severe conditions, including sepsis. Given that this treatment may also remove essential medications, it is necessary to develop administration plans while considering the removal of drugs. A comprehensive understanding of pharmacokinetics, the principles of blood purification therapy, and drug clearance is crucial for optimizing drug therapy during blood purification. To incorporate administration strategies that consider the effects of blood purification therapy in actual clinical practice, it is essential to foster collaboration among various professionals, including physicians, nurses, and clinical engineers. It is speculated that such interdisciplinary collaboration contributes to enhancing the quality of drug administration during blood purification therapy.

For continuous blood purification（CBP）therapy, it is challenging to secure routes, especially in patients who are children. In those patients vascular access can be achieved using an extracorporeal membrane oxygenation (ECMO) circuit. However, this approach has risk of bleeding through the connections or introducing air into the ECMO circuit, requiring better safety measures to anticipate such complications. Although there are various connection methods, our institution performs blood return and withdrawal for CBP at the ECMO venous drainage site and ECMO arterial infusion site, respectively. During this process, when the ECMO venous drainage operates under strong negative pressure, causing the CBP return pressure to become negative as well, additional resistance is incorporated at the CBP return site to counteract the impact. Using this approach, we confirmed that CBP could be safely performed without being affected by negative pressure from the ECMO circuit drainage.