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Appleton RT, Kinsella J, Quasim T. The incidence of intensive care unit-acquired weakness syndromes: A systematic review. J Intensive Care Soc 2014; 16:126-136. [PMID: 28979394 DOI: 10.1177/1751143714563016] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
We conducted a literature review of the intensive care unit-acquired weakness syndromes (critical illness polyneuropathy, critical illness myopathy and critical illness neuromyopathy) with the primary objective of determining their incidence as a combined group. Studies were identified through MEDLINE, Embase, Cochrane Database and article reference list searches and were included if they evaluated the incidence of one or more of these conditions in an adult intensive care unit population. The incidence of an intensive care unit-acquired weakness syndrome in the included studies was 40% (1080/2686 patients, 95% confidence interval 38-42%). The intensive care unit populations included were heterogeneous though largely included patients receiving mechanical ventilation for seven or more days. Additional prespecified outcomes identified that the incidence of intensive care unit-acquired weakness varied with the diagnostic technique used, being lower with clinical (413/1276, 32%, 95% CI 30-35%) compared to electrophysiological techniques (749/1591, 47%, 95% CI 45-50%). Approximately a quarter of patients were not able to comply with clinical evaluation and this may be responsible for potential underreporting of this condition.
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Affiliation(s)
- Richard Td Appleton
- NHS Greater Glasgow & Clyde, Department of Anaesthesia, Southern General Hospital, Glasgow, UK
| | - John Kinsella
- Section of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Tara Quasim
- Section of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
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Fan E, Cheek F, Chlan L, Gosselink R, Hart N, Herridge MS, Hopkins RO, Hough CL, Kress JP, Latronico N, Moss M, Needham DM, Rich MM, Stevens RD, Wilson KC, Winkelman C, Zochodne DW, Ali NA. An Official American Thoracic Society Clinical Practice Guideline: The Diagnosis of Intensive Care Unit–acquired Weakness in Adults. Am J Respir Crit Care Med 2014; 190:1437-46. [DOI: 10.1164/rccm.201411-2011st] [Citation(s) in RCA: 248] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Walsh CJ, Batt J, Herridge MS, Dos Santos CC. Muscle wasting and early mobilization in acute respiratory distress syndrome. Clin Chest Med 2014; 35:811-26. [PMID: 25453427 DOI: 10.1016/j.ccm.2014.08.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Survivors of acute respiratory distress syndrome often sustain muscle wasting and functional impairment related to intensive care unit (ICU)-acquired weakness (ICUAW) and this disability may persist for years after ICU discharge. Early diagnosis in cooperative patients by physical examination is recommended to identify patients at risk for weaning failure and to minimize prolongation of risk factors for ICUAW. When possible, early rehabilitation in critically ill patients improves functional outcomes, likely by reducing disuse atrophy. Interventions designed to correct the functional impairment are lacking and further research to delineate the molecular pathways that give rise to ICUAW are needed.
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Affiliation(s)
- Christopher J Walsh
- Department of Medicine, Institute of Medical Sciences, Keenan Centre for Biomedical Science, Li Ka Shing Knowledge institute, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - Jane Batt
- Department of Medicine, Institute of Medical Sciences, Keenan Centre for Biomedical Science, Li Ka Shing Knowledge institute, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care, University of Toronto, Toronto General Hospital, NCSB 11C-1180, 585 University Avenue, Toronto, ON M5G 2N2, Canada
| | - Claudia C Dos Santos
- Department of Medicine, Institute of Medical Sciences, Keenan Centre for Biomedical Science, Li Ka Shing Knowledge institute, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada.
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ROS and RNS signaling in skeletal muscle: critical signals and therapeutic targets. ANNUAL REVIEW OF NURSING RESEARCH 2014; 31:367-87. [PMID: 24894146 DOI: 10.1891/0739-6686.31.367] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The health of skeletal muscle is promoted by optimal nutrition and activity/exercise through the activation of molecular signaling pathways. Reactive oxygen species (ROS) or reactive nitrogen species (RNS) have been shown to modulate numerous biochemical processes including glucose uptake, gene expression, calcium signaling, and contractility. In pathological conditions, ROS/RNS signaling excess or dysfunction contributes to contractile dysfunction and myopathy in skeletal muscle. Here we provide a brief review of ROS/RNS chemistry and discuss concepts of ROS/RNS signaling and its role in physiological and pathophysiological processes within striated muscle.
