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Bergmann J, Egger M, Müller F, Jahn K. Outcome, predictors and longitudinal trajectories of subjects with critical illness polyneuropathy and myopathy (CINAMOPS): study protocol of an observational cohort study in a clinical and post-clinical setting. BMJ Open 2024; 14:e083553. [PMID: 38670603 PMCID: PMC11057271 DOI: 10.1136/bmjopen-2023-083553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Critical illness polyneuropathy and myopathy (CIP/CIM) are frequent complications in the intensive care unit (ICU) with major consequences for the progress and outcome of subjects. CIP/CIM delays the weaning process, prolongs the hospital stay and increases the mortality rate. Additionally, it may have long-term consequences beyond the hospitalisation phase with prolonged disability. Even though there is growing interest in CIP/CIM, research about the clinical and post-clinical course as well as the middle-term and long-term outcomes of subjects with CIP/CIM is scarce. A large prospective study of critically ill subjects is needed with accurate diagnosis during the acute stage and comprehensive assessment during long-term follow-up. METHODS AND ANALYSIS This prospective observational cohort study aims to compare the clinical and post-clinical course of chronically critically ill subjects with and without the diagnosis of CIP/CIM and to determine predictors for the middle-term and long-term outcomes of subjects with CIP/CIM. In addition, the influence of the preclinical health status and the preclinical frailty on the long-term outcome of subjects with CIP/CIM will be investigated.This single-centre study will include 250 critically ill patients who were invasively ventilated for at least 5 days at the ICU and show reduced motor strength. At five study visits at admission and discharge to neurological rehabilitation, and 12, 18 and 24 months after disease onset, a comprehensive test battery will be applied including assessments of functioning and impairment, independence, health-related quality of life, activity and participation, cognition, gait and balance, fatigue, mental health and frailty.Secondary objectives are the documentation of therapy goals, therapy content and achieved milestones during the rehabilitation, to evaluate the clinimetric properties of the Mini-BESTest in critically ill patients, and to evaluate the time course and outcome of subjects with CIP/CIM after SARS-CoV-2 infection. ETHICS AND DISSEMINATION The study was approved by the ethical committee of the Ludwig-Maximilians University Munich. Participants will be included in the study after having signed informed consent.Results will be published in scientific, peer-reviewed journals and at national and international conferences. TRIAL REGISTRATION NUMBER German Clinical Trial Register (DRKS00021753).
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Affiliation(s)
- Jeannine Bergmann
- Department of Neurology, Schoen Clinic Bad Aibling Harthausen, Bad Aibling, Germany
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-Universität München, Munich, Germany
| | - Marion Egger
- Department of Neurology, Schoen Clinic Bad Aibling Harthausen, Bad Aibling, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Ludwig-Maximilians-Universität München, Munich, Germany
| | - Friedemann Müller
- Department of Neurology, Schoen Clinic Bad Aibling Harthausen, Bad Aibling, Germany
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-Universität München, Munich, Germany
| | - Klaus Jahn
- Department of Neurology, Schoen Clinic Bad Aibling Harthausen, Bad Aibling, Germany
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-Universität München, Munich, Germany
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Elkalawy H, Sekhar P, Abosena W. Early detection and assessment of intensive care unit-acquired weakness: a comprehensive review. Acute Crit Care 2023; 38:409-424. [PMID: 38052508 DOI: 10.4266/acc.2023.00703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 10/17/2023] [Indexed: 12/07/2023] Open
Abstract
Intensive care unit-acquired weakness (ICU-AW) is a serious complication in critically ill patients. Therefore, timely and accurate diagnosis and monitoring of ICU-AW are crucial for effectively preventing its associated morbidity and mortality. This article provides a comprehensive review of ICU-AW, focusing on the different methods used for its diagnosis and monitoring. Additionally, it highlights the role of bedside ultrasound in muscle assessment and early detection of ICU-AW. Furthermore, the article explores potential strategies for preventing ICU-AW. Healthcare providers who manage critically ill patients utilize diagnostic approaches such as physical exams, imaging, and assessment tools to identify ICU-AW. However, each method has its own limitations. The diagnosis of ICU-AW needs improvement due to the lack of a consensus on the appropriate approach for its detection. Nevertheless, bedside ultrasound has proven to be the most reliable and cost-effective tool for muscle assessment in the ICU. Combining the Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation (APACHE) II score assessment, and ultrasound can be a convenient approach for the early detection of ICU-AW. This approach can facilitate timely intervention and prevent catastrophic consequences. However, further studies are needed to strengthen the evidence.
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Affiliation(s)
- Hanan Elkalawy
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - Pavan Sekhar
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - Wael Abosena
- Department of Surgery, Faculty of Medicine, Tanta University, Gharbeya, Egypt
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Gruber L, Loizides A, Gruber H, Skalla E, Haushammer S, Horlings C, Beer R, Helbok R, Löscher WN. Differentiation of Critical Illness Myopathy and Critical Illness Neuropathy Using Nerve Ultrasonography. J Clin Neurophysiol 2023; 40:600-607. [PMID: 35089907 DOI: 10.1097/wnp.0000000000000922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Intensive care unit-acquired weakness occurs frequently in intensive care unit patients, including critical illness myopathy (CIM) and critical illness polyneuropathy (CIPN). The authors present a prospective study to assess the ultrasound pattern sum score to differentiate between confirmed CIM, sensory neuropathy, and CIPN cases. METHODS Cross-sectional areas of 12 predefined nerve segments in 16 patients were sonographically examined. Single-nerve cross-sectional areas and ultrasound pattern sum score values were compared; results are given as P -values and receiver operating characteristic area under the curve (AUC). RESULTS In neuropathy, significant single-nerve cross-sectional area enlargement was observed in the median ( P = 0.04), ulnar ( P = 0.04), and fibular nerves ( P = 0.0003). The ultrasound pattern sum score could reliably differentiate between pure CIM and neuropathy ( P = 0.0002, AUC 0.92), CIM and sensory neuropathy ( P = 0.001, AUC 0.88), and CIM and CIPN ( P = 0.007, AUC 0.92), but not between sensory neuropathy and CIPN ( P = 0.599, AUC 0.48). CONCLUSIONS Nerve ultrasonography reliably identifies neuropathy in intensive care unit-acquired weakness, yet cannot differentiate between sensory neuropathy and CIPN. A standardized ultrasound algorithm can serve as a fast bedside test for the presence of neuropathy in intensive care unit-acquired weakness.
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Affiliation(s)
- Leonhard Gruber
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - Alexander Loizides
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - Hannes Gruber
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - Elisabeth Skalla
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - Silke Haushammer
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - Corinne Horlings
- Department of Neurology, School of Mental Health and Neuroscience, Maastricht University Medical Centre+, Maastricht, the Netherlands; and
| | - Ronny Beer
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Raimund Helbok
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Wolfgang N Löscher
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
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Abstract
PURPOSE OF REVIEW Sepsis, defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, is a leading cause of hospital and ICU admission. The central and peripheral nervous system may be the first organ system to show signs of dysfunction, leading to clinical manifestations such as sepsis-associated encephalopathy (SAE) with delirium or coma and ICU-acquired weakness (ICUAW). In the current review, we want to highlight developing insights into the epidemiology, diagnosis, prognosis, and treatment of patients with SAE and ICUAW. RECENT FINDINGS The diagnosis of neurological complications of sepsis remains clinical, although the use of electroencephalography and electromyography can support the diagnosis, especially in noncollaborative patients, and can help in defining disease severity. Moreover, recent studies suggest new insights into the long-term effects associated with SAE and ICUAW, highlighting the need for effective prevention and treatment. SUMMARY In this manuscript, we provide an overview of recent insights and developments in the prevention, diagnosis, and treatment of patients with SAE and ICUAW.
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Affiliation(s)
- Simone Piva
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital
| | - Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital
| | - Nicola Gitti
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
| | - Francesco A. Rasulo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital
- ’Alessandra Bono’ University Research Center on Long-term Outcome in Critical Illness Survivors, University of Brescia, Brescia, Italy
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital
- ’Alessandra Bono’ University Research Center on Long-term Outcome in Critical Illness Survivors, University of Brescia, Brescia, Italy
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Daste C, Mihoubi F, Roren A, Dumitrache A, Carlier N, Benghanem S, Ruttimann A, Mira JP, Pène F, Roche N, Seror P, Nguyen C, Rannou F, Drapé JL, Lefèvre-Colau MM. Early shoulder-girdle MRI findings in severe COVID-19-related intensive care unit-acquired weakness: a prospective cohort study. Eur Radiol 2023:10.1007/s00330-023-09468-5. [PMID: 36912923 PMCID: PMC10010198 DOI: 10.1007/s00330-023-09468-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 12/23/2022] [Accepted: 01/22/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVE To describe clinical and early shoulder-girdle MR imaging findings in severe COVID-19-related intensive care unit-acquired weakness (ICU-AW) after ICU discharge. METHODS A single-center prospective cohort study of all consecutive patients with COVID-19-related ICU-AW from November 2020 to June 2021. All patients underwent similar clinical evaluations and shoulder-girdle MRI within the first month and then 3 months (± 1 month) after ICU discharge. RESULTS We included 25 patients (14 males; mean [SD] age 62.4 [12.5]). Within the first month after ICU discharge, all patients showed severe proximal predominant bilateral muscular weakness (mean Medical Research Council total score = 46.5/60 [10.1]) associated with bilateral, peripheral muscular edema-like MRI signals of the shoulder girdle in 23/25 (92%) patients. At 3 months, 21/25 (84%) patients showed complete or quasi-complete resolution of proximal muscular weakness (mean Medical Research Council total score > 48/60) and 23/25 (92%) complete resolution of MRI signals of the shoulder girdle, but 12/20 (60%) patients experienced shoulder pain and/or shoulder dysfunction. CONCLUSIONS Early shoulder-girdle MRI findings in COVID-19-related ICU-AW included muscular edema-like peripheral signal intensities, without fatty muscle involution or muscle necrosis, with favorable evolution at 3 months. Precocious MRI can help clinicians distinguish critical illness myopathy from alternative, more severe diagnoses and can be useful in the care of patients discharged from intensive care with ICU-AW. KEY POINTS • We describe the clinical and shoulder-girdle MRI findings of COVID-19-related severe intensive care unit-acquired weakness. • This information can be used by clinicians to achieve a nearly specific diagnosis, distinguish alternative diagnoses, assess functional prognosis, and select the more appropriate health care rehabilitation and shoulder impairment treatment.
