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Khattar G, Bou Sanayeh E. Advancing critical care recovery: The pivotal role of machine learning in early detection of intensive care unit-acquired weakness. World J Clin Cases 2024; 12:4455-4459. [PMID: 39070840 PMCID: PMC11235497 DOI: 10.12998/wjcc.v12.i21.4455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 05/14/2024] [Accepted: 05/27/2024] [Indexed: 06/30/2024] Open
Abstract
This editorial explores the significant challenge of intensive care unit-acquired weakness (ICU-AW), a prevalent condition affecting critically ill patients, characterized by profound muscle weakness and complicating patient recovery. Highlighting the paradox of modern medical advances, it emphasizes the urgent need for early identification and intervention to mitigate ICU-AW's impact. Innovatively, the study by Wang et al is showcased for employing a multilayer perceptron neural network model, achieving high accuracy in predicting ICU-AW risk. This advancement underscores the potential of neural network models in enhancing patient care but also calls for continued research to address limitations and improve model applicability. The editorial advocates for the development and validation of sophisticated predictive tools, aiming for personalized care strategies to reduce ICU-AW incidence and severity, ultimately improving patient outcomes in critical care settings.
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Affiliation(s)
- Georges Khattar
- Department of Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Elie Bou Sanayeh
- Department of Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
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Yao H, Zhang J, Jiang R, Xie Q, Zhou C, Yang Y, Zeng Z, Zhang W. Early predictive value of ultrasound measurements of rectus femoris cross-sectional area to diagnose ICU-acquired weakness in patients undergoing invasive mechanical ventilation: a prospective cohort study. Eur J Med Res 2024; 29:379. [PMID: 39033122 PMCID: PMC11264894 DOI: 10.1186/s40001-024-01966-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 07/08/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND The diagnosis of ICU-acquired weakness (ICUAW) may be delayed due to the complexity of critically ill patients. This study aimed to investigate the value of ultrasound measurements of rectus femoris cross-sectional area (RFCSA) in predicting ICUAW in patients undergoing invasive mechanical ventilation. METHODS This was a prospective cohort study of patients undergoing mechanical ventilation for at least 48 h. RFCSA was measured using ultrasound in patients upon ICU admission and followed until discharge. Using the Medical Research Council score as the gold standard, we evaluated the diagnostic value of ultrasound measurements in predicting ICUAW. Kaplan-Meier curves were constructed to evaluate and compare the length of ICU stay and duration of invasive mechanical ventilation between patients with and without ICUAW. RESULTS Among the 76 patients, 34 (44.7%) were diagnosed with ICUAW using the Medical Research Council score as the gold standard. The RFCSA atrophy rate between day 1 and day 3 was significantly higher in the ICUAW group (7.9 ± 2.8% vs. 4.3 ± 2.1%, p < 0.001). By utilizing a cutoff point of 6.9%, we discovered that the RFCSA atrophy rate exhibited excellent diagnostic accuracy in predicting ICUAW, with a sensitivity of 76.5% and specificity of 92.9%. In ICUAW patients diagnosed based on an RFCSA atrophy rate, the proportion of patients with an ICU stay longer than 14 days was 42.9%, which was significantly higher compared to 22.9% in the non-ICUAW group (HR: 1.768; 95% CI 1.128-2.772; p = 0.006). Similarly, the proportion of patients continuing mechanical ventilation at 14 days was 28.6% versus 4.2% between the two groups (HR: 1.988; 95% CI 1.266-3.120; p < 0.001). CONCLUSION Ultrasound measurements of RFCSA provide a reliable method for diagnosing ICUAW and indicating prognosis in patients undergoing invasive mechanical ventilation.