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Feasibility of neuromuscular electrical stimulation immediately after cardiovascular surgery. Arch Phys Med Rehabil 2014; 96:63-8. [PMID: 25218214 DOI: 10.1016/j.apmr.2014.08.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 08/07/2014] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine the safety and feasibility of neuromuscular electrical stimulation (NMES) from postoperative days (PODs) 1 to 5 after cardiovascular surgery. DESIGN Pre-post interventional study. SETTING Surgical intensive care unit and thoracic surgical ward of a university hospital. PARTICIPANTS Consecutive patients (N=144) who underwent cardiovascular surgery were included. Patients with peripheral arterial disease, psychiatric disease, neuromuscular disease, and dementia were excluded. Patients with severe chronic renal failure and those who required prolonged mechanical ventilation after surgery were also excluded because of the possibility of affecting the outcome of a future controlled study. INTERVENTIONS NMES to the lower extremities was implemented from PODs 1 to 5. MAIN OUTCOME MEASURES Feasibility outcomes included compliance, the number of the patients who had changes in systolic blood pressure (BP) >20 mmHg or an increase in heart rate >20 beats/min during NMES, and the incidence of temporary pacemaker malfunction or postoperative cardiac arrhythmias. RESULTS Sixty-eight of 105 eligible patients participated in this study. Sixty-one (89.7%) of them completed NMES sessions. We found no patients who had excessive changes in systolic blood pressure, increased heart rate, or pacemaker malfunction during NMES. Incidence of atrial fibrillation during the study period was 26.9% (7/26) for coronary artery bypass surgery, 18.2% (4/22) for valvular surgery, and 20.0% (4/20) for combined or aortic surgery. No sustained ventricular arrhythmia or ventricular fibrillation was observed. CONCLUSIONS The results of this study demonstrate that NMES can be safely implemented even in patients immediately after cardiovascular surgery.
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Kukreti V, Shamim M, Khilnani P. Intensive care unit acquired weakness in children: Critical illness polyneuropathy and myopathy. Indian J Crit Care Med 2014; 18:95-101. [PMID: 24678152 PMCID: PMC3943134 DOI: 10.4103/0972-5229.126079] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND AND AIMS Intensive care unit acquired weakness (ICUAW) is a common occurrence in patients who are critically ill. It is most often due to critical illness polyneuropathy (CIP) or to critical illness myopathy (CIM). ICUAW is increasingly being recognized partly as a consequence of improved survival in patients with severe sepsis and multi-organ failure, partly related to commonly used agents such as steroids and muscle relaxants. There have been occasional reports of CIP and CIM in children, but little is known about their prevalence or clinical impact in the pediatric population. This review summarizes the current understanding of pathophysiology, clinical presentation, diagnosis and treatment of CIP and CIM in general with special reference to published literature in the pediatric age group. SUBJECTS AND METHODS Studies were identified through MedLine and Embase using relevant MeSH and Key words. Both adult and pediatric studies were included. RESULTS ICUAW in children is a poorly described entity with unknown incidence, etiology and unclear long-term prognosis. CONCLUSIONS Critical illness polyneuropathy and myopathy is relatively rare, but clinically significant sequelae of multifactorial origin affecting morbidity, length of intensive care unit (ICU) stay and possibly mortality in critically ill children admitted to pediatric ICU.
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Affiliation(s)
- Vinay Kukreti
- Departments of Critical Care, Pediatric Critical Care Unit, The Hospital for Sick Children, Toronto, Canada
| | - Mosharraf Shamim
- Department of Pediatric Critical Care King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Praveen Khilnani
- Pediatric Critical Care Unit, BLK Superspeciality Hospital, New Delhi
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Hasselgren PO. β-Hydroxy-β-methylbutyrate (HMB) and prevention of muscle wasting. Metabolism 2014; 63:5-8. [PMID: 24140096 DOI: 10.1016/j.metabol.2013.09.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 09/17/2013] [Indexed: 01/06/2023]
Affiliation(s)
- Per-Olof Hasselgren
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue ST 919, Boston, MA 02115.
