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Latronico N, Gosselink R. A guided approach to diagnose severe muscle weakness in the intensive care unit. Rev Bras Ter Intensiva 2015; 27:199-201. [PMID: 26376161 PMCID: PMC4592111 DOI: 10.5935/0103-507x.20150036] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 07/23/2015] [Indexed: 01/14/2023] Open
Affiliation(s)
- Nicola Latronico
- Department of Anesthesia, Critical Care Medicine and Emergency, Spedali Civili University Hospital, Brescia, IT
| | - Rik Gosselink
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, BE
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Hermans G, Van den Berghe G. Clinical review: intensive care unit acquired weakness. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:274. [PMID: 26242743 PMCID: PMC4526175 DOI: 10.1186/s13054-015-0993-7] [Citation(s) in RCA: 391] [Impact Index Per Article: 43.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A substantial number of patients admitted to the ICU because of an acute illness, complicated surgery, severe trauma, or burn injury will develop a de novo form of muscle weakness during the ICU stay that is referred to as “intensive care unit acquired weakness” (ICUAW). This ICUAW evoked by critical illness can be due to axonal neuropathy, primary myopathy, or both. Underlying pathophysiological mechanisms comprise microvascular, electrical, metabolic, and bioenergetic alterations, interacting in a complex way and culminating in loss of muscle strength and/or muscle atrophy. ICUAW is typically symmetrical and affects predominantly proximal limb muscles and respiratory muscles, whereas facial and ocular muscles are often spared. The main risk factors for ICUAW include high severity of illness upon admission, sepsis, multiple organ failure, prolonged immobilization, and hyperglycemia, and also older patients have a higher risk. The role of corticosteroids and neuromuscular blocking agents remains unclear. ICUAW is diagnosed in awake and cooperative patients by bedside manual testing of muscle strength and the severity is scored by the Medical Research Council sum score. In cases of atypical clinical presentation or evolution, additional electrophysiological testing may be required for differential diagnosis. The cornerstones of prevention are aggressive treatment of sepsis, early mobilization, preventing hyperglycemia with insulin, and avoiding the use parenteral nutrition during the first week of critical illness. Weak patients clearly have worse acute outcomes and consume more healthcare resources. Recovery usually occurs within weeks or months, although it may be incomplete with weakness persisting up to 2 years after ICU discharge. Prognosis appears compromised when the cause of ICUAW involves critical illness polyneuropathy, whereas isolated critical illness myopathy may have a better prognosis. In addition, ICUAW has shown to contribute to the risk of 1-year mortality. Future research should focus on new preventive and/or therapeutic strategies for this detrimental complication of critical illness and on clarifying how ICUAW contributes to poor longer-term prognosis.
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Affiliation(s)
- Greet Hermans
- Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium. .,Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - Greet Van den Berghe
- Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium. .,Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.
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53
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Critical illness polyneuropathy and myopathy in a rural area in Vietnam. J Neurol Sci 2015; 357:276-81. [PMID: 26276515 DOI: 10.1016/j.jns.2015.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/16/2015] [Accepted: 08/04/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Critical illness polyneuropathy, myopathy and polyneuromyopathy, grouped under the term CIP/CIM, share several risk factors and are associated with debilitating outcomes. OBJECTIVE To assess the incidence and distribution of CIP/CIM subtypes and evaluate the risk factors and outcomes of CIP/CIM in a rural hospital in Vietnam. METHOD One hundred and thirty three critically ill patients treated more than ten days in the ICU were enrolled. The Medical Research Council (MRC) sum scores and the Overall Neuropathy Limitations Scale (ONLS) score were calculated and risk factors were monitored. Extensive electrodiagnostic investigations were performed to confirm the diagnosis of CIP/CIM. RESULTS CIP/CIM was diagnosed in 73 (55%) patients. The distribution of polyneuropathy, myopathy and polyneuromyopathy was 35 (48%), 16 (22%) and 22 (30%), respectively. Independent risk factors included systemic inflammatory response syndrome, shock, and electrolyte disturbances. Compared to patients without CIP/CIM, patients with CIP/CIM experienced a mortality rate of 49% vs. 30%, a length of stay in ICU of 20.3days vs. 14.3days, an ONLS score at day thirty of 4.2 vs. 1.3 and at day ninety of 2.7 vs. 1.8. CONCLUSION The study revealed that the diagnosis of CIP/CIM was associated with significantly poorer outcomes in comparison to controls.
