The Tohoku earthquake and tsunami affected a wide area in the northeast of Japan. We are working at the epicenter of the disaster area, the university hospital in Sendai, the capital of Miyagi prefecture, where 10,000 people died and 500 were seriously injured. We performed acute blood purification (BP) at the advanced emergency and critical care center, assisting the hospital at the frontlines of the affected area. Furthermore, we supported chronic hemodialysis patients who were anxious about their regular dialysis getting interrupted due to the suspension of electrical power, water, and medical supply. The injured with critical crush syndrome (CS) had never visited our hospital previously. However, after 11 March 2011, BP was requested for patients with non-surgical multi organ failure (MOF). Pneumonia was a serious complaint, caused by near-drowning, exposure to mine dust in the debris, living in evacuation shelters, or staying in damaged houses. Every resident in the affected area suffered due to the post-disaster environment and the delayed recovery of infrastructure. These factors also threatened the residents’ health by causing acute infections or aggravating their chronic illness. This brought to our attention the necessity of BP for MOF as well as the complications in patients undergoing chronic dialysis. To summarize, different BP strategies should be created for various natural disasters such as earthquakes, whether or not they are accompanied by a tsunami. We should also prepare for dealing with MOF as a part of disaster critical care during the recovery phase.

Using electronic medical record, the association between incidences of episodes of coagulation of PS hemofilters and severity and prognosis of patients receiving CRRT was retrospectively analyzed. The 171 patients who were treated with CRRT with PS hemofilter between March 2008 and September 2012 were divided into two groups: A, 80 patients who had at least more than one episode of coagulation during 24 hr of CRRT; and B, 91 patients who had no episode. There were no differences in the characteristics of patients and prescriptions for CRRT between the two groups. However, the sequential organ failure assessment (SOFA) score in group A was significantly higher than in group B (12.2＋2.7 vs. 10.8＋2.8; P＜0.05). Moreover, the mortality rate of patients in group A during hospitalization was greater than in group B (20 vs. 8; P＜0.05). These findings revealed that coagulation in PS filters in CRRT may be helpful as an indicator for prognosis of patients receiving CRRT.

【Objective】We developed a tapering protocol from high-flow, high-volume CHDF in which dialysate and replacement flow rates was reduced gradually according to procedure intervals (tapering volume CHDF: TV-CHDF).【Patients and methods】Eight septic patients who received high-flow, high-volume CHDF for more than 72 hours consecutively in the past two years were enrolled in this study. Efficacy of TV-CHDF was assessed by changes in SOFA score, catecholamine dose and lactate level.【Results】SOFA score, catecholamine dose, and lactate level decreased with tapering of the amount of dialysate and replacement flow rates.【Conclusions】TV-CHDF resulted in improvement of septic shock and safety performance despite a time-dependent decline in removal efficacy of TV-CHDF. This TV-CHDF for treatment of septic shock may prevent unnecessary removal of essential substances in the blood and result in a favorable outcome.

Carbon dioxide bubbles are generated in the dialysis circuit when continuous renal replacement therapy (CRRT) is performed using a bicarbonate replenisher for hemofiltration. It is reported that this results in a lowering of the liquid surface level in the venous chamber in ACH-Σ^® (hereinafter, Σ) manufactured by Asahi Kasei Medical Co., Ltd. Therefore, we investigated how the difference in the structural design of the blood purification equipment might affect the amount of bubbles generated in the circuit. Method: We changed the normal circuit (N Circuit) of Σ and created a circuit in which the heater located near the inlet of the fluid replacement pump was bypassed (K-B Circuit) and another in which the scale of the fluid replacement pump was bypassed (J-B Circuit). After performing CHF for 2 hours using the N, K-B and J-B circuits with the fluid replacement flow rate set at 1 L/hr, we measured the amount of bubbles generated in the circuits and collected in the trap chamber. We also measured the inlet pressure of the fluid replacement pump of each circuit. Results: A significantly smaller amount of bubbles was generated in the J-B circuit as compared to that in the N and K-B circuits. The inlet pressure of the fluid replacement pump in the J-B circuit was significantly higher than that in the N and K-B circuits. Conclusion: The results of our investigation suggested that lowering of the inlet pressure of the fluid replacement pump might increase in the amount of bubbles generated in the circuit.

Recently, the effectiveness of Long-Term PMX-DHP treatment is reported. We introduced the combination therapy (long term combination method) PMX-DHP and PMMA-CHDF using PMMA membrane at our hospital intensive care unit during from October, 2012. We performed a retrospective study of the clinical usability on the long term combination method. The targets are the 44 cases that had a diagnosis of a septic shock, and treated the long term combination method and/or the PMX-DHP (2 hours), with enforced the PMMA-CHDF (conventional method) at our hospital intensive care unit during the period from October, 2010 to March, 2014. The outcome measures, we had used systolic pressure, catecholamine index, lactic acid level in blood, PaO₂/FiO₂ ratio (P/F ratio), for the numbers of platelet transition, we divided into two groups; the long term combination method group and the conventional method group. In the long term combination method group, there is a tendency to diachronic drop of Catecholamine Index, and it showed the significant improvements during from the initiating the therapy to after 6 hours, but no significant difference was observed between the two groups. Further examination will be necessary in future to prove the effectiveness of Long-Term combination method.