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Affiliation(s)
- Camille Daste
- Université de Paris, Faculté de Santé, UFR de Médecine, Paris, France.,AP-HP. Centre-Université de Paris Cité, Hôpital Cochin, Service de Rééducation Et de Réadaptation de L'Appareil Locomoteur Et Des Pathologies du Rachis, 27, Rue du Faubourg Saint-Jacques, 75014, Paris, France.,INSERM UMR-S 1153, Centre de Recherche Épidémiologie Et Statistique Paris (CRESS), ECaMO Team, 75004, Paris, France
| | - Fadila Mihoubi
- INSERM UMR-S 1153, Centre de Recherche Épidémiologie Et Statistique Paris (CRESS), ECaMO Team, 75004, Paris, France.,AP-HP. Centre-Université de Paris Cité, Hôpital Cochin, Service de Radiologie Ostéo-Articulaire, 75014, Paris, France
| | - Alexandra Roren
- AP-HP. Centre-Université de Paris Cité, Hôpital Cochin, Service de Rééducation Et de Réadaptation de L'Appareil Locomoteur Et Des Pathologies du Rachis, 27, Rue du Faubourg Saint-Jacques, 75014, Paris, France.,INSERM UMR-S 1153, Centre de Recherche Épidémiologie Et Statistique Paris (CRESS), ECaMO Team, 75004, Paris, France
| | - Alina Dumitrache
- AP-HP. Centre-Université de Paris Cité, Hôpital Corentin Celton, Service de Rééducation Et de Réadaptation, 92130, Issy-Les-Moulineaux, France
| | - Nicolas Carlier
- AP-HP. Centre-Université de Paris Cité, Hôpital Cochin, Service de Pneumologie, 75014, Paris, France
| | - Sarah Benghanem
- Université de Paris, Faculté de Santé, UFR de Médecine, Paris, France.,AP-HP. Centre-Université de Paris Cité, Hôpital Cochin, Service de Médecine Intensive Et Réanimation, 75014, Paris, France.,Neurophysiology Department, GHU Psychiatrie Et Neurosciences, Sainte Anne Hospital, 75014, Paris, France
| | - Aude Ruttimann
- AP-HP. Centre-Université de Paris Cité, Hôpital Cochin, Service de Médecine Intensive Et Réanimation, 75014, Paris, France
| | - Jean-Paul Mira
- Université de Paris, Faculté de Santé, UFR de Médecine, Paris, France.,AP-HP. Centre-Université de Paris Cité, Hôpital Cochin, Service de Médecine Intensive Et Réanimation, 75014, Paris, France
| | - Frédéric Pène
- Université de Paris, Faculté de Santé, UFR de Médecine, Paris, France.,AP-HP. Centre-Université de Paris Cité, Hôpital Cochin, Service de Médecine Intensive Et Réanimation, 75014, Paris, France.,Institut Cochin, INSERM U1016, CNRS UMR8104, 75006, Paris, France
| | - Nicolas Roche
- Université de Paris, Faculté de Santé, UFR de Médecine, Paris, France.,AP-HP. Centre-Université de Paris Cité, Hôpital Cochin, Service de Pneumologie, 75014, Paris, France
| | - Paul Seror
- Laboratoire d'électroneuromyographie, 146 Av Ledru Rollin, 75011, Paris, France
| | - Christelle Nguyen
- Université de Paris, Faculté de Santé, UFR de Médecine, Paris, France.,AP-HP. Centre-Université de Paris Cité, Hôpital Cochin, Service de Rééducation Et de Réadaptation de L'Appareil Locomoteur Et Des Pathologies du Rachis, 27, Rue du Faubourg Saint-Jacques, 75014, Paris, France.,INSERM UMR-S 1124, Toxicité Environnementale, Cibles Thérapeutiques, Signalisation Cellulaire Et Biomarqueurs (T3S), Centre Universitaire Des Saints-Pères, 75006, Paris, France
| | - François Rannou
- Université de Paris, Faculté de Santé, UFR de Médecine, Paris, France.,AP-HP. Centre-Université de Paris Cité, Hôpital Cochin, Service de Rééducation Et de Réadaptation de L'Appareil Locomoteur Et Des Pathologies du Rachis, 27, Rue du Faubourg Saint-Jacques, 75014, Paris, France.,INSERM UMR-S 1124, Toxicité Environnementale, Cibles Thérapeutiques, Signalisation Cellulaire Et Biomarqueurs (T3S), Centre Universitaire Des Saints-Pères, 75006, Paris, France
| | - Jean-Luc Drapé
- Université de Paris, Faculté de Santé, UFR de Médecine, Paris, France.,INSERM UMR-S 1153, Centre de Recherche Épidémiologie Et Statistique Paris (CRESS), ECaMO Team, 75004, Paris, France.,AP-HP. Centre-Université de Paris Cité, Hôpital Cochin, Service de Radiologie Ostéo-Articulaire, 75014, Paris, France
| | - Marie-Martine Lefèvre-Colau
- Université de Paris, Faculté de Santé, UFR de Médecine, Paris, France. .,AP-HP. Centre-Université de Paris Cité, Hôpital Cochin, Service de Rééducation Et de Réadaptation de L'Appareil Locomoteur Et Des Pathologies du Rachis, 27, Rue du Faubourg Saint-Jacques, 75014, Paris, France. .,INSERM UMR-S 1153, Centre de Recherche Épidémiologie Et Statistique Paris (CRESS), ECaMO Team, 75004, Paris, France.
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Younger DS. Critical illness-associated weakness and related motor disorders. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:707-777. [PMID: 37562893 DOI: 10.1016/b978-0-323-98818-6.00031-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Weakness of limb and respiratory muscles that occurs in the course of critical illness has become an increasingly common and serious complication of adult and pediatric intensive care unit patients and a cause of prolonged ventilatory support, morbidity, and prolonged hospitalization. Two motor disorders that occur singly or together, namely critical illness polyneuropathy and critical illness myopathy, cause weakness of limb and of breathing muscles, making it difficult to be weaned from ventilatory support, commencing rehabilitation, and extending the length of stay in the intensive care unit, with higher rates of morbidity and mortality. Recovery can take weeks or months and in severe cases, and may be incomplete or absent. Recent findings suggest an improved prognosis of critical illness myopathy compared to polyneuropathy. Prevention and treatment are therefore very important. Its management requires an integrated team approach commencing with neurologic consultation, creatine kinase (CK) measurement, detailed electrodiagnostic, respiratory and neuroimaging studies, and potentially muscle biopsy to elucidate the etiopathogenesis of the weakness in the peripheral and/or central nervous system, for which there may be a variety of causes. These tenets of care are being applied to new cases and survivors of the coronavirus-2 disease pandemic of 2019. This chapter provides an update to the understanding and approach to critical illness motor disorders.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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Attwell C, Sauterel L, Jöhr J, Piquilloud L, Kuntzer T, Diserens K. Early detection of ICU-acquired weakness in septic shock patients ventilated longer than 72 h. BMC Pulm Med 2022; 22:466. [PMID: 36474276 PMCID: PMC9724444 DOI: 10.1186/s12890-022-02193-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE ICU-acquired weakness, comprising Critical Illness Polyneuropathy (CIP) and Myopathy (CIM) is associated with immobilization and prolonged mechanical ventilation. This study aims to assess feasibility of early detection of CIP and CIM by peroneal nerve test (PENT) and sensory sural nerve action potential (SNAP) screening in patients with septic shock and invasively ventilated for more than 72 h. METHODS We performed repetitive PENT screening from 72 h after intubation until detecting a pathological response. We tested SNAPs in pathological PENT to differentiate CIP from CIM. We performed muscle strength examination in awake patients and recorded time from intubation to first in-bed and out-of-bed mobilization. RESULTS Eighteen patients were screened with PENT and 88.9% had abnormal responses. Mean time between intubation and first screening was 94.38 (± 22.41) hours. Seven patients (38.9%) had CIP, two (11.1%) had CIM, one (5.6%) had CIP and CIM, six (33.3%) had a pathological response on PENT associated with ICU-acquired weakness (but no SNAP could be performed to differentiate between CIP and CIM) and two patients had (11.1%) had no peripheral deficit. In patients where it could be performed, muscle strength testing concorded with electrophysiological findings. Twelve patients (66.7%) had out-of-bed mobilization 10.8 (± 7.4) days after admission. CONCLUSION CIP and CIM are frequent in septic shock patients and can be detected before becoming symptomatic with simple bedside tools. Early detection of CIP and CIM opens new possibilities for their timely management through preventive measures such as passive and active mobilization.
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Affiliation(s)
- Caroline Attwell
- grid.8515.90000 0001 0423 4662Acute Neuro-Rehabilitation Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Laurent Sauterel
- grid.8515.90000 0001 0423 4662Lausanne University Hospital, Lausanne, Switzerland
| | - Jane Jöhr
- grid.8515.90000 0001 0423 4662Acute Neuro-Rehabilitation Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Lise Piquilloud
- grid.8515.90000 0001 0423 4662Adult Intensive Care Unit, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Thierry Kuntzer
- grid.8515.90000 0001 0423 4662Nerve-Muscle Unit, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Karin Diserens
- grid.8515.90000 0001 0423 4662Acute Neuro-Rehabilitation Unit, Lausanne University Hospital, Lausanne, Switzerland
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Grover KM, Sripathi N. Prevention of Adverse Outcomes and Treatment Side Effects in Patients with Neuromuscular Disorders. Semin Neurol 2022; 42:594-610. [PMID: 36400111 DOI: 10.1055/s-0042-1758779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In this article, we review prevention of serious adverse clinical outcomes and treatment side effects in patients with neuromuscular disorders including myopathies and myasthenia gravis. While neither of these entities is preventable, their course can often be modified, and severe sequelae may be prevented, with the identification of risk factors and proactive attention toward treatment planning.
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Affiliation(s)
- Kavita M Grover
- Department of Neurology, Henry Ford Medical Group, Wayne State University, Detroit, Michigan
| | - Naganand Sripathi
- Department of Neurology, Henry Ford Medical Group, Wayne State University, Detroit, Michigan
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Engelhardt LJ, Carbon NM, Weber-Carstens S. [54/m-Muscle weakness and prolonged weaning from mechanical ventilation after peritonitis with septic shock : Preparation course anesthesiological intensive care medicine: case 29]. DIE ANAESTHESIOLOGIE 2022; 71:149-153. [PMID: 35941303 DOI: 10.1007/s00101-022-01166-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/10/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Lilian Jo Engelhardt
- Klinik für Anästhesiologie m.S. operative Intensivmedizin, Charité - Universitätsmedizin Berlin, Campus CVK&CCM, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
- Institut für Medizinische Informatik, Charité - Universitätsmedizin Berlin, Campus CCM, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Niklas M Carbon
- Klinik für Anästhesiologie m.S. operative Intensivmedizin, Charité - Universitätsmedizin Berlin, Campus CVK&CCM, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - Steffen Weber-Carstens
- Klinik für Anästhesiologie m.S. operative Intensivmedizin, Charité - Universitätsmedizin Berlin, Campus CVK&CCM, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland.
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10
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Kny M, Fielitz J. Hidden Agenda - The Involvement of Endoplasmic Reticulum Stress and Unfolded Protein Response in Inflammation-Induced Muscle Wasting. Front Immunol 2022; 13:878755. [PMID: 35615361 PMCID: PMC9124858 DOI: 10.3389/fimmu.2022.878755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Critically ill patients at the intensive care unit (ICU) often develop a generalized weakness, called ICU-acquired weakness (ICUAW). A major contributor to ICUAW is muscle atrophy, a loss of skeletal muscle mass and function. Skeletal muscle assures almost all of the vital functions of our body. It adapts rapidly in response to physiological as well as pathological stress, such as inactivity, immobilization, and inflammation. In response to a reduced workload or inflammation muscle atrophy develops. Recent work suggests that adaptive or maladaptive processes in the endoplasmic reticulum (ER), also known as sarcoplasmic reticulum, contributes to this process. In muscle cells, the ER is a highly specialized cellular organelle that assures calcium homeostasis and therefore muscle contraction. The ER also assures correct folding of proteins that are secreted or localized to the cell membrane. Protein folding is a highly error prone process and accumulation of misfolded or unfolded proteins can cause ER stress, which is counteracted by the activation of a signaling network known as the unfolded protein response (UPR). Three ER membrane residing molecules, protein kinase R-like endoplasmic reticulum kinase (PERK), inositol requiring protein 1a (IRE1a), and activating transcription factor 6 (ATF6) initiate the UPR. The UPR aims to restore ER homeostasis by reducing overall protein synthesis and increasing gene expression of various ER chaperone proteins. If ER stress persists or cannot be resolved cell death pathways are activated. Although, ER stress-induced UPR pathways are known to be important for regulation of skeletal muscle mass and function as well as for inflammation and immune response its function in ICUAW is still elusive. Given recent advances in the development of ER stress modifying molecules for neurodegenerative diseases and cancer, it is important to know whether or not therapeutic interventions in ER stress pathways have favorable effects and these compounds can be used to prevent or treat ICUAW. In this review, we focus on the role of ER stress-induced UPR in skeletal muscle during critical illness and in response to predisposing risk factors such as immobilization, starvation and inflammation as well as ICUAW treatment to foster research for this devastating clinical problem.
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Affiliation(s)
- Melanie Kny
- Experimental and Clinical Research Center (ECRC), Charité-Universitätsmedizin Berlin, Max Delbrück Center (MDC) for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Jens Fielitz
- Department of Molecular Cardiology, DZHK (German Center for Cardiovascular Research), Partner Site, Greifswald, Germany
- Department of Internal Medicine B, Cardiology, University Medicine Greifswald, Greifswald, Germany
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11
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Rodriguez B, Larsson L, Z’Graggen WJ. Critical Illness Myopathy: Diagnostic Approach and Resulting Therapeutic Implications. Curr Treat Options Neurol 2022; 24:173-182. [PMID: 35370393 PMCID: PMC8958813 DOI: 10.1007/s11940-022-00714-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 11/26/2022]
Abstract
Abstract
Purpose of review
Critical illness myopathy (CIM) is a common neuro-muscular complication of intensive care treatment associated with increased morbidity and mortality. The current guidelines for diagnosis include clinical and electrophysiological criteria as well as a muscle biopsy, and allow diagnosis only at an advanced stage of the disease. To date, there is no treatment for CIM available, apart from symptomatic and rehabilitative interventions. In this review, we discuss different diagnostic approaches and describe new treatment possibilities for CIM.
Recent findings
Of the diagnostic approaches evaluated, a new electrophysiological technique for measuring muscle excitability has the greatest potential to allow earlier diagnosis of CIM than the current guidelines do and thereby may facilitate the conduction of future pathophysiological and therapeutic studies. Although clinical trials are still lacking, in animal models, BGP-15, vamorolone, and ruxolitinib have been shown to have anti-inflammatory effects, to reduce muscle wasting and to improve muscle function and survival.
Summary
In recent years, promising methods for early and confirmatory diagnosis of CIM have been developed, but still need validation. Experimental studies on novel pharmacological interventions show promising results in terms of preventive CIM treatments, but future clinical studies will be needed to study the effectiveness and safety of these drugs.