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Cardiovascular and Pulmonary Research. Cardiopulm Phys Ther J 2015. [DOI: 10.1097/cpt.0000000000000008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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55
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Wieske L, Dettling-Ihnenfeldt DS, Verhamme C, Nollet F, van Schaik IN, Schultz MJ, Horn J, van der Schaaf M. Impact of ICU-acquired weakness on post-ICU physical functioning: a follow-up study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:196. [PMID: 25928709 PMCID: PMC4427976 DOI: 10.1186/s13054-015-0937-2] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Accepted: 04/21/2015] [Indexed: 01/04/2023]
Abstract
Introduction ICU-acquired weakness is thought to mediate physical impairments in survivors of critical illness, but few studies have investigated this thoroughly. The purpose was to investigate differences in post-ICU mortality and physical functioning between patients with and without ICU-acquired weakness at 6 months after ICU discharge. Method ICU patients, mechanically ventilated ≥2 days, were included in a single-center prospective observational cohort study. ICU-acquired weakness was diagnosed when the average Medical Research Council score was <4 in awake and attentive patients. Post-ICU mortality was recorded until 6 months after ICU discharge; in surviving patients, physical functioning was assessed using the Short-Form Health Survey physical functioning domain. The independent effect of ICU-acquired weakness on post-ICU mortality was analyzed using a multivariable Cox proportional hazards model. The independent effect of ICU-acquired weakness on the physical functioning domain score was analyzed using a multivariable linear regression model. Results Of the 156 patients included, 80 had ICU-acquired weakness. Twenty-three patients died in the ICU (20 with ICU-acquired weakness); during 6 months follow-up after ICU discharge another 25 patients died (17 with ICU-acquired weakness). Physical functioning domain scores were available for 96 survivors (39 patients with ICU-acquired weakness). ICU-acquired weakness was independently associated with an increase in post-ICU mortality (hazard ratio 3.6, 95% confidence interval, 1.3 to 9.8; P = 0.01) and with a decrease in physical functioning (β: -16.7 points; 95% confidence interval, -30.2 to -3.1; P = 0.02). Conclusion ICU-acquired weakness is independently associated with higher post-ICU mortality and with clinically relevant lower physical functioning in survivors at 6 months after ICU discharge. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0937-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luuk Wieske
- Department of Intensive Care Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Department of Neurology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | | | - Camiel Verhamme
- Department of Neurology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Frans Nollet
- Department of Rehabilitation, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Ivo N van Schaik
- Department of Neurology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Marcus J Schultz
- Department of Intensive Care Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Janneke Horn
- Department of Intensive Care Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Marike van der Schaaf
- Department of Rehabilitation, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Baum P, Classen J. Long-term recovery in critical illness myopathy is complete, contrary to polyneuropathy. Muscle Nerve 2015; 51:624-5. [DOI: 10.1002/mus.24532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Petra Baum
- Department of Neurology; University Hospital Leipzig; Leipzig Germany
| | - Joseph Classen
- Department of Neurology; University Hospital Leipzig; Leipzig Germany
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[Neurological and psychological long-term effects of sepsis]. Med Klin Intensivmed Notfmed 2014; 109:596-603. [PMID: 25326073 DOI: 10.1007/s00063-014-0380-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 09/04/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND In addition to the limitations to the health-related quality of life that have been compiled with validated test instruments, a number of former sepsis patients suffer from functional impairments, which are categorized under the terms critical illness polyneuropathy (CIP) or critical illness myopathy (CIM), which have been in existence for over 20 years now. CURRENT FOCUS The issues of delirium during intensive therapy and persistent residual neurocognitive impairments, posttraumatic stress disorder (PTSD) and states of depression related to perihospital functional development have increasingly attracted notice. FUTURE The degree of functional deficits resulting from sepsis and the actual quality of life of those affected may, however, be influenced by taking appropriate rehabilitation measures. However, neither therapeutic rehabilitation standards nor any rehabilitation facilities tailored to the needs of these patients currently exist.
