Since the 1950s, more and more medical equipments have been introduced into the medical field, so that medical professionals are required to operate, maintain, and inspect medical equipments. The Japanese Society of ME and other related academic societies lobbied the government, which led to the Clinical Engineer’s Law being enacted in 1987 and coming into effect in 1988. In 2021, the Clinical Engineer’s Law was revised to allow to secure intravenous lines and administer drugs in intensive care units. Clinical engineers are allowed to operate life-support equipments under the direction of a physician, but their specific duties are not stipulated and it is considered appropriate to take decisions in light of socially accepted norms. Although instructions from a physician are required for a clinical engineer to perform medical procedures, physicians do not necessarily have knowledge about studies that form the basis of the medical procedures performed by the clinical engineer. Therefore, the performance of medical procedures by clinical engineers not only requires one-way instructions from the physician to the clinical engineer, but also two-way communication that includes consultation of and suggestions from the clinical engineer.

Physical therapy in the ICU for patients with acute respiratory failure during ventilatory management or in the perioperative period. Used to focus on chest physiotherapy the importance of early mobilization and exercise therapy has been emphasized since the late 2000s. Early rehabilitation in the ICU in Japan has often been performed empirically before, but, the standard physical therapy was proposed by Evidence based expert consensus for early rehabilitation in the intensive care unit in 2017. In 2018, the Japanese national health insurance system introduced a financial incentive scheme to promote early mobilization and rehabilitation in ICUs. In the future, there is an urgent need to verify the efficacy of physical therapy for each disease and to accumulate evidence on the efficacy of physical therapy for elderly patients in ICUs.

Mechanical circulatory support (MCS) devices provide hemodynamic assistance in patients with severe heart failure or shock. Use of temporary MCS has increased dramatically in recent years despite the lack of high-quality evidence, with their use generally based on expert consensus.There is no single treatment that is suitable for every patient with cardiogenic shock, as the clinical condition varies among patients and also changes rapidly. Therefore, use of MCS should be tailored based on the severity, phenotype, and phase of the disease in each individual patient.Future studies are needed to clarify the factors that can enable matching of “the right MCS to the right patient at the right time.”

Cardiac arrest occurs in <5% of patients who undergo cardiac surgery. The mechanisms underlying cardiac arrest include fatal arrhythmias, hemorrhagic shock, cardiac tamponade, and bradycardia. Postoperative cardiac arrest often occurs in the intensive care unit; however, as a medical professional is the bystander at the time of the event, the resuscitation rate is high in this clinical setting. Immediate chest compression is not recommended in patients who develop cardiac arrest after cardiac surgery, in contrast to the practice in standard cardiopulmonary resuscitation, considering the risk of injury to the sutured graft and aortic or cardiac rupture when chest compression is performed too soon after the procedure. Guidelines recommend resuscitation interventions that avoid chest compression for 1 min. Concurrent with that response, preparation for resternotomy is important. Chest compressions aimed at achieving a systolic blood pressure of 60 mm Hg should be initiated if the heartbeat is not restored after a 1-min response. In the first minute after cardiac arrest, three consecutive shocks for shockable rhythms (ventricular fibrillation) should be administered. Shock may be ineffective in cases of severe bradycardia and asystole, and pacing is preferable using the pacing lead inserted intraoperatively; if the 1-min intervention is unsuccessful, open chest cardiac massage with re-sternotomy should be initiated within 5 min. Immediate resternotomy is not recommended after the 10th postoperative day. Simulation training is useful for an appropriate response to cardiac arrest after cardiac surgery.

Gut microbiota are closely related to host metabolism and immunity. When the host is severely invaded, a rapid change occurs in which the number and the proportion of resident bacteria decrease and pathogenic bacteria increase in the gut. This change also induces bacterial translocation and changes in immune function, which cause systemic inflammation originating from the intestinal tract. To ameliorate these effects, enteric therapies such as selective digestive decontamination, probiotics or synbiotics therapy, and fecal microbiota transplantation have been performed on critically ill patients. There are also expectations for new intestinal treatments that target gut microbiota, such as bacterial cocktail therapy and phage therapy. This review outlines the relationship between the gut microbiota and the host, describes the characteristics of the gut microbiota of critically ill patients, and summarizes the current status and prospects of enteric therapies.

Background: The efficacy of skin counter warming (SCW) at extremities during targeted temperature management (TTM) in preventing shivering is still unclear. Methods: In this single-center, randomized, controlled study, adult patients who had undergone TTM for more than 24 hours either received SCW only at extremities or did not receive SCW. Extracorporeal membrane oxygenation (ECMO) or intravascular cooling devices were used as cooling methods. We assessed the occurrence of shivering every 1 hour. The primary outcome was the number of shivering for 24 hours after initiating SCW. Results: After randomization, 39 patients were included in the analysis (20 and 19 in SCW and non-SCW group, respectively). Median age was 60 years [IQR 52–73 years], 77% patients were males, and there were no differences in baseline characteristics. Skin temperature at all extremities was significantly increased 8 hours after initiation of SCW; however, no differences were observed in the number of shivering for 24 hours after initiating SCW (SCW group, median 1.5 [0–7] vs. non-SCW group, 6 [1–11]; P=0.18). Moreover, there was no change in the number of shivering and the Bedside Shivering Assessment Scale for every 8 hours, and in total 24-hour doses of sedatives and opioid in both groups. Conclusion: SCW only at extremities did not prevent shivering in patients who had undergone TTM.