We experienced four cases of streptococcal toxic shock-like syndrome (STSS) requiring multidisciplinary therapy. All cases were middle-aged males with underlying diseases such as chronic kidney disease, liver cirrhosis, etc. Group G hemolytic streptococcus (GGS) was isolated from blood cultures. The chief complaints were high fever, disturbance of consciousness, and difficulty of movement. Although the origin of infection was unclear in one case, suppurative diseases were found in the other three cases. Blood purification with continuous renal replacement therapy was required in three cases. In two severe cases, which presented with leukopenia and thrombocytopenia, the prognosis was poor. Clinical features were consistent with past reports. In recent years, case reports describing STSS due to GGS have increased. Here this clinical entity was recognized as toxic shock-like syndrome characterized with rapid onset of sepsis and extremely poor prognosis. If we examine a middle-aged patient presenting with symptoms such as high fever, disturbance of consciousness, and difficulty of movement associated with an underlying disease, we must consider STSS due to GGS as a component of the differential diagnosis.

A 80-year-old woman was transferred to our medical intensive care unit because of vomiting and unconsciousness. She had taken type 2 diabetes medication for 25 years and had been under hemodialysis therapy for 6 years. Her systolic blood pressure was 91 mmHg. Blood gas analysis revealed severe lactic acidosis: pH 6.724, lactate 30 mmol/L. Sustained low-efficiency dialysis (SLED) with a blood flow rate of 120mL/min and a dialysate flow rate of 300mL/min was initiated to treat the metabolic acidosis. After initiating the SLED, we were informed that she had taken biguanide (buformin) for 5 days. To remove the buformin, high-flow hemodialysis with an increased dialysate flow rate (700mL/min) was performed for 12 hours. She underwent intermittent hemodialysis treatment on the second and the third day. After the treatment, her vital signs were stable and metabolic acidosis improved. Her blood buformin level was 3,790 ng/mL on arrival and 940 ng/mL after hemodialysis on the second day (Cmax 260〜410ng/mL). Biguanide-associated lactic acidosis is a rare but potentially life-threatening complication. In our case, a good prognosis was obtained by prompt diagnosis and early treatment with high-flow hemodialysis.

Reduction ratios of small molecules are influenced not only by the modality of dialysis, but also the molecule size, production rate, clearance, and volume of distribution. Under clinical circumstances, urea and creatinine are often used to assess dialysis efficacy. However, ICU patients usually struggle with hemorrhage, hypercatabolism, muscle atrophy, and other severe clinical problems arising from the large scale of medication and infusion, which might strongly influence the blood concentrations of urea (UN), creatinine (Cre) and uric acid (UA). In this study, the reduction ratios for respective molecules were UN 23.2±24.2% (24 h), 36.2±35.4% (48 h), Cre 25.8±23.9% (24 h)，40.2±29.3% (48 h), UA 39.9±17.7% (24 h) and 58.1±19.8% (48 h). We clarified that the reduction ratio of uric acid was larger than UN at 24 h and 48 h after CRRT initiation. Results show that uric acid is more influenced by the CRRT clearance than UN, because of its small metabolic pool and volume of distribution, which are little influenced by extrinsic factors or production. Further study must be conducted to elucidate the usefulness of the uric acid reduction ratio.

Japan Society for Premature and Newborn Medicine neonatal extra-corporeal hemofiltration guidelines recommend priming with blood products which have corrected levels of potassium, calcium and bicarbonate to prevent hypotension and a reduction in colloid osmotic pressure. We describe a new method of correction in endotoxin absorption therapy by direct hemoperfusion using a polymyxin-B immobilized fiber (PMX) column in three neonates ≤ 2 kg with sepsis at our hospital. We designed a circuit with a PMX column and attached a bypass circuit and hemofilter in tandem. The whole circuit was then filled with blood products. For correction of priming solution, the circuit was changed to the bypass circuit and hemofilter. Our method allowed two types of PMX therapy, sole PMX and combined PMX with hemodiafiltration. For sole PMX, blood flow to the bypass circuit and the hemofilter was shut off with forceps. For PMX with hemodiafiltration, the bypass circuit was shut off with forceps, resulting in a circuit with the PMX column and hemofilter. In all three patients, there were no adverse events, and no sequelae following PMX therapy. Our results suggest that our method safely facilitates combined hemodiafiltration therapy using the same circuit.

We have limited experienced of continuous renal replacement therapy performed in children, in our hospital. Due to differences between children and adults, criteria have yet to be established for indications and settings for acute blood purification. Here we report two cases treated with continuous hemodialysis in children with hyperammonemia. Although we were successful in lowering ammonia levels in both cases, we were unable to save patient 1. Patient 2 recovered and was discharged. Patient 2 was subsequently readmitted with recurrent hyperammonemia associated with infection, and was treated with continuous hemodialysis again. He recovered and was able to undergo a live donor liver transplant. Acute blood purification in cases with metabolic disorders often needs higher blood flow and dialysate flow rates than other cases. More examination of the terms of blood purification induction and settings for therapeutic effect is required to perform the safe and efficacious blood purification for children.

With the development of new technology, recent progress has been made in acute blood purification, including that used in continuous renal replacement therapy (CRRT). CRRT is becoming widely used in intensive care medicine, where safe management of blood purification devices during CRRT is vital, because patients receiving CRRT are often in a critical condition and must be treated over the long term. Clinical engineers are always present in our hospital to manage blood purification devices and troubleshoot. This involvement of clinical engineers has improved the safety and efficacy of the acute blood purification therapy provided at our hospital. We recommend that clinical engineers manage these devices routinely to maximize the safety and success of acute blood purification. Total management of blood purification devices by clinical engineers is useful as risk management in acute blood purification therapy.