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59
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Paratz JD, Kayambu G. Early exercise and attenuation of myopathy in the patient with sepsis in ICU. PHYSICAL THERAPY REVIEWS 2013. [DOI: 10.1179/1743288x11y.0000000002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Resource-efficient mobilization programs in the intensive care unit: who stands to win? Am J Surg 2013; 206:488-93. [DOI: 10.1016/j.amjsurg.2013.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 02/14/2013] [Accepted: 03/21/2013] [Indexed: 11/21/2022]
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Meyer MJ, Stanislaus AB, Lee J, Waak K, Ryan C, Saxena R, Ball S, Schmidt U, Poon T, Piva S, Walz M, Talmor DS, Blobner M, Latronico N, Eikermann M. Surgical Intensive Care Unit Optimal Mobilisation Score (SOMS) trial: a protocol for an international, multicentre, randomised controlled trial focused on goal-directed early mobilisation of surgical ICU patients. BMJ Open 2013; 3:e003262. [PMID: 23959756 PMCID: PMC3753523 DOI: 10.1136/bmjopen-2013-003262] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Immobilisation in the intensive care unit (ICU) leads to muscle weakness and is associated with increased costs and long-term functional disability. Previous studies showed early mobilisation of medical ICU patients improves clinical outcomes. The Surgical ICU Optimal Mobilisation Score (SOMS) trial aims to test whether a budget-neutral intervention to facilitate goal-directed early mobilisation in the surgical ICU improves participant mobilisation and associated clinical outcomes. METHODS AND ANALYSIS The SOMS trial is an international, multicentre, randomised clinical study being conducted in the USA and Europe. We are targeting 200 patients. The primary outcome is average daily SOMS level and key secondary outcomes are ICU length of stay until discharge readiness and 'mini' modified Functional Independence Measure (mmFIM) at hospital discharge. Additional secondary outcomes include quality of life assessed at 3 months after hospital discharge and global muscle strength at ICU discharge. Exploratory outcomes will include: ventilator-free days, ICU and hospital length of stay and 3-month mortality. We will explore genetic influences on the effectiveness of early mobilisation and centre-specific effects of early mobilisation on outcomes. ETHICS AND DISSEMINATION Following Institutional Review Board (IRB) approval in three institutions, we started study recruitment and plan to expand to additional centres in Germany and Italy. Safety monitoring will be the domain of the Data and Safety Monitoring Board (DSMB). The SOMS trial will also explore the feasibility of a transcontinental study on early mobilisation in the surgical ICU. RESULTS The results of this study, along with those of ancillary studies, will be made available in the form of manuscripts and presentations at national and international meetings. REGISTRATION This study has been registered at clinicaltrials.gov (NCT01363102).
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Affiliation(s)
- Matthew J Meyer
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Anne B Stanislaus
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jarone Lee
- Department of Surgery, Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Karen Waak
- Department of Physical and Occupational Therapy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Cheryl Ryan
- Department of Clinical Nursing Services, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Richa Saxena
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Stephanie Ball
- Department of Clinical Nursing Services, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ulrich Schmidt
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Trudy Poon
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Simone Piva
- Department of Anesthesia, Intensive Care and Perioperative Medicine, University of Brescia at Spedali Civili, Brescia, Italy
| | - Matthias Walz
- UMass Memorial Medical Center and UMass Medical School, Worcester, Massachusetts, USA
| | - Daniel S Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Manfred Blobner
- Klinik für Anaesthesiologie, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Nicola Latronico
- Department of Anesthesia, Intensive Care and Perioperative Medicine, University of Brescia at Spedali Civili, Brescia, Italy
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Universitaet Duisburg-Essen, Germany
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Lee PHU, Vandenburgh HH. Skeletal muscle atrophy in bioengineered skeletal muscle: a new model system. Tissue Eng Part A 2013; 19:2147-55. [PMID: 23574457 DOI: 10.1089/ten.tea.2012.0597] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Skeletal muscle atrophy has been well characterized in various animal models, and while certain pathways that lead to disuse atrophy and its associated functional deficits have been well studied, available drugs to counteract these deficiencies are limited. An ex vivo tissue-engineered skeletal muscle offers a unique opportunity to study skeletal muscle physiology in a controlled in vitro setting. Primary mouse myoblasts isolated from adult muscle were tissue engineered into bioartificial muscles (BAMs) containing hundreds of aligned postmitotic muscle fibers expressing sarcomeric proteins. When electrically stimulated, BAMs generated measureable active forces within 2-3 days of formation. The maximum isometric tetanic force (Po) increased for ∼3 weeks to 2587±502 μN/BAM and was maintained at this level for greater than 80 days. When BAMs were reduced in length by 25% to 50%, muscle atrophy occurred in as little as 6 days. Length reduction resulted in significant decreases in Po (50.4%), mean myofiber cross-sectional area (21.7%), total protein synthesis rate (22.0%), and noncollagenous protein content (6.9%). No significant changes occurred in either the total metabolic activity or protein degradation rates. This study is the first in vitro demonstration that length reduction alone can induce skeletal muscle atrophy, and establishes a novel in vitro model for the study of skeletal muscle atrophy.