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Affiliation(s)
- Belén Rodriguez
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Lars Larsson
- Section of Clinical Neurophysiology, Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
- Viron Molecular Medicine Institute, Boston, MA 02108 USA
| | - Werner J. Z’Graggen
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
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12
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Intiso D, Centra AM, Bartolo M, Gatta MT, Gravina M, Di Rienzo F. Recovery and long term functional outcome in people with critical illness polyneuropathy and myopathy: a scoping review. BMC Neurol 2022; 22:50. [PMID: 35148710 PMCID: PMC8831873 DOI: 10.1186/s12883-022-02570-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/28/2022] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Intensive care unit acquired weakness (ICUAW), embraces an array of disorders labeled "critical illness polyneuropathy" (CIP), "critical illness myopathy" (CIM) or "critical illness polyneuromyopathy" (CIPNM). Several studies have addressed the various characteristics of ICUAW, but the recovery is still unclear. OBJECTIVE The present review investigated the recovery and the long-term functional outcome of subjects with ICUAW, whether the types of ICUAW have different outcomes and whether there is any supporting evidence. METHODS Literature search was performed from MEDLINE/PubMed, CINAHL, EMBASE, PeDro, Web of Science and Scopus. Inclusion criteria were: i) sample size including five or more subjects; ii) subjects who suffered from ICUAW and/or CIP, CIM and CIP/CIM; iii) ICUAW ascertained by EMG. Follow-ups longer than one year were defined as long-term. RESULTS Twenty-nine studies met the inclusion criteria. In total, 788 subjects with ICUAW were enrolled: 159 (20.1%) died and 588 (74.6%) were followed. Of all the included patients, 613 (77.7%) had CIP, 82 (10.4%) CIM and 56 (7.1%) CIP/CIM. Overall, 70.3% of the subjects with ICUAW fully recovered. Seven (24.1%) studies had a follow-up longer than 1 year (range 2-8) with 173 (21.9%) subjects enrolled globally and 108 followed. Of these subjects, 88.8% gained full recovery. Most of the studies did not use proper functional scales and only 4 and 3 studies employed the Barthel scale and the Functional Independence Measure (FIM) scale. Differentiation between the types of ICUAW was performed in 7 studies, but only 3 studies reported that subjects with CIM had a better prognosis and earlier recovery than subjects with CIP/CIM. CONCLUSIONS Subjects with ICUAW could achieve good recovery and could improve at follow-up. However, the quality of the published studies due to short follow-ups and the paucity of defined outcome measures require confirms.
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Affiliation(s)
- Domenico Intiso
- Unit of Neuro-Rehabilitation and Rehabilitation Medicine, IRCCS "Casa Sollievo della Sofferenza", Viale dei Cappuccini, 71013, San Giovanni Rotondo (FG), Italy.
| | - Antonello Marco Centra
- Unit of Neuro-Rehabilitation and Rehabilitation Medicine, IRCCS "Casa Sollievo della Sofferenza", Viale dei Cappuccini, 71013, San Giovanni Rotondo (FG), Italy
| | - Michelangelo Bartolo
- Department of Rehabilitation, Neurorehabilitation Unit, Habilita Care & Research, Zingonia (Bergamo), Italy
| | - Maria Teresa Gatta
- Unit of Neuro-Rehabilitation and Rehabilitation Medicine, IRCCS "Casa Sollievo della Sofferenza", Viale dei Cappuccini, 71013, San Giovanni Rotondo (FG), Italy
| | - Michele Gravina
- Unit of Neuro-Rehabilitation and Rehabilitation Medicine, IRCCS "Casa Sollievo della Sofferenza", Viale dei Cappuccini, 71013, San Giovanni Rotondo (FG), Italy
| | - Filomena Di Rienzo
- Unit of Neuro-Rehabilitation and Rehabilitation Medicine, IRCCS "Casa Sollievo della Sofferenza", Viale dei Cappuccini, 71013, San Giovanni Rotondo (FG), Italy
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Nonoyama T, Shigemi H, Yasutake C, Matsumine A, Ishizuka T. Effective Mechanical Insufflation-Exsufflation in a Patient With Difficulty in Sputum Discharge and Intensive Care Unit-Acquired Weakness: A Case Report. Cureus 2022; 14:e21847. [PMID: 35291546 PMCID: PMC8896922 DOI: 10.7759/cureus.21847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2022] [Indexed: 11/18/2022] Open
Abstract
Intensive care unit-acquired weakness (ICU-AW), a common complication in critically ill patients, may result in diaphragmatic dysfunction, which delays weaning from artificial ventilators. Here, we present the case of a patient with difficulty in sputum discharge due to ICU-AW. In the ICU, postural drainage sputum aspiration by bronchoscopy and squeezing were performed daily, but the patient’s condition did not resolve. Mechanical insufflation-exsufflation (MI-E) enabled the sputum to move to the main bronchus from the peripheral bronchi, and suctioning using a bronchoscope was no longer necessary. However, the presence of sputum persisted, and MI-E was necessary after weaning, proving crucial in treating the patient with sputum discharge difficulty complicated by ICU-AW after being removed from an artificial ventilator. MI-E can be useful for patients with difficulty in sputum discharge due to ICU-AW; however, the weaning process may be prolonged in such cases.
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14
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Vrettou CS, Mantziou V, Vassiliou AG, Orfanos SE, Kotanidou A, Dimopoulou I. Post-Intensive Care Syndrome in Survivors from Critical Illness including COVID-19 Patients: A Narrative Review. Life (Basel) 2022; 12:life12010107. [PMID: 35054500 PMCID: PMC8778667 DOI: 10.3390/life12010107] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 12/21/2022] Open
Abstract
Current achievements in medical science and technological advancements in intensive care medicine have allowed better support of critically ill patients in intensive care units (ICUs) and have increased survival probability. Post-intensive care syndrome (PICS) is a relatively new term introduced almost 10 years ago, defined as "new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization". A significant percentage of critically ill patients suffer from PICS for a prolonged period of time, with physical problems being the most common. The exact prevalence of PICS is unknown, and many risk factors have been described well. Coronavirus disease 2019 (COVID-19) survivors seem to be at especially high risk for developing PICS. The families of ICU survivors can also be affected as a response to the stress suffered during the critical illness of their kin. This separate entity is described as PICS family (PICS-F). A multidisciplinary approach is warranted for the treatment of PICS, involving healthcare professionals, clinicians, and scientists from different areas. Improving outcomes is both challenging and imperative for the critical care community. The review of the relevant literature and the study of the physical, cognitive, and mental sequelae could lead to the prevention and timely management of PICS and the subsequent improvement of the quality of life for ICU survivors.
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15
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Tortuyaux R, Davion JB, Jourdain M. Intensive care unit-acquired weakness: Questions the clinician should ask. Rev Neurol (Paris) 2022; 178:84-92. [PMID: 34998522 DOI: 10.1016/j.neurol.2021.12.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 12/29/2022]
Abstract
Intensive care unit (ICU)-acquired weakness (ICU-AW) is defined as clinically detected weakness in critically ill patients in whom there is no plausible etiology other than critical illness. Using electrophysiological methods, patients with ICU-AW are classified in three subcategories: critical illness polyneuropathy, critical illness myopathy and critical illness neuromyopathy. ICU-AW is a frequent complication occurring in critical ill patients. Risk factors include illness severity and organ failure, age, hyperglycemia, parenteral nutrition, drugs and immobility. Due to short- and long-term complications, ICU-AW results in longer hospital stay and increased mortality. Its management is essentially preventive avoiding modifiable risk factors, especially duration of sedation and immobilization that should be as short as possible. Pharmacological approaches have been studied but none have proven efficacy. In the present review, we propose practical questions that the clinician should ask in case of acquired weakness during ICU stay: when to suspect ICU-AW, what risk factors should be identified, how to diagnose ICU-AW, what is the prognosis and how can recovery be improved?
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Affiliation(s)
- R Tortuyaux
- CHU de Lille, médecine intensive-réanimation, 59000 Lille, France; CHU de Lille, department of clinical neurophysiology, 59000 Lille, France.
| | - J-B Davion
- CHU de Lille, centre de référence des maladies neuromusculaires, 59000 Lille, France
| | - M Jourdain
- CHU de Lille, médecine intensive-réanimation, 59000 Lille, France; Université Lille, Inserm U1190, 59000 Lille, France
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16
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Vanhorebeek I, Derese I, Gunst J, Wouters PJ, Hermans G, Van den Berghe G. Persisting neuroendocrine abnormalities and their association with physical impairment 5 years after critical illness. Crit Care 2021; 25:430. [PMID: 34915907 PMCID: PMC8675467 DOI: 10.1186/s13054-021-03858-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
Abstract
Background Critical illness is hallmarked by neuroendocrine alterations throughout ICU stay. We investigated whether the neuroendocrine axes recover after ICU discharge and whether any residual abnormalities associate with physical functional impairments assessed 5 years after critical illness.
Methods In this preplanned secondary analysis of the EPaNIC randomized controlled trial, we compared serum concentrations of hormones and binding proteins of the thyroid axis, the somatotropic axis and the adrenal axis in 436 adult patients who participated in the prospective 5-year clinical follow-up and who provided a blood sample with those in 50 demographically matched controls. We investigated independent associations between any long-term hormonal abnormalities and physical functional impairments (handgrip strength, 6-min walk distance, and physical health-related quality-of-life) with use of multivariable linear regression analyses. Results At 5-year follow-up, patients and controls had comparable serum concentrations of thyroid-stimulating hormone, thyroxine (T4), triiodothyronine (T3) and thyroxine-binding globulin, whereas patients had higher reverse T3 (rT3, p = 0.0002) and lower T3/rT3 (p = 0.0012) than controls. Patients had comparable concentrations of growth hormone, insulin-like growth factor-I (IGF-I) and IGF-binding protein 1 (IGFBP1), but higher IGFBP3 (p = 0.030) than controls. Total and free cortisol, cortisol-binding globulin and albumin concentrations were comparable for patients and controls. A lower T3/rT3 was independently associated with lower handgrip strength and shorter 6-min walk distance (p ≤ 0.036), and a higher IGFBP3 was independently associated with higher handgrip strength (p = 0.031). Conclusions Five years after ICU admission, most hormones and binding proteins of the thyroid, somatotropic and adrenal axes had recovered. The residual long-term abnormality within the thyroid axis was identified as risk factor for long-term physical impairment, whereas that within the somatotropic axis may be a compensatory protective response. Whether targeting of the residual abnormality in the thyroid axis may improve long-term physical outcome of the patients remains to be investigated. Trial registration ClinicalTrials.gov: NCT00512122, registered on July 31, 2007 (https://www.clinicaltrials.gov/ct2/show/NCT00512122). Graphical Abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03858-1.
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Affiliation(s)
- Ilse Vanhorebeek
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Inge Derese
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Jan Gunst
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Pieter J Wouters
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Greet Hermans
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Greet Van den Berghe
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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17
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Gustafson OD, Williams MA, McKechnie S, Dawes H, Rowland MJ. Musculoskeletal complications following critical illness: A scoping review. J Crit Care 2021; 66:60-66. [PMID: 34454181 PMCID: PMC8516358 DOI: 10.1016/j.jcrc.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/19/2021] [Accepted: 08/06/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE To explore the extent to which musculoskeletal (MSK) complications have been reported following critical illness, identifying evidence gaps and providing recommendations for future research. MATERIALS AND METHODS We searched five databases from January 1st 2000 to March 31st 2021. We included published original research reporting MSK complications in patients discharged from hospital following an admission to an intensive care unit (ICU). Two reviewers independently screened English language articles for eligibility. Data extracted included the MSK area of investigation and MSK outcome measures. The overall quality of study was evaluated against standardised reporting guidelines. RESULTS 4512 titles were screened, and 32 met the inclusion criteria. Only one study included was interventional, with the majority being prospective cohort studies (n = 22). MSK complications identified included: muscle weakness or atrophy, chronic pain, neuromuscular dysfunction, peripheral joint impairment and fracture risk. The quality of the overall reporting in the studies was deemed adequate. CONCLUSIONS We identified a heterogenous body of literature reporting a high prevalence of a variety of MSK complications extending beyond muscle weakness, therefore future investigation should include evaluations of more than one MSK area. Further investigation of MSK complications could inform the development of future post critical illness rehabilitation programs.