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Affiliation(s)
- Huiming Yao
- Department of Critical Care Medicine, Medical Center of Anesthesiology and Pain, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Jie Zhang
- Department of Critical Care Medicine, Medical Center of Anesthesiology and Pain, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Rong Jiang
- Department of Critical Care Medicine, Medical Center of Anesthesiology and Pain, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Qian Xie
- Department of Critical Care Medicine, Medical Center of Anesthesiology and Pain, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Chaoqi Zhou
- Department of Critical Care Medicine, Medical Center of Anesthesiology and Pain, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Yuting Yang
- Department of Critical Care Medicine, Medical Center of Anesthesiology and Pain, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Zhenguo Zeng
- Department of Critical Care Medicine, Medical Center of Anesthesiology and Pain, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China.
| | - Wei Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China.
- Jiangxi Provincial Key Laboratory of Respiratory Diseases, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China.
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Zhang Q, Wang X, Liu M, Li B, Zhang K, Han Y, Li J, Xin Y, Huo Y, Hu Z. Assessing the Diagnostic Efficacy of Handgrip Dynamometry and Diaphragmatic Ultrasound in Intensive Care Unit-Acquired Weakness. J Multidiscip Healthc 2024; 17:2359-2370. [PMID: 38774623 PMCID: PMC11106916 DOI: 10.2147/jmdh.s462297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/30/2024] [Indexed: 05/24/2024] Open
Abstract
Objective The aim of this study is to examine the diagnostic significance of using handgrip dynamometry and diaphragmatic ultrasound in intensive care unit-acquired weakness (ICU-AW). Methods This study included patients who received mechanical ventilation in the ICU at the Fourth Hospital of Hebei Medical University from July to December 2020. We collected comprehensive demographic data and selected conscious patients for muscle strength and ICU-AW assessments. The evaluation comprised grip strength measurement and bedside ultrasound for diaphragmatic excursion (DE) and thickening fraction (DTF). Results were documented for comparative analysis between patient groups, focusing on the diagnostic efficacy of grip strength, DE, DTF, and their combined application in diagnosing ICU-AW. Results A total of 95 patients were initially considered for inclusion in this study. Following the exclusion of 20 patients, a final cohort of 75 patients were enrolled, comprising of 32 patients (42.6%) diagnosed with ICU-AW and 43 patients (57.4%) classified as non-ICU-AW. Comparative analysis revealed that grip strength, DE, and DTF were significantly lower in the ICU-AW group (P < 0.05). Subgroup analysis specific to male patients demonstrated a noteworthy decrease in grip strength, DE, and DTF within the ICU-AW group (P < 0.05). Receiver operating characteristic curve analysis indicated statistically significant diagnostic value for ICU-AW with grip strength, DE, DTF, and grip strength and diaphragmatic ultrasound (P < 0.01). Furthermore, it was observed that the amalgamation of grip strength and diaphragmatic ultrasound significantly enhanced the diagnostic accuracy of ICU-AW in patients who are critically ill. Conclusion Grip strength, DE, DTF, and the combined use of grip strength with diaphragm ultrasound demonstrated diagnostic efficacy in ICU-AW. Notably, the integration of grip strength with diaphragm ultrasound exhibited a heightened capacity to enhance the diagnostic value specifically in patients diagnosed who are critically ill with ICU-AW.