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Affiliation(s)
- Peter H U Lee
- Department of Pathology and Laboratory Medicine, The Warren Alpert Medical School of Brown University and The Miriam Hospital, Providence, Rhode Island, USA.
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Sellathurai J, Cheedipudi S, Dhawan J, Schrøder HD. A novel in vitro model for studying quiescence and activation of primary isolated human myoblasts. PLoS One 2013; 8:e64067. [PMID: 23717533 PMCID: PMC3662676 DOI: 10.1371/journal.pone.0064067] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 04/09/2013] [Indexed: 01/01/2023] Open
Abstract
Skeletal muscle stem cells, satellite cells, are normally quiescent but become activated upon muscle injury. Recruitment of resident satellite cells may be a useful strategy for treatment of muscle disorders, but little is known about gene expression in quiescent human satellite cells or the mechanisms involved in their early activation. We have developed a method to induce quiescence in purified primary human myoblasts isolated from healthy individuals. Analysis of the resting state showed absence of BrdU incorporation and lack of KI67 expression, as well as the extended kinetics during synchronous reactivation into the cell cycle, confirming arrest in the G0 phase. Reactivation studies showed that the majority (>95%) of the G0 arrested cells were able to re-enter the cell cycle, confirming reversibility of arrest. Furthermore, a panel of important myogenic factors showed expression patterns similar to those reported for mouse satellite cells in G0, reactivated and differentiated cultures, supporting the applicability of the human model. In addition, gene expression profiling showed that a large number of genes (4598) were differentially expressed in cells activated from G0 compared to long term exponentially proliferating cultures normally used for in vitro studies. Human myoblasts cultured through many passages inevitably consist of a mixture of proliferating and non-proliferating cells, while cells activated from G0 are in a synchronously proliferating phase, and therefore may be a better model for in vivo proliferating satellite cells. Furthermore, the temporal propagation of proliferation in these synchronized cultures resembles the pattern seen in vivo during regeneration. We therefore present this culture model as a useful and novel condition for molecular analysis of quiescence and reactivation of human myoblasts.