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Latronico N, Nattino G, Guarneri B, Fagoni N, Amantini A, Bertolini G. Validation of the peroneal nerve test to diagnose critical illness polyneuropathy and myopathy in the intensive care unit: the multicentre Italian CRIMYNE-2 diagnostic accuracy study. F1000Res 2014; 3:127. [PMID: 25309729 PMCID: PMC4184363 DOI: 10.12688/f1000research.3933.1] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2014] [Indexed: 11/15/2023] Open
Abstract
OBJECTIVES To evaluate the accuracy of the peroneal nerve test (PENT) in the diagnosis of critical illness polyneuropathy (CIP) and myopathy (CIM) in the intensive care unit (ICU). We hypothesised that abnormal reduction of peroneal compound muscle action potential (CMAP) amplitude predicts CIP/CIM diagnosed using a complete nerve conduction study and electromyography (NCS-EMG) as a reference diagnostic standard. DESIGN prospective observational study. SETTING Nine Italian ICUs. PATIENTS One-hundred and twenty-one adult (≥18 years) neurologic (106) and non-neurologic (15) critically ill patients with an ICU stay of at least 3 days. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS PATIENTS underwent PENT and NCS-EMG testing on the same day conducted by two independent clinicians who were blind to the results of the other test. Cases were considered as true negative if both NCS-EMG and PENT measurements were normal. Cases were considered as true positive if the PENT result was abnormal and NCS-EMG showed symmetric abnormal findings, independently from the specific diagnosis by NCS-EMG (CIP, CIM, or combined CIP and CIM). All data were centrally reviewed and diagnoses were evaluated for consistency with predefined electrophysiological diagnostic criteria for CIP/CIM. During the study period, 342 patients were evaluated, 124 (36.3%) were enrolled and 121 individuals with no protocol violation were studied. Sensitivity and specificity of PENT were 100% (95% CI 96.1-100.0) and 85.2% (95% CI 66.3-95.8). Of 23 patients with normal results, all presented normal values on both tests with no false negative results. Of 97 patients with abnormal results, 93 had abnormal values on both tests (true positive), whereas four with abnormal findings with PENT had only single peroneal nerve neuropathy at complete NCS-EMG (false positive). CONCLUSIONS PENT has 100% sensitivity and high specificity, and can be used to diagnose CIP/CIM in the ICU.
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Affiliation(s)
- Nicola Latronico
- Department of Anesthesia and Critical Care Medicine, University of Brescia at Spedali Civili, Brescia, 25123, Italy
| | - Giovanni Nattino
- Department of Clinical Epidemiology, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Ranica (BG), 24020, Italy
| | - Bruno Guarneri
- Department of Neuroscience, Section of Clinical Neurophysiology, Spedali Civili, Brescia, 25123, Italy
| | - Nazzareno Fagoni
- Department of Anesthesia and Critical Care Medicine, University of Brescia at Spedali Civili, Brescia, 25123, Italy
- Department of Anesthesia and Critical Care Medicine, Section of Neuroanesthesia and Neurocritical Care, University of Brescia at Spedali Civili, Brescia, 25123, Italy
| | - Aldo Amantini
- Department of Neuroscience, Section of Clinical Neurophysiology, Azienda Ospedaliero-Universitaria Careggi, Firenze, 50134, Italy
| | - Guido Bertolini
- Department of Clinical Epidemiology, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Ranica (BG), 24020, Italy
| | - and GiVITI Study Investigators
- Department of Anesthesia and Critical Care Medicine, University of Brescia at Spedali Civili, Brescia, 25123, Italy
- Department of Clinical Epidemiology, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Ranica (BG), 24020, Italy
- Department of Neuroscience, Section of Clinical Neurophysiology, Spedali Civili, Brescia, 25123, Italy
- Department of Anesthesia and Critical Care Medicine, Section of Neuroanesthesia and Neurocritical Care, University of Brescia at Spedali Civili, Brescia, 25123, Italy
- Department of Neuroscience, Section of Clinical Neurophysiology, Azienda Ospedaliero-Universitaria Careggi, Firenze, 50134, Italy