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Affiliation(s)
- Owen D Gustafson
- Oxford Allied Health Professions Research & Innovation Unit, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK; Centre for Movement, Occupational and Rehabilitation Sciences, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford OX3 0BP, UK.
| | - Mark A Williams
- Centre for Movement, Occupational and Rehabilitation Sciences, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford OX3 0BP, UK; Department of Sport, Health Sciences and Social Work, Oxford Brookes University, Headington Campus, Oxford OX3 0BP, UK
| | - Stuart McKechnie
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
| | - Helen Dawes
- Centre for Movement, Occupational and Rehabilitation Sciences, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford OX3 0BP, UK; Department of Sport, Health Sciences and Social Work, Oxford Brookes University, Headington Campus, Oxford OX3 0BP, UK
| | - Matthew J Rowland
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK; Kadoorie Centre for Critical Care Research, Oxford NIHR Biomedical Research Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
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18
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Whitehead J, Summers MJ, Louis R, Weinel LM, Lange K, Dunn B, Chapman MJ, Chapple LAS. Assessment of physiological barriers to nutrition following critical illness. Clin Nutr 2021; 41:11-20. [PMID: 34861624 DOI: 10.1016/j.clnu.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/26/2021] [Accepted: 11/01/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND & AIMS Nutrition may be important for recovery from critical illness. Gastrointestinal dysfunction is a key barrier to nutrition delivery in the Intensive Care Unit (ICU) and metabolic rate is elevated exacerbating nutritional deficits. Whether these factors persist following ICU discharge is unknown. We assessed whether delayed gastric emptying (GE) and impaired glucose absorption persist post-ICU discharge. METHODS A prospective observational study was conducted in mechanically ventilated adults at 3 time-points: in ICU (V1); on the post-ICU ward (V2); and 3-months after ICU discharge (V3); and compared to age-matched healthy volunteers. On each visit, all participants received a test-meal containing 100 ml of 1 kcal/ml liquid nutrient, labelled with 0.1 g 13C-octanoic acid and 3 g 3-O-Methyl-glucose (3-OMG), and breath and blood samples were collected over 240min to quantify GE (gastric emptying coefficient (GEC)), and glucose absorption (3-OMG concentration; area under the curve (AUC)). Data are mean ± standard error of the mean (SEM) and differences shown with 95% confidence intervals (95%CI). RESULTS Twenty-six critically ill patients completed V1 (M:F 20:6; 62.0 ± 2.9 y; BMI 29.8 ± 1.2 kg/m2; APACHE II 19.7 ± 1.9), 15 completed V2 and eight completed V3; and were compared to 10 healthy volunteers (M:F 6:4; 60.5 ± 7.5 y; BMI 26.0 ± 1.0 kg/m2). GE was significantly slower on V1 compared to health (GEC difference: -0.96 (95%CI -1.61, -0.31); and compared to V2 (-0.73 (-1.16, -0.31) and V3 (-1.03 (-1.47, -0.59). GE at V2 and V3 were not different to that in health (V2: -0.23 (-0.61, 0.14); V3: 0.10 (-0.27, 0.46)). GEC: V1: 2.64 ± 0.19; V2: 3.37 ± 0.12; V3: 3.67 ± 0.10; health: 3.60 ± 0.13. Glucose absorption (3-OMG AUC0-240) was impaired on V1 compared to V2 (-37.9 (-64.2, -11.6)), and faster on V3 than in health (21.8 (0.14, 43.4) but absorption at V2 and V3 did not differ from health. Intestinal glucose absorption: V1: 63.8 ± 10.4; V2: 101.7 ± 7.0; V3: 111.9 ± 9.7; health: 90.7 ± 3.8. CONCLUSION This study suggests that delayed GE and impaired intestinal glucose absorption recovers rapidly post-ICU. This requires further confirmation in a larger population. The REINSTATE trial was prospectively registered at www.anzctr.org.au. TRIAL ID ACTRN12618000370202.
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Affiliation(s)
- James Whitehead
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Matthew J Summers
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia; Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Rhea Louis
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia; Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Luke M Weinel
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia; Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Kylie Lange
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia; Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Bethany Dunn
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia; Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Marianne J Chapman
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia; Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia; Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Lee-Anne S Chapple
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia; Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia; Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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19
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Ishiyama H, Ishii J, Yoshimura H, Tsunogae M, Fujiwara S, Hiya S, Inui R, Shiomi Y, Nakazawa S, Kimura M, Kuroda T, Murakami Y, Maekawa K, Ohara N, Kohara N, Kawamoto M. Neurological Manifestations and Long-term Sequelae in Hospitalized Patients with COVID-19. Intern Med 2021; 60:3559-3567. [PMID: 34511566 PMCID: PMC8666216 DOI: 10.2169/internalmedicine.7802-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/29/2021] [Indexed: 11/29/2022] Open
Abstract
Objective Various neurological manifestations have been increasingly reported in coronavirus disease 2019 (COVID-19). We determined the neurological features and long-term sequelae in hospitalized COVID-19 patients. Methods We retrospectively studied 95 consecutive hospitalized patients with COVID-19 between March 1 and May 13, 2020. Acute neurological presentations (within two weeks of the symptom onset of COVID-19) were compared between 60 non-severe and 35 severely infected patients who required high-flow oxygen. In the 12 ventilated patients (the most severe group), we evaluated neurological complications during admission, subacute neurological presentations, and neurological sequelae (51 and 137 days from the onset [median], respectively). Results Of the 95 patients (mean age 53 years old; 40% women), 63% had acute neurological presentations, with an increased prevalence in cases of severe infections (83% vs. 52%, p<0.001). Impaired consciousness and limb weakness were more frequent in severe patients than in non-severe ones (0% vs. 49%; p<0.001, and 0% vs. 54%; p<0.001, respectively). In the most severe group (mean age 72 years old; 42% women), 83% of patients had neurological complications [cerebrovascular disease (17%), encephalopathy (82%), and neuropathy (55%)], and 92% had subacute neurological presentations [impaired consciousness (17%), higher brain dysfunction (82%), limb weakness (75%), and tremor (58%)]. Neurological sequelae were found in 83% of cases, including higher brain dysfunction (73%), limb weakness (50%), and tremor (58%). Conclusions Neurological manifestations are common in COVID-19, with the possibility of long-lasting sequelae.
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Affiliation(s)
- Hiroyuki Ishiyama
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Junko Ishii
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Hajime Yoshimura
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Marie Tsunogae
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Satoru Fujiwara
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Satomi Hiya
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Ryoma Inui
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Yuma Shiomi
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Shinsaku Nakazawa
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Masamune Kimura
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Takehito Kuroda
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Yasutaka Murakami
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Kota Maekawa
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Nobuyuki Ohara
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Nobuo Kohara
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Michi Kawamoto
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
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Abstract
PURPOSE OF REVIEW This article discusses the pathophysiology, presentation, diagnosis, treatment, and prognosis of common neuromuscular disorders seen in the intensive care unit, including Guillain-Barré syndrome, myasthenia gravis, and intensive care unit-acquired weakness. RECENT FINDINGS Guillain-Barré syndrome can have an excellent prognosis if patients are diagnosed early, appropriately treated, and monitored for complications, including respiratory failure and dysautonomia. Intensive care unit-acquired weakness increases overall mortality in patients who are critically ill, and distinguishing between critical illness myopathy and critical illness polyneuropathy may have important prognostic implications. SUMMARY Neuromuscular disorders are not rare in the intensive care unit setting, and precise identification and treatment of these conditions can greatly impact long-term outcomes.
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21
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Haberecht-Müller S, Krüger E, Fielitz J. Out of Control: The Role of the Ubiquitin Proteasome System in Skeletal Muscle during Inflammation. Biomolecules 2021; 11:biom11091327. [PMID: 34572540 PMCID: PMC8468834 DOI: 10.3390/biom11091327] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 02/07/2023] Open
Abstract
The majority of critically ill intensive care unit (ICU) patients with severe sepsis develop ICU-acquired weakness (ICUAW) characterized by loss of muscle mass, reduction in myofiber size and decreased muscle strength leading to persisting physical impairment. This phenotype results from a dysregulated protein homeostasis with increased protein degradation and decreased protein synthesis, eventually causing a decrease in muscle structural proteins. The ubiquitin proteasome system (UPS) is the predominant protein-degrading system in muscle that is activated during diverse muscle atrophy conditions, e.g., inflammation. The specificity of UPS-mediated protein degradation is assured by E3 ubiquitin ligases, such as atrogin-1 and MuRF1, which target structural and contractile proteins, proteins involved in energy metabolism and transcription factors for UPS-dependent degradation. Although the regulation of activity and function of E3 ubiquitin ligases in inflammation-induced muscle atrophy is well perceived, the contribution of the proteasome to muscle atrophy during inflammation is still elusive. During inflammation, a shift from standard- to immunoproteasome was described; however, to which extent this contributes to muscle wasting and whether this changes targeting of specific muscular proteins is not well described. This review summarizes the function of the main proinflammatory cytokines and acute phase response proteins and their signaling pathways in inflammation-induced muscle atrophy with a focus on UPS-mediated protein degradation in muscle during sepsis. The regulation and target-specificity of the main E3 ubiquitin ligases in muscle atrophy and their mode of action on myofibrillar proteins will be reported. The function of the standard- and immunoproteasome in inflammation-induced muscle atrophy will be described and the effects of proteasome-inhibitors as treatment strategies will be discussed.
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Affiliation(s)
- Stefanie Haberecht-Müller
- Institute of Medical Biochemistry and Molecular Biology, University Medicine Greifswald, 17475 Greifswald, Germany;
| | - Elke Krüger
- Institute of Medical Biochemistry and Molecular Biology, University Medicine Greifswald, 17475 Greifswald, Germany;
- Correspondence: (E.K.); (J.F.)
| | - Jens Fielitz
- DZHK (German Centre for Cardiovascular Research), Partner Site Greifswald, 17475 Greifswald, Germany
- Department of Internal Medicine B, Cardiology, University Medicine Greifswald, 17475 Greifswald, Germany
- Correspondence: (E.K.); (J.F.)
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22
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Stoian A, Bajko Z, Maier S, Cioflinc RA, Grigorescu BL, Moțățăianu A, Bărcuțean L, Balașa R, Stoian M. High-dose intravenous immunoglobulins as a therapeutic option in critical illness polyneuropathy accompanying SARS-CoV-2 infection: A case-based review of the literature (Review). Exp Ther Med 2021; 22:1182. [PMID: 34475972 PMCID: PMC8406741 DOI: 10.3892/etm.2021.10616] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 07/27/2021] [Indexed: 01/08/2023] Open
Abstract
The still ongoing COVID-19 pandemic has exposed the medical community to a number of major challenges. A significant number of patients require admission to intensive care unit (ICU) services due to severe respiratory, thrombotic and septic complications and require long-term hospitalization. Neuromuscular weakness is a common complication in critically ill patients who are treated in ICUs and are mechanically ventilated. This complication is frequently caused by critical illness myopathy (CIM) or critical illness polyneuropathy (CIP) and leads to difficulty in weaning from the ventilator. It is thought to represent an important neurologic manifestation of the systemic inflammatory response syndrome (SIRS). COVID-19 infection is known to trigger strong immune dysregulation, with an intense cytokine storm, as a result, the frequency of CIP is expected to be higher in this setting. The mainstay in the diagnosis of this entity beside the high level of clinical awareness is the electrophysiological examination that provides evidence of axonal motor and sensory polyneuropathy. The present article presents the case of a 54-year-old woman with severe COVID 19 infection who developed neuromuscular weakness, which turned out to be secondary to CIP and was treated successfully with a high dose of human intravenous immunoglobulins. Related to this case, we reviewed the relevant literature data regarding the epidemiology, pathophysiology and clinical features of this important complication and discussed also the treatment options and prognosis.
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Affiliation(s)
- Adina Stoian
- Department of Pathophysiology, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Zoltan Bajko
- Department of Neurology, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Smaranda Maier
- Department of Neurology, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | | | - Bianca Liana Grigorescu
- Department of Pathophysiology, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Anca Moțățăianu
- Department of Neurology, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Laura Bărcuțean
- Department of Neurology, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Rodica Balașa
- Department of Neurology, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Mircea Stoian
- Department of Anesthesiology and Intensive Therapy, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
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23
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Cheung K, Rathbone A, Melanson M, Trier J, Ritsma BR, Allen MD. Pathophysiology and management of critical illness polyneuropathy and myopathy. J Appl Physiol (1985) 2021; 130:1479-1489. [PMID: 33734888 PMCID: PMC8143786 DOI: 10.1152/japplphysiol.00019.2021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Critical illness-associated weakness (CIAW) is an umbrella term used to describe a group of neuromuscular disorders caused by severe illness. It can be subdivided into three major classifications based on the component of the neuromuscular system (i.e. peripheral nerves or skeletal muscle or both) that are affected. This includes critical illness polyneuropathy (CIP), critical illness myopathy (CIM), and an overlap syndrome, critical illness polyneuromyopathy (CIPNM). It is a common complication observed in people with critical illness requiring intensive care unit (ICU) admission. Given CIAW is found in individuals experiencing grave illness, it can be challenging to study from a practical standpoint. However, over the past 2 decades, many insights into the pathophysiology of this condition have been made. Results from studies in both humans and animal models have found that a profound systemic inflammatory response and factors related to bioenergetic failure as well as microvascular, metabolic, and electrophysiological alterations underlie the development of CIAW. Current management strategies focus on early mobilization, achieving euglycemia, and nutritional optimization. Other interventions lack sufficient evidence, mainly due to a dearth of large trials. The goal of this Physiology in Medicine article is to highlight important aspects of the pathophysiology of these enigmatic conditions. It is hoped that improved understanding of the mechanisms underlying these disorders will lead to further study and new investigations for novel pharmacologic, nutritional, and exercise-based interventions to optimize patient outcomes.