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Affiliation(s)
- Jeeva Sellathurai
- Institute of Clinical Research, SDU Muscle Research Cluster (SMRC), University of Southern Denmark, Odense, Denmark
| | | | - Jyotsna Dhawan
- Institute for Stem Cell Biology and Regenerative Medicine (InStem), National Centre for Biological Sciences, Tata Institute of Fundamental Research, Bangalore, India
| | - Henrik Daa Schrøder
- Institute of Clinical Research, SDU Muscle Research Cluster (SMRC), University of Southern Denmark, Odense, Denmark
- Department of Clinical Pathology, Odense University Hospital, Odense, Denmark
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Castillero E, Alamdari N, Aversa Z, Gurav A, Hasselgren PO. PPARβ/δ regulates glucocorticoid- and sepsis-induced FOXO1 activation and muscle wasting. PLoS One 2013; 8:e59726. [PMID: 23555761 PMCID: PMC3605288 DOI: 10.1371/journal.pone.0059726] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 02/17/2013] [Indexed: 01/01/2023] Open
Abstract
FOXO1 is involved in glucocorticoid- and sepsis-induced muscle wasting, in part reflecting regulation of atrogin-1 and MuRF1. Mechanisms influencing FOXO1 expression in muscle wasting are poorly understood. We hypothesized that the transcription factor peroxisome proliferator-activated receptor β/δ (PPARβ/δ) upregulates muscle FOXO1 expression and activity with a downstream upregulation of atrogin-1 and MuRF1 expression during sepsis and glucocorticoid treatment and that inhibition of PPARβ/δ activity can prevent muscle wasting. We found that activation of PPARβ/δ in cultured myotubes increased FOXO1 activity, atrogin-1 and MuRF1 expression, protein degradation and myotube atrophy. Treatment of myotubes with dexamethasone increased PPARβ/δ expression and activity. Dexamethasone-induced FOXO1 activation and atrogin-1 and MuRF1 expression, protein degradation, and myotube atrophy were inhibited by PPARβ/δ blocker or siRNA. Importantly, muscle wasting induced in rats by dexamethasone or sepsis was prevented by treatment with a PPARβ/δ inhibitor. The present results suggest that PPARβ/δ regulates FOXO1 activation in glucocorticoid- and sepsis-induced muscle wasting and that treatment with a PPARβ/δ inhibitor may ameliorate loss of muscle mass in these conditions.
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Affiliation(s)
- Estibaliz Castillero
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Nima Alamdari
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Zaira Aversa
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Aniket Gurav
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Per-Olof Hasselgren
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Abstract
Research supports the provision of physical therapy intervention and early mobilization in the management of patients with critical illness. However, the translation of care from that of well-controlled research protocols to routine practice can be challenging and warrants further study. Discussions in the critical care and physical therapy communities, as well as in the published literature, are investigating factors related to early mobilization such as transforming culture in the intensive care unit (ICU), encouraging interprofessional collaboration, coordinating sedation interruption with mobility sessions, and determining the rehabilitation modalities that will most significantly improve patient outcomes. Some variables, however, need to be investigated and addressed specifically by the physical therapy profession. They include assessing and increasing physical therapist competence managing patients with critical illness in both professional (entry-level) education programs and clinical settings, determining and providing an adequate number of physical therapists for a given ICU, evaluating methods of prioritization of patients in the acute care setting, and adding to the body of research to support specific functional outcome measures to be used with patients in the ICU. Additionally, because persistent weakness and functional limitations can exist long after the critical illness itself has resolved, there is a need for increased awareness and involvement of physical therapists in all settings of practice, including outpatient clinics. The purpose of this article is to explore the issues that the physical therapy profession needs to address as the rehabilitation management of the patient with critical illness evolves.
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Mechanical ventilation reduces rat diaphragm blood flow and impairs oxygen delivery and uptake. Crit Care Med 2012; 40:2858-66. [PMID: 22846782 DOI: 10.1097/ccm.0b013e31825b933a] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Although mechanical ventilation is a life-saving intervention in patients suffering from respiratory failure, prolonged mechanical ventilation is often associated with numerous complications including problematic weaning. In contracting skeletal muscle, inadequate oxygen supply can limit oxidative phosphorylation resulting in muscular fatigue. However, whether prolonged mechanical ventilation results in decreased diaphragmatic blood flow and induces an oxygen supply-demand imbalance in the diaphragm remains unknown. DESIGN We tested the hypothesis that prolonged controlled mechanical ventilation results in a time-dependent reduction in rat diaphragmatic blood flow and microvascular PO2 and that prolonged mechanical ventilation would diminish the diaphragm's ability to increase blood flow in response to muscular contractions. MEASUREMENTS AND MAIN RESULTS Compared to 30 mins of mechanical ventilation, 6 hrs of mechanical ventilation resulted in a 75% reduction in diaphragm blood flow (via radiolabeled microspheres), which did not occur in the intercostal muscle or high-oxidative hindlimb muscle (e.g., soleus). There was also a time-dependent decline in diaphragm microvascular PO2 (via phosphorescence quenching). Further, contrary to 30 mins of mechanical ventilation, 6 hrs of mechanical ventilation significantly compromised the diaphragm's ability to increase blood flow during electrically-induced contractions, which resulted in a ~80% reduction in diaphragm oxygen uptake. In contrast, 6 hrs of spontaneous breathing in anesthetized animals did not alter diaphragm blood flow or the ability to augment flow during electrically-induced contractions. CONCLUSIONS These new and important findings reveal that prolonged mechanical ventilation results in a time-dependent decrease in the ability of the diaphragm to augment blood flow to match oxygen demand in response to contractile activity and could be a key contributing factor to difficult weaning. Although additional experiments are required to confirm, it is tempting to speculate that this ventilator-induced decline in diaphragmatic oxygenation could promote a hypoxia-induced generation of reactive oxygen species in diaphragm muscle fibers and contribute to ventilator-induced diaphragmatic atrophy and contractile dysfunction.