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Affiliation(s)
- Qian Zhang
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, 050000, People’s Republic of China
| | - Xiaomei Wang
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, 050000, People’s Republic of China
| | - Mingzhe Liu
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, 050000, People’s Republic of China
| | - Bin Li
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, 050000, People’s Republic of China
| | - Kun Zhang
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, 050000, People’s Republic of China
| | - Yaqi Han
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, 050000, People’s Republic of China
| | - Jiali Li
- Department of Intensive Care Unit, The Sixth People’s Hospital of Hengshui, Hengshui, Hebei Province, 053000, People’s Republic of China
| | - Yan Xin
- Department of Intensive Care Unit, The Third Hospital of Shijiazhuang, Shijiazhuang, Hebei Province, 050000, People’s Republic of China
| | - Yan Huo
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, 050000, People’s Republic of China
| | - Zhenjie Hu
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, 050000, People’s Republic of China
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Sekhniashvili M, Baum P, Toyka KV. Temporary and highly variable recovery of neuromuscular dysfunction by electrical stimulation in the follow-up of acute critical illness neuromyopathy: a pilot study. Neurol Res Pract 2023; 5:66. [PMID: 38151742 PMCID: PMC10753844 DOI: 10.1186/s42466-023-00293-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/23/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND In sepsis-associated critical illness neuromyopathy (CIPNM) serial electrical stimulation of motor nerves induces a short-lived temporary recovery of compound muscle action potentials (CMAPs) termed facilitation phenomenon (FP). This technique is different from other stimulation techniques published. The identification of FP suggests a major functional component in acute CIPNM. METHODS From our previous study cohort of 18 intensive care unit patients with sepsis associated CIPNM showing profound muscle weakness and low or missing CMAPs on nerve conduction studies, six patients with different severity could be followed. In a pilot sub-study we analyzed the variability of FP during follow up. Over up to 6 weeks we performed 2-6 nerve conduction studies with our novel stimulation paradigm. Motor nerves were stimulated at 0.2-0.5 Hz with 60-100 mA at 0.2-0.5 ms duration, and CMAP responses were recorded. Standard motor nerve conduction velocities (NCV) could be done when utilizing facilitated CMAPs. Needle electromyography was checked once for spontaneous activity to discover potential denervation and muscle fiber degeneration. Serum electrolytes were checked before any examination and corrected if abnormal. RESULTS In all six patients a striking variability in the magnitude and pattern of FP could be observed at each examination in the same and in different motor nerves over time. With the first stimulus most CMAPs were below 0.1 mV or absent. With slow serial pulses CMAPs could gradually recover with normal shape and near normal amplitudes. With facilitated CMAPs NCV measurements revealed low normal values. With improvement of muscle weakness subsequent tests revealed larger first CMAP amplitudes and smaller magnitudes of FP. Needle EMG showed occasional spontaneous activity in the tibialis anterior muscle. CONCLUSION In this pilot study striking variability and magnitude of FP during follow-up was a reproducible feature indicating major fluctuations of neuromuscular excitability that may improve during follow-up. FP can be assessed by generally available electrophysiological techniques, even before patients could be tested for muscle strength. Large scale prospective studies of the facilitation phenomenon in CIPNM with or without sepsis are needed to define diagnostic specificity and to better understand the still enigmatic pathophysiology. TRIAL REGISTRATION This trial was registered at the Leipzig University Medical Center in 2021 after approval by the Ethics Committee.
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Affiliation(s)
- Madona Sekhniashvili
- Department of Neurology, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
- Department of Neurology of S. Khechinashvili University Clinic, Tbilisi State Medical University, Chavchavadze Ave. 33, 0179, Tbilisi, Georgia.