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Affiliation(s)
- Kevin Cheung
- School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Alasdair Rathbone
- Department of Physical Medicine and Rehabilitation, Queen's University, Kingston, Ontario, Canada
| | - Michel Melanson
- Division of Neurology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Jessica Trier
- Department of Physical Medicine and Rehabilitation, Queen's University, Kingston, Ontario, Canada
| | - Benjamin R Ritsma
- Department of Physical Medicine and Rehabilitation, Queen's University, Kingston, Ontario, Canada
| | - Matti D Allen
- Department of Physical Medicine and Rehabilitation, Queen's University, Kingston, Ontario, Canada.,School of Kinesiology, Faculty of Arts and Sciences, Queen's University, Kingston, Ontario, Canada
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Tankisi A, Pedersen TH, Bostock H, Z'Graggen WJ, Larsen LH, Meldgaard M, Elkmann T, Tankisi H. Early detection of evolving critical illness myopathy with muscle velocity recovery cycles. Clin Neurophysiol 2021; 132:1347-1357. [PMID: 33676846 DOI: 10.1016/j.clinph.2021.01.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/29/2020] [Accepted: 01/19/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate the sensitivity of muscle velocity recovery cycles (MVRCs) for detecting altered membrane properties in critically ill patients, and to compare this to conventional nerve conduction studies (NCS) and quantitative electromyography (qEMG). METHODS Twenty-four patients with intensive care unit acquired weakness (ICUAW) and 34 healthy subjects were prospectively recruited. In addition to NCS (median, ulnar, peroneal, tibial and sural nerves) and qEMG (biceps brachii, vastus medialis and anterior tibial muscles), MVRCs with frequency ramp were recorded from anterior tibial muscle. RESULTS MVRC and frequency ramp parameters showed abnormal muscle fiber membrane properties with up to 100% sensitivity and specificity. qEMG showed myopathy in 15 patients (63%) while polyneuropathy was seen in 3 (13%). Decreased compound muscle action potential (CMAP) amplitude (up to 58%) and absent F-waves (up to 75%) were frequent, but long duration CMAPs were only seen in one patient with severe myopathy. CONCLUSIONS Altered muscle fiber membrane properties can be detected in patients with ICUAW not yet fulfilling diagnostic criteria for critical illness myopathy (CIM). MVRCs may therefore serve as a tool for early detection of evolving CIM. SIGNIFICANCE CIM is often under-recognized by intensivists, and large-scale longitudinal studies are needed to determine its incidence and pathogenesis.
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Affiliation(s)
- A Tankisi
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - T H Pedersen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - H Bostock
- Institute of Neurology, University College London, Queen Square House, London, United Kingdom
| | - W J Z'Graggen
- Departments of Neurology and Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - L H Larsen
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - M Meldgaard
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - T Elkmann
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - H Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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Rudra RT, Lin D, Miller B, Du P, Zhang S. Investigating inpatient rehabilitation outcomes of patients with intensive care unit-acquired weakness, and identifying comorbidities associated with unfavorable outcomes. PM R 2021; 14:190-197. [PMID: 33528114 DOI: 10.1002/pmrj.12565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 01/15/2021] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Data are consistent on the benefits of inpatient rehabilitation for intensive care unit-acquired weaknesses (ICUAW), including critical illness myopathy, critical illness polyneuropathy, critical illness polyneuromyopathy, and disuse atrophy. This study focuses on the effects of inpatient rehabilitation on patients with ICUAW, specifically those with a clinical pattern of proximal muscle weakness and sensory sparing. OBJECTIVES To evaluate the impact of inpatient rehabilitation on patients with ICUAW versus other medically complex patients, and to identify comorbidities associated with poor rehabilitation outcomes. DESIGN Retrospective cohort study. SETTING Institutional, inpatient rehabilitation hospital. PATIENTS Two hundred seventy adult patients (≥18 years) divided into two groups: diagnosis of ICUAW (N = 55) or otherwise medically complex (N = 215), and admitted under the care of one physiatrist. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES For all patients we compared functional independence measure (FIM) gain, FIM efficiency, rehabilitation length of stay (RLOS), discharge disposition, and major medical comorbidities. RESULTS Patients with ICUAW had significantly greater FIM gain (P = .015) and RLOS (P = .02). There was no significant difference in FIM efficiency (P = .15). Patients with ICUAW had a significantly lower odds of acute hospital transfer (odds ratio [OR] = 0.52, with 95% confidence interval [CI] 0.47, 0.58) and skilled nursing facility discharge (OR = 0.19, with 95% CI 0.038, 0.95). However, patients with ICUAW did have a higher percent of acute hospital transfers than other medically complex patients (P = .017). In addition, patients with ICUAW were more medically complex, as evidenced by a significantly higher Charlson Comorbidity Index (P < .001), prevalence of anemia (P < .001), atrial fibrillation (P = .009), obstructive sleep apnea (P = .018), and bacteremia (P = .041). CONCLUSIONS Patients with ICUAW with a clinical pattern of proximal muscle weakness and sensory sparing benefit from inpatient rehabilitation as evidenced by FIM gain and high home discharge rate. However, they have multiple medical comorbidities, which require judicious medical management and may contribute to a longer RLOS.
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Affiliation(s)
- Renuka T Rudra
- Department of Physical Medicine and Rehabilitation, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Dan Lin
- Department of Public Health Sciences, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Benjamin Miller
- College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Ping Du
- Department of Public Health Sciences, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Shangming Zhang
- Department of Physical Medicine and Rehabilitation, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
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Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
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Cabañes-Martínez L, Villadóniga M, González-Rodríguez L, Araque L, Díaz-Cid A, Ruz-Caracuel I, Pian H, Sánchez-Alonso S, Fanjul S, Del Álamo M, Regidor I. Neuromuscular involvement in COVID-19 critically ill patients. Clin Neurophysiol 2020; 131:2809-2816. [PMID: 33137571 PMCID: PMC7558229 DOI: 10.1016/j.clinph.2020.09.017] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Coronavirus disease 2019 (COVID-19) has a high incidence of intensive care admittance due to the severe acute respiratory syndrome (SARS). Intensive care unit (ICU)-acquired weakness (ICUAW) is a common complication of ICU patients consisting of symmetric and generalised weakness. The aim of this study was to determine the presence of myopathy, neuropathy or both in ICU patients affected by COVID-19 and whether ICUAW associated with COVID-19 differs from other aetiologies. METHODS Twelve SARS CoV-2 positive patients referred with the suspicion of critical illness myopathy (CIM) or polyneuropathy (CIP) were included between March and May 2020. Nerve conduction and concentric needle electromyography were performed in all patients while admitted to the hospital. Muscle biopsies were obtained in three patients. RESULTS Four patients presented signs of a sensory-motor axonal polyneuropathy and seven patients showed signs of myopathy. One muscle biopsy showed scattered necrotic and regenerative fibres without inflammatory signs. The other two biopsies showed non-specific myopathic findings. CONCLUSIONS We have not found any distinctive features in the studies of the ICU patients affected by SARS-CoV-2 infection. SIGNIFICANCE Further studies are needed to determine whether COVID-19-related CIM/CIP has different features from other aetiologies. Neurophysiological studies are essential in the diagnosis of these patients.
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Affiliation(s)
- Lidia Cabañes-Martínez
- Clinical Neurophysiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - Marta Villadóniga
- Clinical Neurophysiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Lesly Araque
- Clinical Neurophysiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Alba Díaz-Cid
- Clinical Neurophysiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Ignacio Ruz-Caracuel
- Pathology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Research Group in Muscle Regeneration, University of Cordoba, Córdoba, Spain
| | - Héctor Pian
- Pathology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Samira Fanjul
- Neurology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Marta Del Álamo
- Neurosurgery Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Ignacio Regidor
- Clinical Neurophysiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Intensive Care Unit-Acquired Weakness: Not just Another Muscle Atrophying Condition. Int J Mol Sci 2020; 21:ijms21217840. [PMID: 33105809 PMCID: PMC7660068 DOI: 10.3390/ijms21217840] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/18/2020] [Accepted: 10/19/2020] [Indexed: 02/07/2023] Open
Abstract
Intensive care unit-acquired weakness (ICUAW) occurs in critically ill patients stemming from the critical illness itself, and results in sustained disability long after the ICU stay. Weakness can be attributed to muscle wasting, impaired contractility, neuropathy, and major pathways associated with muscle protein degradation such as the ubiquitin proteasome system and dysregulated autophagy. Furthermore, it is characterized by the preferential loss of myosin, a distinct feature of the condition. While many risk factors for ICUAW have been identified, effective interventions to offset these changes remain elusive. In addition, our understanding of the mechanisms underlying the long-term, sustained weakness observed in a subset of patients after discharge is minimal. Herein, we discuss the various proposed pathways involved in the pathophysiology of ICUAW, with a focus on the mechanisms underpinning skeletal muscle wasting and impaired contractility, and the animal models used to study them. Furthermore, we will explore the contributions of inflammation, steroid use, and paralysis to the development of ICUAW and how it pertains to those with the corona virus disease of 2019 (COVID-19). We then elaborate on interventions tested as a means to offset these decrements in muscle function that occur as a result of critical illness, and we propose new strategies to explore the molecular mechanisms of ICUAW, including serum-related biomarkers and 3D human skeletal muscle culture models.
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Abstract
Critical illness polyneuropathy (CIP) along with critical illness myopathy (CIM) is a frequent condition in critically ill patients. Similar to critical illness myopathy, the exact incidence, etiology, and mechanisms of CIP are not well understood. Although decreased compound muscle action potential amplitudes may be seen in both conditions, differentiation mostly relies on sensory nerve conduction studies which require special care to perform at intensive care units. In some instances, both CIP and critical illness myopathy are observed, and this condition is called critical illness neuromyopathy. In this review, nerve conduction studies and needle electromyography for the diagnosis of CIP and differentiation of CIP from critical illness myopathy and other conditions at intensive care units are summarized.
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30
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Li Z, Cai Y, Zhang Q, Zhang P, Sun R, Jiang H, Wan J, Wu F, Wang X, Tao X. Intensive care unit acquired weakness: A protocol for an overview of systematic reviews and meta-analysis. Medicine (Baltimore) 2020; 99:e21926. [PMID: 32846861 PMCID: PMC7447417 DOI: 10.1097/md.0000000000021926] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 07/28/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Intensive care unit-acquired weakness (ICU-AW) is an acquired neuromuscular lesion and a common occurrence in patients who are critically ill. There are already systematic reviews on ICU-AW. Therefore, we provide a protocol for an overview of systematic reviews to improve the effectiveness of the construction of an evidence-based practice for prevention of ICU-AW. METHODS We will search the PubMed, CINAHL, EMBASE, and the Cochrane Library for the relevant systematic review or meta-analyses about ICU-AW. Study selection, data extraction, and the quality assessment of the included studies will be performed independently by 2 reviewers. And the methodological quality, report quality and evidence quality will be evaluated by Assessment of Multiple Systematic Reviews-2 tool, Preferred Reporting Items for Systematic Reviews and Meta Analyses Statement checklist and Grading of Recommendations Assessment, Development and Evaluation system, respectively. RESULTS This overview of systematic reviews and meta-analysis will collect the evidence published about the ICU-AW. CONCLUSION We hope that our research will contribute to clinicians and public decision making about the ICU-AW. REGISTRATION NUMBER INPLASY202070067.
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Affiliation(s)
- Zheng Li
- Graduate College, Wannan Medical College, Wuhu
| | - Yitong Cai
- School of Nursing, Lanzhou University, Lanzhou
| | - Qian Zhang
- School of Nursing, Lanzhou University, Lanzhou
| | - Peng Zhang
- The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Ruixiang Sun
- The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Haijiao Jiang
- The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | | | - Fang Wu
- Graduate College, Wannan Medical College, Wuhu
| | - Xiaoye Wang
- The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Xiubin Tao
- Graduate College, Wannan Medical College, Wuhu
- The First Affiliated Hospital of Wannan Medical College, Wuhu, China
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Abstract
PURPOSE OF REVIEW This article reviews the pathogenesis, clinical features, and management of toxic myopathy related to common medications, critical illness, and illicit substances. RECENT FINDINGS Muscle symptoms are common among statin users and are usually reversible after discontinuation of the statin; rarely, however, statins trigger an immune-mediated necrotizing myopathy that persists and requires immunomodulatory therapy. Autoantibodies targeting 3-hydroxy-3-methylglutaryl coenzyme A reductase can distinguish the toxic and immune-mediated forms. Immune checkpoint inhibitors, increasingly used in the treatment of advanced cancer, have recently been associated with the development of inflammatory myositis. A reversible mitochondrial myopathy has long been associated with zidovudine, but recent reports elucidate the risk of myopathy with newer antivirals, such as telbivudine and raltegravir. SUMMARY The medications most commonly associated with myopathy include statins, amiodarone, chloroquine, hydroxychloroquine, colchicine, certain antivirals, and corticosteroids, and myopathy can occur with chronic alcoholism. Certain clinical, electrodiagnostic, and histologic features can aid in early recognition. Stopping the use of the offending agent reverses symptoms in most cases, but specific and timely treatment may be required in cases related to agents that trigger immune-mediated muscle injury.