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Oujamaa L, Marquer A, Francony G, Davoine P, Chrispin A, Payen JF, Pérennou D. [Early rehabilitation for neurologic patients]. ACTA ACUST UNITED AC 2012; 31:e253-63. [PMID: 23021934 DOI: 10.1016/j.annfar.2012.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Rehabilitation improves the functional prognosis of patients after a neurologic lesion, and tendency is to begin rehabilitation as soon as possible. This review focuses on the interest and the feasibility of very early rehabilitation, initiated from critical care units. It is necessary to precisely assess patients' impairments and disabilities in order to define rehabilitation objectives. Valid and simple tools must support this evaluation. Rehabilitation will be directed to preventing decubitus complications and active rehabilitation. The sooner rehabilitation is started; the better functional prognosis seems to be.
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Affiliation(s)
- L Oujamaa
- Équipe santé, plasticité, motricité, clinique MPR-CHU, laboratoire TIMC-IMAG CNRS 5525, université Joseph-Fourier, Grenoble 1, Grenoble, France
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La stimulation électrique neuromusculaire au cœur des soins intensifs. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0498-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
Patients undergoing critical illness and mechanical ventilation are at risk of developing neuromuscular and neurocognitive impairments that can impact physical function and quality of life. Mobilizing patients early in the course of critical illness may improve outcomes. Recent literature on early mobilization is reviewed, suggestions for implementation are discussed, and areas for future research are identified.
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Affiliation(s)
- Amy J Pawlik
- Therapy Services, University of Chicago Medical Center, MC 1081, W109, 5841 South Maryland Avenue, Chicago, IL 60637-1470, USA.
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Winkelman C, Johnson KD, Hejal R, Gordon NH, Rowbottom J, Daly J, Peereboom K, Levine AD. Examining the positive effects of exercise in intubated adults in ICU: a prospective repeated measures clinical study. Intensive Crit Care Nurs 2012; 28:307-18. [PMID: 22458998 DOI: 10.1016/j.iccn.2012.02.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Revised: 02/28/2012] [Accepted: 02/29/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Determining the optimal timing and progression of mobility exercise has the potential to affect functional recovery of critically ill adults. This study compared standard care with care delivered using a mobility protocol. We examined the effects of exercise on vital signs and inflammatory biomarkers and the effects of the nurse-initiated mobility protocol on outcomes. METHODS Prospective, repeated measures study with a control (standard care) and intervention (protocol) period. RESULTS 75 heterogeneous subjects admitted to a Medical or Surgical intensive care unit (ICU) were enrolled. In <5% of exercise periods, there was a concerning alteration in respiratory rate or peripheral oxygen saturation; no other adverse events occurred. Findings suggested the use of a protocol with one 20 minute episode of exercise daily for 2 or more days reduced ICU length of stay. Duration of exercise was linked to increased IL-10, suggesting brief episodes of low intensity exercise positively altered inflammatory dysregulation in this sample. CONCLUSION A growing body of evidence demonstrates that early, progressive exercise has significant benefits to intubated adults. These results should encourage clinicians to add mobility protocols to the care of ICU adults and lead to future studies to determine optimal "dosing" of exercise in ICU patients.
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Affiliation(s)
- Chris Winkelman
- Case Western Reserve University, Frances Payne Bolton School of Nursing, 10900 Euclid Ave, Cleveland, OH 44016, USA.