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Latronico N, Nattino G, Guarneri B, Fagoni N, Amantini A, Bertolini G. Validation of the peroneal nerve test to diagnose critical illness polyneuropathy and myopathy in the intensive care unit: the multicentre Italian CRIMYNE-2 diagnostic accuracy study. F1000Res 2014; 3:127. [PMID: 25309729 PMCID: PMC4184363 DOI: 10.12688/f1000research.3933.3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2014] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To evaluate the accuracy of the peroneal nerve test (PENT) in the diagnosis of critical illness polyneuropathy (CIP) and myopathy (CIM) in the intensive care unit (ICU). We hypothesised that abnormal reduction of peroneal compound muscle action potential (CMAP) amplitude predicts CIP/CIM diagnosed using a complete nerve conduction study and electromyography (NCS-EMG) as a reference diagnostic standard. DESIGN prospective observational study. SETTING Nine Italian ICUs. PATIENTS One-hundred and twenty-one adult (≥18 years) neurologic (106) and non-neurologic (15) critically ill patients with an ICU stay of at least 3 days. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS PATIENTS underwent PENT and NCS-EMG testing on the same day conducted by two independent clinicians who were blind to the results of the other test. Cases were considered as true negative if both NCS-EMG and PENT measurements were normal. Cases were considered as true positive if the PENT result was abnormal and NCS-EMG showed symmetric abnormal findings, independently from the specific diagnosis by NCS-EMG (CIP, CIM, or combined CIP and CIM). All data were centrally reviewed and diagnoses were evaluated for consistency with predefined electrophysiological diagnostic criteria for CIP/CIM. During the study period, 342 patients were evaluated, 124 (36.3%) were enrolled and 121 individuals with no protocol violation were studied. Sensitivity and specificity of PENT were 100% (95% CI 96.1-100.0) and 85.2% (95% CI 66.3-95.8). Of 23 patients with normal results, all presented normal values on both tests with no false negative results. Of 97 patients with abnormal results, 93 had abnormal values on both tests (true positive), whereas four with abnormal findings with PENT had only single peroneal nerve neuropathy at complete NCS-EMG (false positive). CONCLUSIONS PENT has 100% sensitivity and high specificity, and can be used as a screening test to diagnose CIP/CIM in the ICU.
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Affiliation(s)
- Nicola Latronico
- Department of Anesthesia and Critical Care Medicine, University of Brescia at Spedali Civili, Brescia, 25123, Italy
| | - Giovanni Nattino
- Department of Clinical Epidemiology, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Ranica (BG), 24020, Italy
| | - Bruno Guarneri
- Department of Neuroscience, Section of Clinical Neurophysiology, Spedali Civili, Brescia, 25123, Italy
| | - Nazzareno Fagoni
- Department of Anesthesia and Critical Care Medicine, University of Brescia at Spedali Civili, Brescia, 25123, Italy
- Department of Anesthesia and Critical Care Medicine, Section of Neuroanesthesia and Neurocritical Care, University of Brescia at Spedali Civili, Brescia, 25123, Italy
| | - Aldo Amantini
- Department of Neuroscience, Section of Clinical Neurophysiology, Azienda Ospedaliero-Universitaria Careggi, Firenze, 50134, Italy
| | - Guido Bertolini
- Department of Clinical Epidemiology, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Ranica (BG), 24020, Italy
| | - and GiVITI Study Investigators
- Department of Anesthesia and Critical Care Medicine, University of Brescia at Spedali Civili, Brescia, 25123, Italy
- Department of Clinical Epidemiology, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Ranica (BG), 24020, Italy
- Department of Neuroscience, Section of Clinical Neurophysiology, Spedali Civili, Brescia, 25123, Italy
- Department of Anesthesia and Critical Care Medicine, Section of Neuroanesthesia and Neurocritical Care, University of Brescia at Spedali Civili, Brescia, 25123, Italy
- Department of Neuroscience, Section of Clinical Neurophysiology, Azienda Ospedaliero-Universitaria Careggi, Firenze, 50134, Italy
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