| | - Petra Baum
- Department of Neurology, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Klaus V Toyka
- Department of Neurology, University of Würzburg, Josef Schneider Str.11, 97080, Würzburg, Germany
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Zulehner G, Schörgenhofer C, Rommer P, Merrelaar M, Behrens S, Ponleitner M, Herkner H, Staudinger T, Zauner C, Roth D, Altmann P, Kienbacher CL. Serum neurofilament light chain as an early diagnostic biomarker for critical illness polyneuropathy. Minerva Anestesiol 2023; 89:1099-1104. [PMID: 37851416 DOI: 10.23736/s0375-9393.23.17490-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
BACKGROUND Critical illness polyneuropathy (CIP) commonly occurs in critical care unit (CCU) patients, but timely diagnosis can be challenging. Therefore, new biomarkers, such as serum neurofilament light chain (sNfL), could help to improve early identification of patients with this condition. METHODS CIP was diagnosed or excluded with neurological assessment and nerve conduction measurement in a prospective study of CCU patients. sNfL and secondary predictors for neuropathy (neuron-specific enolase (NSE), S100, folic acid, and vitamin B12) were measured at admission. Cases and controls were compared regarding the predictors. RESULTS Nineteen patients met the inclusion criteria. CIP was considered definitely or most likely present in seven (37%, cases) and definitely or most likely absent in 12 individuals (63%, controls). At admission, sNfL levels were significantly higher in the cases than in the controls: 405 (IQR 77 to 835) vs. 27 (IQR 12 to 90) pg/mL; difference of medians 375, 95% confidence interval [14, 736], pg/mL; P=0.04. We found no significant differences regarding the secondary predictors at baseline. Cases had longer durations of CCU stay (median 19 (IQR 11 to 44) vs. 8 (IQR five to ten) and increased mortality (57% vs. 33% deceased) compared to controls. CONCLUSIONS Levels of serum neurofilament light chain are higher in patients who develop CIP soon after CCU admission and might be helpful in identifying those individuals early.
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Affiliation(s)
- Gudrun Zulehner
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Paulus Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Marieke Merrelaar
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Sybille Behrens
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Markus Ponleitner
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Staudinger
- Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Christian Zauner
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Dominik Roth
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Patrick Altmann
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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Zulehner G, Seidel S, Polanz A, Schörgenhofer C, Rommer P, Merrelaar M, Roth D, Herkner H, Behrens S, Kienbacher CL. Lower serum cholesterol levels as a risk factor for critical illness polyneuropathy: a matched case-control study. Sci Rep 2023; 13:20405. [PMID: 37990042 PMCID: PMC10663605 DOI: 10.1038/s41598-023-47232-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 11/10/2023] [Indexed: 11/23/2023] Open
Abstract
Critical illness polyneuropathy (CIP) is a frequent and underdiagnosed phenomenon among intensive care unit patients. The lipophilic nature of neuronal synapses may result in the association of low serum cholesterol levels with a higher rate of CIP development. We aimed to investigate this issue in critically ill patients. All cases diagnosed with CIP in our tertiary care hospital between 2013 and 2017 were 1:1 matched with controls without the condition by age, sex, and ICD diagnoses. The main risk factors examined were the differences in change between initial and minimum serum total cholesterol levels, and minimum serum total cholesterol levels between matched pairs. Other predictors were serum markers of acute inflammation. We included 67 cases and 67 controls (134 critically ill patients, 49% female, 46% medical). Serum total cholesterol levels decreased more profoundly in cases than controls (median: -74 (IQR -115 to -24) vs. -39 (IQR -82 to -4), median difference: -28, 95% CI [-51, -5]), mg/dl). Minimum serum total cholesterol levels were lower in the cases (median difference: -24, 95% CI [-39, -9], mg/dl). We found significant median differences across matched pairs in maximum serum C-reactive protein (8.9, 95% CI [4.6, 13.2], mg/dl), minimum albumin (-4.2, 95% CI [-6.7, -1.7], g/l), decrease in albumin (-3.9, 95% CI [-7.6, -0.2], g/l), and lowest cholinesterase levels (-0.72, 95% CI [-1.05, -0.39], U/l). Subsequently, more pronounced decreases in serum total cholesterol levels and lower minimum total cholesterol levels during critical care unit hospitalizations may be a risk factor for CIP.