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Muscle atrophy and preferential loss of myosin in prolonged critically ill patients*. Crit Care Med 2012; 40:79-89. [DOI: 10.1097/ccm.0b013e31822d7c18] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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de Gonzalo-Calvo D, de Luxan-Delgado B, Rodriguez-Gonzalez S, Garcia-Macia M, Suarez FM, Solano JJ, Rodriguez-Colunga MJ, Coto-Montes A. Oxidative Protein Damage Is Associated With Severe Functional Dependence Among the Elderly Population: A Principal Component Analysis Approach. J Gerontol A Biol Sci Med Sci 2011; 67:663-70. [DOI: 10.1093/gerona/glr215] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Impact of pain reported during isometric quadriceps muscle strength testing in people with knee pain: data from the osteoarthritis initiative. Phys Ther 2011; 91:1478-89. [PMID: 21835892 PMCID: PMC3185222 DOI: 10.2522/ptj.20110034] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Muscle force testing is one of the more common categories of diagnostic tests used in clinical practice. Clinicians have little evidence to guide interpretations of muscle force tests when pain is elicited during testing. OBJECTIVE The purpose of this study was to examine the construct validity of isometric quadriceps muscle strength tests by determining whether the relationship between maximal isometric quadriceps muscle strength and functional status was influenced by pain during isometric testing. DESIGN A cross-sectional design was used. METHODS Data from the Osteoarthritis Initiative were used to identify 1,344 people with unilateral knee pain and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale scores of 1 or higher on the involved side. Measurements of maximal isometric quadriceps strength and ratings of pain during isometric testing were collected. Outcome variables were WOMAC physical function subscale, 20-m walk test, 400-m walk test, and a repeated chair stand test. Multiple regression models were used to determine whether pain during testing modified or confounded the relationship between strength and functional status. RESULTS Pearson r correlations among the isometric quadriceps strength measures and the 4 outcome measures ranged from -.36 (95% confidence interval=-.41, -.31) for repeated chair stands to .36 (95% confidence interval=.31, .41) for the 20-m walk test. In the final analyses, neither effect modification nor confounding was found for the repeated chair stand test, the 20-m walk test, the 400-m walk test, or the WOMAC physical function subscale. Moderate or severe pain during testing was weakly associated with reduced strength, but mild pain was not. LIMITATIONS The disease spectrum was skewed toward mild or moderate symptoms, and the pain measurement scale used during muscle force testing was not ideal. CONCLUSIONS Given that the spectrum of the sample was skewed toward mild or moderate symptoms and disease, the data suggest that isometric quadriceps muscle strength tests maintain their relationship with self-report or performance-based disability measures even when pain is elicited during testing.
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Aversa Z, Alamdari N, Hasselgren PO. Molecules modulating gene transcription during muscle wasting in cancer, sepsis, and other critical illness. Crit Rev Clin Lab Sci 2011; 48:71-86. [DOI: 10.3109/10408363.2011.591365] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Frings-Meuthen P, Buehlmeier J, Baecker N, Stehle P, Fimmers R, May F, Kluge G, Heer M. High sodium chloride intake exacerbates immobilization-induced bone resorption and protein losses. J Appl Physiol (1985) 2011; 111:537-42. [DOI: 10.1152/japplphysiol.00454.2011] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We examined, in immobilization, the effect of a diet high in sodium chloride (NaCl) on bone markers, nitrogen balance, and acid-base status. Eight healthy male test subjects participated in a 14-day head-down-tilt bed rest (HDBR) study. During the bed rest period they received, in a randomized crossover design, a high (7.7 meq Na+/kg body wt per day) and a low (0.7 meq Na+/kg body wt per day) NaCl diet. As expected, 24-h excretion of urinary calcium was significantly greater in the high-NaCl-intake HDBR phase than in the low-NaCl-intake HDBR phase ( P < 0.001). High NaCl intake caused a 43–50% greater excretion of the bone resorption markers COOH- (CTX) and NH2- (NTX) terminal telopeptide of type I collagen in HDBR than low NaCl in HDBR (CTX/NTX: P < 0.001). Serum concentrations of the bone formation markers bone-specific alkaline phosphatase (bAP) and NH2-terminal propeptide of type I procollagen (PINP) were identical in both NaCl intake phases. High NaCl intake led to a more negative nitrogen balance in HDBR ( P < 0.001). Changes were accompanied by increased serum chloride concentration ( P = 0.008), reduced blood bicarbonate ( P = 0.017), and base excess ( P = 0.009) whereas net acid excretion was lower during high than during low NaCl intake in immobilization ( P < 0.001). High NaCl intake during immobilization exacerbates disuse-induced bone and muscle loss by causing further protein wasting and an increase in bone resorption. Changes in the acid-base status, mainly caused by disturbances in electrolyte metabolism, seem to determine NaCl-induced degradation processes.