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Vanhorebeek I, Latronico N, Van den Berghe G. ICU-acquired weakness. Intensive Care Med 2020; 46:637-653. [PMID: 32076765 PMCID: PMC7224132 DOI: 10.1007/s00134-020-05944-4] [Citation(s) in RCA: 260] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/16/2020] [Indexed: 01/04/2023]
Abstract
Critically ill patients often acquire neuropathy and/or myopathy labeled ICU-acquired weakness. The current insights into incidence, pathophysiology, diagnostic tools, risk factors, short- and long-term consequences and management of ICU-acquired weakness are narratively reviewed. PubMed was searched for combinations of “neuropathy”, “myopathy”, “neuromyopathy”, or “weakness” with “critical illness”, “critically ill”, “ICU”, “PICU”, “sepsis” or “burn”. ICU-acquired weakness affects limb and respiratory muscles with a widely varying prevalence depending on the study population. Pathophysiology remains incompletely understood but comprises complex structural/functional alterations within myofibers and neurons. Clinical and electrophysiological tools are used for diagnosis, each with advantages and limitations. Risk factors include age, weight, comorbidities, illness severity, organ failure, exposure to drugs negatively affecting myofibers and neurons, immobility and other intensive care-related factors. ICU-acquired weakness increases risk of in-ICU, in-hospital and long-term mortality, duration of mechanical ventilation and of hospitalization and augments healthcare-related costs, increases likelihood of prolonged care in rehabilitation centers and reduces physical function and quality of life in the long term. RCTs have shown preventive impact of avoiding hyperglycemia, of omitting early parenteral nutrition use and of minimizing sedation. Results of studies investigating the impact of early mobilization, neuromuscular electrical stimulation and of pharmacological interventions were inconsistent, with recent systematic reviews/meta-analyses revealing no or only low-quality evidence for benefit. ICU-acquired weakness predisposes to adverse short- and long-term outcomes. Only a few preventive, but no therapeutic, strategies exist. Further mechanistic research is needed to identify new targets for interventions to be tested in adequately powered RCTs.
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Affiliation(s)
- Ilse Vanhorebeek
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123, Brescia, Italy.,Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123, Brescia, Italy
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Five-year impact of ICU-acquired neuromuscular complications: a prospective, observational study. Intensive Care Med 2020; 46:1184-1193. [DOI: 10.1007/s00134-020-05927-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 01/08/2020] [Indexed: 10/25/2022]
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Sidiras G, Patsaki I, Karatzanos E, Dakoutrou M, Kouvarakos A, Mitsiou G, Routsi C, Stranjalis G, Nanas S, Gerovasili V. Long term follow-up of quality of life and functional ability in patients with ICU acquired Weakness – A post hoc analysis. J Crit Care 2019; 53:223-230. [DOI: 10.1016/j.jcrc.2019.06.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/19/2019] [Accepted: 06/20/2019] [Indexed: 12/29/2022]
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Inoue S, Hatakeyama J, Kondo Y, Hifumi T, Sakuramoto H, Kawasaki T, Taito S, Nakamura K, Unoki T, Kawai Y, Kenmotsu Y, Saito M, Yamakawa K, Nishida O. Post-intensive care syndrome: its pathophysiology, prevention, and future directions. Acute Med Surg 2019; 6:233-246. [PMID: 31304024 PMCID: PMC6603316 DOI: 10.1002/ams2.415] [Citation(s) in RCA: 246] [Impact Index Per Article: 49.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 03/11/2019] [Indexed: 12/21/2022] Open
Abstract
Expanding elderly populations are a major social challenge in advanced countries worldwide and have led to a rapid increase in the number of elderly patients in intensive care units (ICUs). Innovative advances in medical technology have enabled lifesaving of patients in ICUs, but there remain various problems to improve their long-term prognoses. Post-intensive care syndrome (PICS) refers to physical, cognition, and mental impairments that occur during ICU stay, after ICU discharge or hospital discharge, as well as the long-term prognosis of ICU patients. Its concept also applies to pediatric patients (PICS-p) and the mental status of their family (PICS-F). Intensive care unit-acquired weakness, a syndrome characterized by acute symmetrical limb muscle weakness after ICU admission, belongs to physical impairments in three domains of PICS. Prevention of PICS requires performance of the ABCDEFGH bundle, which incorporates the prevention of delirium, early rehabilitation, family intervention, and follow-up from the time of ICU admission to the time of discharge. Diary, nutrition, nursing care, and environmental management for healing are also important in the prevention of PICS. This review outlines the pathophysiology, prevention, and future directions of PICS.
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Affiliation(s)
- Shigeaki Inoue
- Department of Disaster and Emergency and Critical Care Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - Junji Hatakeyama
- Department of Emergency and Critical Care Medicine Yokohama City Minato Red Cross Hospital Yokohama Kanagawa Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine Juntendo University Urayasu Hospital Urayasu Chiba Japan
| | - Toru Hifumi
- Emergency and Critical Care Medicine St. Luke's International Hospital Tokyo Japan
| | - Hideaki Sakuramoto
- Department of Adult Health Nursing College of Nursing Ibaraki Christian University Hitachi Japan
| | - Tatsuya Kawasaki
- Department of Pediatric Critical Care Shizuoka Children's Hospital Shizuoka Japan
| | - Shunsuke Taito
- Department of Clinical Practice and Support Division of Rehabilitation Hiroshima University Hospital Hiroshima Japan
| | - Kensuke Nakamura
- Department of Emergency and Critical Care Medicine Hitachi General Hospital Hitachi Ibaraki Japan
| | - Takeshi Unoki
- Department of Adult Health Nursing School of Nursing Sapporo City University Sapporo Japan
| | - Yusuke Kawai
- Department of Nursing Fujita Health University Hospital Toyoake Aichi Japan
| | - Yuji Kenmotsu
- Department of Nursing Tokai University Hachioji Hospital Hachioji Tokyo Japan
| | - Masafumi Saito
- Department of Disaster and Emergency and Critical Care Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care Osaka General Medical Center Osaka City Osaka Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine Fujita Health University School of Medicine Toyoake Aichi Japan
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What is in the Myopathy Literature? J Clin Neuromuscul Dis 2018; 19:217-223. [PMID: 29794577 DOI: 10.1097/cnd.0000000000000203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This update covers the results of a randomized, placebo-controlled study that provides evidence that lamotrigine is effective in treating nondystrophic myotonias. Next, an overview of adverse effects of immune checkpoint inhibitors is provided, and the association of autoimmune myopathy and these monoclonal antibody therapies is discussed in light of recent reports. Last, the utility of electrodiagnostic testing in patients with intensive care unit weakness is addressed with emphasis on the high sensitivity and specificity of prolonged compound muscle action potential amplitudes in diagnosing critical illness myopathy.
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Nozoe M, Kamo A, Shimada S, Mase K. Neuromuscular electrical stimulation is ineffective for treating quadriceps muscle wasting with ruptured aneurysm: A case report. Ann Med Surg (Lond) 2018; 35:90-94. [PMID: 30294437 PMCID: PMC6170208 DOI: 10.1016/j.amsu.2018.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 08/31/2018] [Accepted: 09/15/2018] [Indexed: 11/25/2022] Open
Abstract
Introduction Neuromuscular electrical stimulation (NMES) is a preventive intervention for muscle wasting in patients with aneurysms during the acute phase; however, its efficacy still remains unclear. In this case study, we report the effects of NMES on quadriceps muscle wasting for a patient with ruptured middle cerebral artery aneurysms during the acute phase. Presentation of case A 66-year-old woman was admitted because of a ruptured middle cerebral artery aneurysm resulting from intracerebral hematoma with subarachnoid hemorrhage. The following day, the patient started undergoing 60–120-min NMES treatment for both her quadriceps muscles, which was continued for 10 days in 2 weeks. Quadriceps muscle thickness as measured by ultrasonography was decreased in both sides (26% and 35% for the right and left sides, respectively). The compound muscle action potential (CMAP) amplitude in the peroneal nerve was also decreased in both sides (73% vs 76%). Discussion The lack of efficacy of NMES in preventing muscle wasting is the decreased CMAP amplitude in this patient, which showed the possibility of existence of critical illness polyneuropathy. Conclusion NMES had no effect on quadriceps muscle wasting in a patient with ruptured middle cerebral artery aneurysms who had decreased CMAP amplitude in the peroneal nerve during the acute phase. NMES is not effective for patients with peripheral nerve conduction abnormalities. NMES is not effective for preventing muscle wasting and disability. NMES is not effective for patients with peripheral nerve conduction abnormalities. The efficacy of NMES is dependent on whether conduction abnormalities exist.
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Key Words
- CIM, critical illness myopathy
- CINM, CIP and CIM
- CIP, critical illness polyneuropathy
- CMAP, compound muscle action potential
- CSD, cross sectional diameter
- Case report
- Critical illness
- EDB, extensor digitorum brevis
- Electric stimulation therapy
- FSS-ICU, Functional Status Score for the ICU
- GCS, Glasgow coma scale
- ICU-AW, ICU-acquired weakness
- MCVs, motor conduction velocities
- MRC sum score, Medical Research Council sum score
- Muscle weakness
- NCV, nerve conduction velocity
- NMES, Neuromuscular electrical stimulation
- QMT, quadriceps muscle thickness
- RF, rectus femoris
- VI, vastus intermedius
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Affiliation(s)
- Masafumi Nozoe
- Department of Physical Therapy, Faculty of Nursing and Rehabilitation, Konan Women's University, Japan
| | - Arisa Kamo
- Department of Rehabilitation, Itami Kousei Neurosurgical Hospital, Itami, Japan
| | - Shinichi Shimada
- Department of Neurosurgery, Itami Kousei Neurosurgical Hospital, Itami, Japan
| | - Kyoshi Mase
- Department of Physical Therapy, Faculty of Nursing and Rehabilitation, Konan Women's University, Japan
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Thabet Mahmoud A, Tawfik MAM, Abd El Naby SA, Abo El Fotoh WMM, Saleh NY, Abd El Hady NMS. Neurophysiological study of critical illness polyneuropathy and myopathy in mechanically ventilated children; additional aspects in paediatric critical illness comorbidities. Eur J Neurol 2018; 25:991-e76. [PMID: 29604150 DOI: 10.1111/ene.13649] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 03/27/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Critical illness polyneuropathy and myopathy (CIP/CIM) is being increasingly recognized as a significant clinical problem in critically ill children especially if they have spent long periods in the intensive care unit. So the aim was to determine the frequency of CIP/CIM amongst mechanically ventilated children and to analyse the associated risk factors and drawbacks frequently encountered in this cohort. METHODS The study included 105 patients admitted to the paediatric intensive care unit who underwent mechanical ventilation for ≥7 days. These patients were screened daily for awakening. Patients with severe muscle weakness on day 7 post-awakening underwent nerve conduction studies and electromyography. Accordingly, the patients were classified as CIP/CIM patients if they had abnormal neurophysiology studies or control patients if normal neurophysiology studies were obtained. Their clinical and laboratory profiles had been recorded as well. RESULTS Overall, of 105 patients who achieved satisfactory awakening, 34 patients (32.4%) developed CIP/CIM mostly of the axonal polyneuropathy pattern (27.6%) whilst 71 control patients (67.6%) showed normal electrophysiological studies. The mean duration of mechanical ventilation was significantly longer in patients with CIP/CIM compared to control patients (P = 0.001). The study also revealed that 62.1% of our CIP/CIM patients failed weaning trials and finally died. CIP/CIM was significantly associated with decreased platelets, elevated liver enzymes and prolonged prothrombin time. Acidosis, low serum calcium and albumin levels and higher blood glucose were also found to be more significant in CIP/CIM patients compared to control patients. CONCLUSION Critically ill children frequently develop CIP/CIM, mostly of axonal polyneuropathy pattern, which compromises rehabilitation and recovery and is associated with a number of comorbidities.