Background: Acute kidney injury is common in ICUs; however, it lacks established treatments, often requiring continuous renal replacement therapy (CRRT). The extracorporeal circulation is prone to blood coagulation, leading to treatment interruptions and reduced efficiency. Nafamostat mesylate is widely used in Japan for its anticoagulant properties and a short half-life, suggesting reduced bleeding risks. However, its optimal use in critically ill patients remain unclear. Methods: A scoping review was performed to summarise comprehensively about using nafamostat mesylate during CRRT and its effects on filter life. MEDLINE, Embase, Cochrane EBM Reviews, and ICHUSHI were searched in December 2023. It included studies reporting on filter life if using nafamostat for CRRT anticoagulation in any forms of reports, including original data. Screening was performed independently by two researchers, based on titles and abstracts, followed by full-text reviews to finalise the selection. Study characteristics and details on using nafamostat were collected. Results: Of 357 records screened, 32 studies were eligible, most being observational studies. Nafamostat doses reportedly ranged from 10–40 mg/hr, with the majority around 30 mg/hr. Eleven studies reported activated clotting time (ACT) values, with seven adjusting nafamostat doses accordingly. Target ACT levels varied widely, with some studies maintaining a fixed dose. Filter life spanned from 11.8–54.6 hr, with a weighted average of 34.1 hr. Hemorrhagic complications’ rate during CRRT ranged 0–6.6% for filter numbers, and high transfusion rates were noted. Conclusions: In using nafamostat as an anticoagulant during CRRT, filters typically last approximately 34 hours on average. Doses varied, with most studies monitoring anticoagulant function with ACT. However, patient characteristics and membrane selection may influence filter life. The findings suggest a need for further research to standardise the optimal use of nafamostat during CRRT.

Bronchobiliary fistula, characterized by bile leakage into the bronchial tree and consequent chemical pneumonia is rare, and currently, there is no consensus regarding the treatment strategy. An 82-year-old man developed recurrent chronic respiratory infection secondary to bronchobiliary fistula after treatment for hepatocellular carcinoma. He had a history of external choledochostomy with stable symptoms. However, external drainage tube obstruction caused chemical pneumonia with bile aspiration. His respiratory condition worsened, which necessitated intensive care unit admission, and he was intubated using a double-lumen tube. Differential lung ventilation was performed to protect the contralateral lung. After changing the external drainage tube to the bigger one, the bile reflux volume was evaluated using a bronchoscope when changing the ventilator settings, changing the patient’s body position, and at initiation of enteral nutrition, which reduced bile reflux and improved the patient’s respiratory status. Protection of the contralateral lung and prompt control of bile reflux with external drainage are essential in patients with bronchobiliary fistula.

Pharmacists are crucial members of the multidisciplinary team caring for critically ill patients. Patient management by pharmacists in the ICU involves ensuring the quality of both direct and indirect care as well as honing professionalism as critical care pharmacists. “Position paper on critical care pharmacists in Japan” aptly outlines balanced behavioral objectives across these three domains. However, there is concern that the heterogeneity of processes for assessing patients and managing the workforce in clinical practice may lead to variability in patient outcomes. In addition, education for pharmacists to provide pharmacological care in the ICU is not widespread among all pharmacists. Demonstrating and continually refining appropriate indicators, along with providing systematic education on intensive care medicine not only to pharmacists but also to pharmacy students, may contribute to the continued evolution of critical care pharmacists in the ICU. The anticipated evolution of patient management by critical care pharmacists in the ICU is expected not only to deliver appropriate pharmacotherapy but also to contribute to further enhance patient outcomes further.

Primary brain injuries, such as traumatic brain injury and stroke, can cause intricate progressive pathophysiological changes, including cerebral edema and seizures, which could contribute to secondary brain injuries. The brain's fragility also allows irreversible damage of the brain, even within a short period. Cerebral multimodality monitoring (MMM), which includes multiple indicators (e.g., intracranial pressure monitoring, electroencephalography, and so on) to assess multidimensional brain function, is essential, as it allows us to optimize advanced care and minimize the risk of secondary brain injuries. However, no standards have been established yet for implementation of MMM. Additionally, not all of the devices and technologies that are standard outside of Japan are available in Japan. This review offers a literature-based overview, including highlighting the characteristics of each device utilized for MMM.

Little research, both in terms of quantity and quality, has been published in the field of pediatric critical care medicine as compared with that in the fields of neonatal and adult critical care medicine. This is due to patient heterogeneity, rarity, and ethical constraints, for example, in decision-making, growth and developmental considerations, and surrogate involvement in pediatric patients. Additionally, there is also a lack of research resources and support, including research grants. In addition, the mindset of pediatric intensivists towards research is also thought to be an important factor. Since its inception, the focus of education and scholarly activity in this field has been on the distribution and sharing of knowledge and experience, and creation of new knowledge is a relatively minor activity. Physicians, as specialists, should recognize academic activities as part of the standard of care and contribute to academic maturation of the field. The potential for future pediatric critical care medicine research will be described, focusing on data utilization and artificial intelligence, the practice of multicenter and international collaborative research, and the challenges and solutions in planning issues with sustainable medicine in mind.