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Affiliation(s)
| | - Judith Buehlmeier
- German Aerospace Center (DLR), Institute of Aerospace Medicine, Cologne
| | - Natalie Baecker
- German Aerospace Center (DLR), Institute of Aerospace Medicine, Cologne
| | - Peter Stehle
- University of Bonn, Department of Nutrition and Food Science, Bonn; and
| | - Rolf Fimmers
- University of Bonn, Institute for Medical Biometry, Informatics and Epidemiology, Bonn, Germany
| | - Francisca May
- German Aerospace Center (DLR), Institute of Aerospace Medicine, Cologne
| | - Goetz Kluge
- German Aerospace Center (DLR), Institute of Aerospace Medicine, Cologne
| | - Martina Heer
- German Aerospace Center (DLR), Institute of Aerospace Medicine, Cologne
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Maxson PM, Lovely JK, Wrobleski DM, Isaacson EC. Using evidence to enhance the recovery of patients undergoing colorectal surgery: part 3. J Contin Educ Nurs 2011; 42:246-7. [PMID: 21627056 DOI: 10.3928/00220124-20110523-03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This is the third part of a three-part series describing how an enhanced recovery clinical pathway uses a multidisciplinary team to reduce postoperative stress and complications, improve recovery, and decrease hospital length of stay without affecting patient safety for patients undergoing colorectal surgery. Last month, multimodal analgesia and standardized postoperative nausea and vomiting prophylaxis were discussed. This part discusses fluids, diet, tubes and drains, and early mobilization.
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Effect of transcutaneous electrical muscle stimulation on muscle volume in patients with septic shock. Crit Care Med 2011; 39:456-61. [PMID: 21150583 DOI: 10.1097/ccm.0b013e318205c7bc] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Intensive care unit admission is associated with muscle wasting and impaired physical function. We investigated the effect of early transcutaneous electrical muscle stimulation on quadriceps muscle volume in patients with septic shock. DESIGN Randomized interventional study using a single-legged exercise design with the contralateral leg serving as a paired control. SETTING A mixed 18-bed intensive care unit at a tertiary care university hospital. PATIENTS Eight adult male intensive care unit patients with septic shock included within 72 hrs of diagnosis. INTERVENTIONS After randomization of the quadriceps muscles, transcutaneous electrical muscle stimulation was applied on the intervention side for 7 consecutive days and for 60 mins per day. All patients underwent computed tomographic scans of both thighs immediately before and after the 7-day treatment period. The quadriceps muscle was manually delineated on the computed tomography slices, and muscle volumes were calculated after three-dimensional reconstruction. MEASUREMENTS AND MAIN RESULTS Median age and Acute Physiology and Chronic Health Evaluation II score were 67 years (interquartile range, 64-72 years) and 25 (interquartile range, 20-29), respectively. During the 7-day study period, the volume of the quadriceps muscle on the control thigh decreased by 16% (4-21%, p=.03) corresponding to a rate of 2.3% per day. The volume of the stimulated muscle decreased by 20% (3-25%, p=.04) corresponding to a rate of 2.9% per day (p=.12 for the difference in decrease). There was no difference in muscle volume between the stimulated and nonstimulated thigh at baseline (p=.10) or at day 7 (p=.12). The charge delivered to the muscle tissue per training session (0.82 [0.66-1.18] coulomb) correlated with the maximum sequential organ failure assessment score. CONCLUSIONS We observed a marked decrease in quadriceps volume within the first week of intensive care for septic shock. This loss of muscle mass was unaffected by transcutaneous electrical muscle stimulation applied for 60 mins per day for 7 days.
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