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Affiliation(s)
- A Thabet Mahmoud
- Faculty of Medicine, Menoufia University Hospitals, Shebin El-Kom, Egypt
| | - M A M Tawfik
- Faculty of Medicine, Menoufia University Hospitals, Shebin El-Kom, Egypt
| | - S A Abd El Naby
- Faculty of Medicine, Menoufia University Hospitals, Shebin El-Kom, Egypt
| | - W M M Abo El Fotoh
- Faculty of Medicine, Menoufia University Hospitals, Shebin El-Kom, Egypt
| | - N Y Saleh
- Faculty of Medicine, Menoufia University Hospitals, Shebin El-Kom, Egypt
| | - N M S Abd El Hady
- Faculty of Medicine, Menoufia University Hospitals, Shebin El-Kom, Egypt
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Nishida O, Ogura H, Egi M, Fujishima S, Hayashi Y, Iba T, Imaizumi H, Inoue S, Kakihana Y, Kotani J, Kushimoto S, Masuda Y, Matsuda N, Matsushima A, Nakada TA, Nakagawa S, Nunomiya S, Sadahiro T, Shime N, Yatabe T, Hara Y, Hayashida K, Kondo Y, Sumi Y, Yasuda H, Aoyama K, Azuhata T, Doi K, Doi M, Fujimura N, Fuke R, Fukuda T, Goto K, Hasegawa R, Hashimoto S, Hatakeyama J, Hayakawa M, Hifumi T, Higashibeppu N, Hirai K, Hirose T, Ide K, Kaizuka Y, Kan’o T, Kawasaki T, Kuroda H, Matsuda A, Matsumoto S, Nagae M, Onodera M, Ohnuma T, Oshima K, Saito N, Sakamoto S, Sakuraya M, Sasano M, Sato N, Sawamura A, Shimizu K, Shirai K, Takei T, Takeuchi M, Takimoto K, Taniguchi T, Tatsumi H, Tsuruta R, Yama N, Yamakawa K, Yamashita C, Yamashita K, Yoshida T, Tanaka H, Oda S. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016). J Intensive Care 2018; 6:7. [PMID: 29435330 PMCID: PMC5797365 DOI: 10.1186/s40560-017-0270-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 12/11/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND PURPOSE The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 and published in the Journal of JSICM, [2017; Volume 24 (supplement 2)] 10.3918/jsicm.24S0001 and Journal of Japanese Association for Acute Medicine [2017; Volume 28, (supplement 1)] http://onlinelibrary.wiley.com/doi/10.1002/jja2.2017.28.issue-S1/issuetoc.This abridged English edition of the J-SSCG 2016 was produced with permission from the Japanese Association of Acute Medicine and the Japanese Society for Intensive Care Medicine. METHODS Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ) and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (> 66.6%) majority vote of each of the 19 committee members. RESULTS A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation, and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty-seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for five CQs. CONCLUSIONS Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.
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Affiliation(s)
- Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192 Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Moritoki Egi
- Department of anesthesiology, Kobe University Hospital, Kobe, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiro Hayashi
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hitoshi Imaizumi
- Department of Anesthesiology and Critical Care Medicine, Tokyo Medical University School of Medicine, Tokyo, Japan
| | - Shigeaki Inoue
- Department of Emergency and Critical Care Medicine, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Yasuyuki Kakihana
- Department of Emergency and Intensive Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Joji Kotani
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshiki Masuda
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Naoyuki Matsuda
- Department of Emergency & Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Asako Matsushima
- Department of Advancing Acute Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Taka-aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Satoshi Nakagawa
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Shin Nunomiya
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Tomohito Sadahiro
- Department of Emergency and Critical Care Medicine, Tokyo Women’s Medical University Yachiyo Medical Center, Tokyo, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Institute of Biomedical & Health Sciences, Hiroshima University, Higashihiroshima, Japan
| | - Tomoaki Yatabe
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kochi, Japan
| | - Yoshitaka Hara
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192 Japan
| | - Kei Hayashida
- Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Yutaka Kondo
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Yuka Sumi
- Healthcare New Frontier Promotion Headquarters Office, Kanagawa Prefectural Government, Yokohama, Japan
| | - Hideto Yasuda
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Kazuyoshi Aoyama
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Canada
- Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Takeo Azuhata
- Division of Emergency and Critical Care Medicine, Departmen of Acute Medicine, Nihon university school of Medicine, Tokyo, Japan
| | - Kent Doi
- Department of Acute Medicine, The University of Tokyo, Tokyo, Japan
| | - Matsuyuki Doi
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Naoyuki Fujimura
- Department of Anesthesiology, St. Mary’s Hospital, Westminster, UK
| | - Ryota Fuke
- Division of Infectious Diseases and Infection Control, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Japan
| | - Tatsuma Fukuda
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Koji Goto
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Oita University, Oita, Japan
| | - Ryuichi Hasegawa
- Department of Emergency and Intensive Care Medicine, Mito Clinical Education and Training Center, Tsukuba University Hospital, Mito Kyodo General Hospital, Mito, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Tsukuba, Japan
| | - Junji Hatakeyama
- Department of Intensive Care Medicine, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Mineji Hayakawa
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Toru Hifumi
- Emergency Medical Center, Kagawa University Hospital, Miki, Japan
| | - Naoki Higashibeppu
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Kobe City Hospital Organization, Kobe, Japan
| | - Katsuki Hirai
- Department of Pediatrics, Kumamoto Red cross Hospital, Kumamoto, Japan
| | - Tomoya Hirose
- Emergency and Critical Care Medical Center, Osaka Police Hospital, Osaka, Japan
| | - Kentaro Ide
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yasuo Kaizuka
- Department of Emergency & ICU, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Tomomichi Kan’o
- Department of Emergency & Critical Care Medicine Kitasato University, Tokyo, Japan
| | - Tatsuya Kawasaki
- Department of Pediatric Critical Care, Shizuoka Children’s Hospital, Shizuoka, Japan
| | - Hiromitsu Kuroda
- Department of Anesthesia, Obihiro Kosei Hospital, Obihiro, Japan
| | - Akihisa Matsuda
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Japan
| | - Shotaro Matsumoto
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Masaharu Nagae
- Department of anesthesiology, Kobe University Hospital, Kobe, Japan
| | - Mutsuo Onodera
- Department of Emergency and Critical Care Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Tetsu Ohnuma
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, USA
| | - Kiyohiro Oshima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Nobuyuki Saito
- Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Japan
| | - So Sakamoto
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Mikio Sasano
- Department of Intensive Care Medicine, Nakagami Hospital, Uruma, Japan
| | - Norio Sato
- Department of Aeromedical Services for Emergency and Trauma Care, Ehime University Graduate School of Medicine, Matsuyama, Japan
| | - Atsushi Sawamura
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kentaro Shimizu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kunihiro Shirai
- Department of Emergency and Critical Care Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Tetsuhiro Takei
- Department of Emergency and Critical Care Medicine, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
| | - Kohei Takimoto
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Takumi Taniguchi
- Department of Anesthesiology and Intensive Care Medicine, Kanazawa University, Kanazawa, Japan
| | - Hiroomi Tatsumi
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Naoya Yama
- Department of Diagnostic Radiology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Chizuru Yamashita
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192 Japan
| | - Kazuto Yamashita
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Yoshida
- Intensive Care Unit, Osaka University Hospital, Osaka, Japan
| | - Hiroshi Tanaka
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Shigeto Oda
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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Intiso D. ICU-acquired weakness: should medical sovereignty belong to any specialist? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:1. [PMID: 29301549 PMCID: PMC5755267 DOI: 10.1186/s13054-017-1923-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 12/11/2017] [Indexed: 02/04/2023]
Abstract
ICU-acquired weakness (ICUAW), including critical illness polyneuropathy, critical illness myopathy, and critical illness polyneuropathy and myopathy, is a frequent disabling disorder in ICU subjects. Research has predominantly been performed by intensivists, whose efforts have permitted the diagnosis of ICUAW early during an ICU stay and understanding of several of the pathophysiological and clinical aspects of this disorder. Despite important progress, the therapeutic strategies are unsatisfactory and issues such as functional outcomes and long-term recovery remain unclear. Studies involving multiple specialists should be planned to better differentiate the ICUAW types and provide proper functional outcome measures and follow-up. A more strict collaboration among specialists interested in ICUAW, in particular physiatrists, is desirable to plan proper care pathways after ICU discharge and to better meet the health needs of subjects with ICUAW.
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Affiliation(s)
- Domenico Intiso
- Unit of Neuro-Rehabilitation, Hospital IRCCS "Casa Sollievo della Sofferenza", Viale dei Cappuccini, 71013, San Giovanni Rotondo, FG, Italy.
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Nishida O, Ogura H, Egi M, Fujishima S, Hayashi Y, Iba T, Imaizumi H, Inoue S, Kakihana Y, Kotani J, Kushimoto S, Masuda Y, Matsuda N, Matsushima A, Nakada T, Nakagawa S, Nunomiya S, Sadahiro T, Shime N, Yatabe T, Hara Y, Hayashida K, Kondo Y, Sumi Y, Yasuda H, Aoyama K, Azuhata T, Doi K, Doi M, Fujimura N, Fuke R, Fukuda T, Goto K, Hasegawa R, Hashimoto S, Hatakeyama J, Hayakawa M, Hifumi T, Higashibeppu N, Hirai K, Hirose T, Ide K, Kaizuka Y, Kan'o T, Kawasaki T, Kuroda H, Matsuda A, Matsumoto S, Nagae M, Onodera M, Ohnuma T, Oshima K, Saito N, Sakamoto S, Sakuraya M, Sasano M, Sato N, Sawamura A, Shimizu K, Shirai K, Takei T, Takeuchi M, Takimoto K, Taniguchi T, Tatsumi H, Tsuruta R, Yama N, Yamakawa K, Yamashita C, Yamashita K, Yoshida T, Tanaka H, Oda S. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016). Acute Med Surg 2018; 5:3-89. [PMID: 29445505 PMCID: PMC5797842 DOI: 10.1002/ams2.322] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 10/11/2017] [Indexed: 11/11/2022] Open
Abstract
Background and Purpose The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 in Japanese. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. Methods Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ), and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (>66.6%) majority vote of each of the 19 committee members. Results A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for 5 CQs. Conclusions Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.
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Cunningham CJB, Finlayson HC, Henderson WR, O'Connor RJ, Travlos A. Impact of Critical Illness Polyneuromyopathy in Rehabilitation: A Prospective Observational Study. PM R 2017; 10:494-500. [PMID: 29054691 DOI: 10.1016/j.pmrj.2017.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 08/25/2017] [Accepted: 09/24/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Critical illness polyneuromyopathy (CIPNM) increasingly is recognized as a source of disability in patients requiring intensive care unit (ICU) admission. The prevalence and impact of CIPNM on patients in the rehabilitation setting has not been established. OBJECTIVES To determine the proportion of at-risk rehabilitation inpatients with evidence of CIPNM and the functional sequelae of this disorder. DESIGN Prospective observational study. SETTING Tertiary academic rehabilitation hospital. PATIENTS Rehabilitation inpatients with a history of ICU admission for at least 72 hours. METHODS Electrodiagnostic studies were performed to evaluate for axonal neuropathy and/or myopathy in at least one upper and one lower limb. MAIN OUTCOME MEASUREMENTS The primary outcome was prevalence of CIPNM. Secondary outcomes included Functional Independence Measure (FIM) scores, rehabilitation length of stay (RLOS), and discharge disposition. RESULTS A total of 33 participants were enrolled; 70% had evidence of CIPNM. Admission FIM score, discharge FIM, FIM gain, and FIM efficiency were 64.1, 89.9, 25.5, and 0.31 in those with CIPNM versus 78.4, 94.6, 16.1, and 0.33 in those without CIPNM, respectively. Average RLOS was 123 days versus 76 days and discharge to home was 57% versus 90% in the CIPNM and non-CIPNM groups, respectively. CONCLUSIONS CIPNM is very common in rehabilitation inpatients with a history of ICU admission. It was associated with a lower functional status at rehabilitation admission, but functional improvement was at a similar rate to those without CIPNM. Longer RLOS stay may be required to achieve the same functional level. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Cameron J B Cunningham
- Department of Medicine and Division of Physical Medicine and Rehabilitation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada.,Department of Medicine, Division of Physical Medicine and Rehabilitation, Division of Critical Care Medicine, and GF Strong Rehabilitation Centre, University of British Columbia, and Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Department of Medicine, Division of Critical Care Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada.,Department of Medicine, Division of Physical Medicine and Rehabilitation, and GF Strong Rehabilitation Centre, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Heather C Finlayson
- Department of Medicine and Division of Physical Medicine and Rehabilitation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada.,Department of Medicine, Division of Physical Medicine and Rehabilitation, Division of Critical Care Medicine, and GF Strong Rehabilitation Centre, University of British Columbia, and Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Department of Medicine, Division of Critical Care Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada.,Department of Medicine, Division of Physical Medicine and Rehabilitation, and GF Strong Rehabilitation Centre, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - William R Henderson
- Department of Medicine and Division of Physical Medicine and Rehabilitation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada.,Department of Medicine, Division of Physical Medicine and Rehabilitation, Division of Critical Care Medicine, and GF Strong Rehabilitation Centre, University of British Columbia, and Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Department of Medicine, Division of Critical Care Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada.,Department of Medicine, Division of Physical Medicine and Rehabilitation, and GF Strong Rehabilitation Centre, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Russell J O'Connor
- Department of Medicine and Division of Physical Medicine and Rehabilitation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada.,Department of Medicine, Division of Physical Medicine and Rehabilitation, Division of Critical Care Medicine, and GF Strong Rehabilitation Centre, University of British Columbia, and Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Department of Medicine, Division of Critical Care Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada.,Department of Medicine, Division of Physical Medicine and Rehabilitation, and GF Strong Rehabilitation Centre, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Andrew Travlos
- Department of Medicine and Division of Physical Medicine and Rehabilitation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada.,Department of Medicine, Division of Physical Medicine and Rehabilitation, Division of Critical Care Medicine, and GF Strong Rehabilitation Centre, University of British Columbia, and Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Department of Medicine, Division of Critical Care Medicine, and Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada.,Department of Medicine, Division of Physical Medicine and Rehabilitation, and GF Strong Rehabilitation Centre, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
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Prognosis of neurologic complications in critical illness. HANDBOOK OF CLINICAL NEUROLOGY 2017. [PMID: 28190446 DOI: 10.1016/b978-0-444-63599-0.00041-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Neurologic complications of critical illness require extensive clinical and neurophysiologic evaluation to establish a reliable prognosis. Many sequelae of intensive care unit (ICU) treatment, such as delirium and ICU-acquired weakness, although highly associated with adverse outcomes, are less suitable for prognostication, but should rather prompt clinicians to seek previously unnoticed persisting underlying illnesses. Prognostication can be confounded by drug administration particularly because its clearance is abnormal in critical illness. Some neurological complications are severe, and can last for months or years after discharge from ICU. The most important ethical aspects regarding neurologic complications in critically ill patients are prevention, recognition, and identification, and prevention of self-fulfilling prophecies. This chapter summarizes the tool of prognostication of major neurological complications of critical illness.
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Effect of neuromuscular stimulation and individualized rehabilitation on muscle strength in Intensive Care Unit survivors: A randomized trial. J Crit Care 2017; 40:76-82. [PMID: 28364678 DOI: 10.1016/j.jcrc.2017.03.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 02/20/2017] [Accepted: 03/19/2017] [Indexed: 01/16/2023]
Abstract
PURPOSE Intensive Care Unit (ICU) survivors experience muscle weakness leading to restrictions in functional ability. Neuromuscular electrical stimulation (NMES) has been an alternative to exercise in critically ill patients. The aim of our study was to investigate its effects along with individualized rehabilitation on muscle strength of ICU survivors. MATERIAL AND METHODS Following ICU discharge, 128 patients (age: 53±16years) were randomly assigned to daily NMES sessions and individualized rehabilitation (NMES group) or to control group. Muscle strength was assessed by the Medical Research Council (MRC) score and hand grip at hospital discharge. Secondary outcomes were functional ability and hospital length of stay. RESULTS MRC, handgrip, functional status and hospital length of stay did not differ at hospital discharge between groups (p>0.05). ΔMRC% one and two weeks after ICU discharge tended to be higher in NMES group, while it was significant higher in NMES group of patients with ICU-acquired weakness at two weeks (p=0.05). CONCLUSIONS NMES and personalized physiotherapy in ICU survivors did not result in greater improvement of muscle strength and functional status at hospital discharge. However, in patients with ICU-aw NMES may be effective. The potential benefits of rehabilitation strategies should be explored in larger number of patients in future studies. CLINICAL TRIAL REGISTRATION www.Clinicaltrials.gov: NCT01717833.
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Abstract
When critically ill, a severe weakness of the limbs and respiratory muscles often develops with a prolonged stay in the intensive care unit (ICU), a condition vaguely termed intensive care unit-acquired weakness (ICUAW). Many of these patients have serious nerve and muscle injury. This syndrome is most often seen in surviving critically ill patients with sepsis or extensive inflammatory response which results in increased duration of mechanical ventilation and hospital length of stay. Patients with ICUAW often do not fully recover and the disability will seriously impact on their quality of life. In this chapter we discuss the current knowledge on the pathophysiology and risk factors of ICUAW. Tools to diagnose ICUAW, how to separate ICUAW from other disorders, and which possible treatment strategies can be employed are also described. ICUAW is finally receiving the attention it deserves and the expectation is that it can be better understood and prevented.
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Affiliation(s)
- J Horn
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands.
| | - G Hermans
- Department of General Internal Medicine, UZ Leuven, Leuven, Belgium
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Affiliation(s)
- Cameron Cunningham
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, BC
| | - Heather Finlayson
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, BC
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Wieske L, Verhamme C, Witteveen E, Bouwes A, Dettling-Ihnenfeldt DS, van der Schaaf M, Schultz MJ, van Schaik IN, Horn J. Feasibility and diagnostic accuracy of early electrophysiological recordings for ICU-acquired weakness: an observational cohort study. Neurocrit Care 2016; 22:385-94. [PMID: 25403763 DOI: 10.1007/s12028-014-0066-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND An early diagnosis of ICU-acquired weakness (ICU-AW) is difficult because disorders of consciousness frequently preclude muscle strength assessment. In this study, we investigated feasibility and accuracy of electrophysiological recordings to diagnose ICU-AW early in non-awake critically ill patients. METHODS Newly admitted patients, mechanically ventilated ≥2 days and unreactive to verbal stimuli, were included in this study. Electrophysiological recordings comprised nerve conduction studies (NCS) of three nerves and, if coagulation was normal, myography in three muscles. Upon awakening, strength was assessed (ICU-AW: average Medical Research Council score <4), blinded for electrophysiological recordings. Feasibility was expressed as the percentage of recordings that were both possible and had sufficient technical quality. Diagnostic accuracy of feasible (i.e., feasibility >75 %) recordings was analyzed based on cut-off values from healthy controls and from critically ill patients with and without ICU-AW. RESULTS Thirty-five patients were included (17 with ICU-AW). Recordings were obtained on day 4 (IQR: 3-6). Feasibility was acceptable for ulnar and peroneal nerve recordings, and low for sural recordings and myography. Diagnostic accuracy based on cut-off values from healthy controls was low. When using cut-off values from critically ill patients with and without ICU-AW, the peroneal compound muscle action potential amplitude and ulnar sensory nerve action potential amplitude had good diagnostic accuracy. CONCLUSION Nerve conduction studies of the ulnar and peroneal nerve are feasible in critically ill patients. The diagnostic accuracy is low using cut-off values from healthy controls. Cut-off values validated specifically for discrimination between critically ill patients with and without ICU-AW may improve diagnostic accuracy.
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Affiliation(s)
- Luuk Wieske
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, room C3-311, PO box 22700, 1105 AZ, Amsterdam, The Netherlands,
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Axer H, Grimm A, Pausch C, Teschner U, Zinke J, Eisenach S, Beck S, Guntinas-Lichius O, Brunkhorst FM, Witte OW. The impairment of small nerve fibers in severe sepsis and septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:64. [PMID: 26984636 PMCID: PMC4793743 DOI: 10.1186/s13054-016-1241-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 02/13/2016] [Indexed: 11/10/2022]
Abstract
Background A decrease of small nerve fibers in skin biopsies during the course of critical illness has been demonstrated recently. However, the diagnostic use of skin biopsies in sepsis and its time course is not known. Methods Patients (n=32) with severe sepsis or septic shock were examined using skin biopsies, neurological examination, nerve conduction studies, and sympathetic skin response in the first week after onset of sepsis, 2 weeks and 4 months later and compared to gender- and age-matched healthy controls. Results Skin biopsies at the ankle and thigh revealed a significant decrease of intraepidermal nerve fiber density (IENFD) during the first week of sepsis and 2 weeks later. All patients developed critical illness polyneuropathy (CIP) according to electrophysiological criteria and 11 showed IENFD values lower than the 0.05 quantile. Four patients were biopsied after 4 months and still showed decreased IENFD. Results of nerve conduction studies and IENFD did considerably change over time. No differences for survival time between patients with IEFND lower and larger than 3.5 fibers/mm were found. Conclusions Skin biopsy is able to detect an impairment of small sensory nerve fibers early in the course of sepsis. However, it may not be suited as a prognostic parameter for survival. Trial registration German Clinical Trials Register, DRKS-ID: DRKS00000642, 12/17/2010 Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1241-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hubertus Axer
- Hans Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, D-07747, Jena, Germany.
| | - Alexander Grimm
- Hans Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, D-07747, Jena, Germany.,Department of Neurology and Epileptology, University of Tuebingen, Tuebingen, Germany
| | - Christine Pausch
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany.,Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University Leipzig, Leipzig, Germany
| | - Ulrike Teschner
- Hans Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, D-07747, Jena, Germany
| | - Jan Zinke
- Hans Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, D-07747, Jena, Germany
| | - Sven Eisenach
- Hans Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, D-07747, Jena, Germany
| | - Sindy Beck
- Hans Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, D-07747, Jena, Germany
| | | | | | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital, Erlanger Allee 101, D-07747, Jena, Germany
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Abstract
Abstract
Muscle weakness is common in the surgical intensive care unit (ICU). Low muscle mass at ICU admission is a significant predictor of adverse outcomes. The consequences of ICU-acquired muscle weakness depend on the underlying mechanism. Temporary drug-induced weakness when properly managed may not affect outcome. Severe perioperative acquired weakness that is associated with adverse outcomes (prolonged mechanical ventilation, increases in ICU length of stay, and mortality) occurs with persistent (time frame: days) activation of protein degradation pathways, decreases in the drive to the skeletal muscle, and impaired muscular homeostasis. ICU-acquired muscle weakness can be prevented by early treatment of the underlying disease, goal-directed therapy, restrictive use of immobilizing medications, optimal nutrition, activating ventilatory modes, early rehabilitation, and preventive drug therapy. In this article, the authors review the nosology, epidemiology, diagnosis, and prevention of ICU-acquired weakness in surgical ICU patients.
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Ali Abdelhamid Y, Phillips L, Horowitz M, Deane A. Survivors of intensive care with type 2 diabetes and the effect of shared care follow-up clinics: study protocol for the SWEET-AS randomised controlled feasibility study. Pilot Feasibility Stud 2016; 2:62. [PMID: 27965877 PMCID: PMC5153915 DOI: 10.1186/s40814-016-0104-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 10/01/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Many patients who survive the intensive care unit (ICU) experience long-term complications such as peripheral neuropathy and nephropathy which represent a major source of morbidity and affect quality of life adversely. Similar pathophysiological processes occur frequently in ambulant patients with diabetes mellitus who have never been critically ill. Some 25 % of all adult ICU patients have diabetes, and it is plausible that ICU survivors with co-existing diabetes are at heightened risk of sequelae from their critical illness. ICU follow-up clinics are being progressively implemented based on the concept that interventions provided in these clinics will alleviate the burdens of survivorship. However, there is only limited information about their outcomes. The few existing studies have utilised the expertise of healthcare professionals primarily trained in intensive care and evaluated heterogenous cohorts. A shared care model with an intensivist- and diabetologist-led clinic for ICU survivors with type 2 diabetes represents a novel targeted approach that has not been evaluated previously. Prior to undertaking any definitive study, it is essential to establish the feasibility of this intervention. METHODS This will be a prospective, randomised, parallel, open-label feasibility study. Eligible patients will be approached before ICU discharge and randomised to the intervention (attending a shared care follow-up clinic 1 month after hospital discharge) or standard care. At each clinic visit, patients will be assessed independently by both an intensivist and a diabetologist who will provide screening and targeted interventions. Six months after discharge, all patients will be assessed by blinded assessors for glycated haemoglobin, peripheral neuropathy, cardiovascular autonomic neuropathy, nephropathy, quality of life, frailty, employment and healthcare utilisation. The primary outcome of this study will be the recruitment and retention at 6 months of all eligible patients. DISCUSSION This study will provide preliminary data about the potential effects of critical illness on chronic glucose metabolism, the prevalence of microvascular complications, and the impact on healthcare utilisation and quality of life in intensive care survivors with type 2 diabetes. If feasibility is established and point estimates are indicative of benefit, funding will be sought for a larger, multi-centre study. TRIAL REGISTRATION ANZCTR ACTRN12616000206426.
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Affiliation(s)
- Yasmine Ali Abdelhamid
- Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 5000 Australia
- Discipline of Acute Care Medicine, The University of Adelaide, North Terrace, Adelaide, South Australia 5000 Australia
| | - Liza Phillips
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 5000 Australia
- Discipline of Medicine, The University of Adelaide, North Terrace, Adelaide, South Australia 5000 Australia
| | - Michael Horowitz
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 5000 Australia
- Discipline of Medicine, The University of Adelaide, North Terrace, Adelaide, South Australia 5000 Australia
| | - Adam Deane
- Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 5000 Australia
- Discipline of Acute Care Medicine, The University of Adelaide, North Terrace, Adelaide, South Australia 5000 Australia
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