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Affiliation(s)
- Gudrun Zulehner
- Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Stefan Seidel
- Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Alexander Polanz
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christian Schörgenhofer
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Paulus Rommer
- Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Marieke Merrelaar
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Dominik Roth
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Sybille Behrens
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Calvin Lukas Kienbacher
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Shehata AH, Anter AF, Ahmed ASF. Role of SIRT1 in sepsis-induced encephalopathy: Molecular targets for future therapies. Eur J Neurosci 2023; 58:4211-4235. [PMID: 37840012 DOI: 10.1111/ejn.16167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/17/2023]
Abstract
Sepsis induces neuroinflammation, BBB disruption, cerebral hypoxia, neuronal mitochondrial dysfunction, and cell death causing sepsis-associated encephalopathy (SAE). These pathological consequences lead to short- and long-term neurobehavioural deficits. Till now there is no specific treatment that directly improves SAE and its associated behavioural impairments. In this review, we discuss the underlying mechanisms of sepsis-induced brain injury with a focus on the latest progress regarding neuroprotective effects of SIRT1 (silent mating type information regulation-2 homologue-1). SIRT1 is an NAD+ -dependent class III protein deacetylase. It is able to modulate multiple downstream signals (including NF-κB, HMGB, AMPK, PGC1α and FoxO), which are involved in the development of SAE by its deacetylation activity. There are multiple recent studies showing the neuroprotective effects of SIRT1 in neuroinflammation related diseases. The proposed neuroprotective action of SIRT1 is meant to bring a promising therapeutic strategy for managing SAE and ameliorating its related behavioural deficits.
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Affiliation(s)
- Alaa H Shehata
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, Minia, Egypt
| | - Aliaa F Anter
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, Minia, Egypt
| | - Al-Shaimaa F Ahmed
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, Minia, Egypt
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Leduc-Gaudet JP, Miguez K, Cefis M, Faitg J, Moamer A, Chaffer TJ, Reynaud O, Broering FE, Shams A, Mayaki D, Huck L, Sandri M, Gouspillou G, Hussain SN. Autophagy ablation in skeletal muscles worsens sepsis-induced muscle wasting, impairs whole-body metabolism, and decreases survival. iScience 2023; 26:107475. [PMID: 37588163 PMCID: PMC10425945 DOI: 10.1016/j.isci.2023.107475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 05/18/2023] [Accepted: 07/21/2023] [Indexed: 08/18/2023] Open
Abstract
Septic patients frequently develop skeletal muscle wasting and weakness, resulting in severe clinical consequences and adverse outcomes. Sepsis triggers sustained induction of autophagy, a key cellular degradative pathway, in skeletal muscles. However, the impact of enhanced autophagy on sepsis-induced muscle dysfunction remains unclear. Using an inducible and muscle-specific Atg7 knockout mouse model (Atg7iSkM-KO), we investigated the functional importance of skeletal muscle autophagy in sepsis using the cecal ligation and puncture model. Atg7iSkM-KO mice exhibited a more severe phenotype in response to sepsis, marked by severe muscle wasting, hypoglycemia, higher ketone levels, and a decreased in survival as compared to mice with intact Atg7. Sepsis and Atg7 deletion resulted in the accumulation of mitochondrial dysfunction, although sepsis did not further worsen mitochondrial dysfunction in Atg7iSkM-KO mice. Overall, our study demonstrates that autophagy inactivation in skeletal muscles triggers significant worsening of sepsis-induced muscle and metabolic dysfunctions and negatively impacts survival.
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Affiliation(s)
- Jean-Philippe Leduc-Gaudet
- Research Group in Cellular Signaling, Department of Medical Biology, Université du Québec À Trois-Rivières, Trois-Rivières, QC G9A 5H7, Canada
- Department of Critical Care and Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Centre (MUHC), Montréal, QC H3H 2R9, Canada
- Meakins-Christie Laboratories, Department of Medicine, Faculty of Medicine, McGill University, Montréal, QC H4A 3J1, Canada
- Département des sciences de l’activité physique, Faculté des sciences, Université du Québec à Montréal (UQAM), Montréal, QC H2X 1Y4, Canada
| | - Kayla Miguez
- Department of Critical Care and Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Centre (MUHC), Montréal, QC H3H 2R9, Canada
- Meakins-Christie Laboratories, Department of Medicine, Faculty of Medicine, McGill University, Montréal, QC H4A 3J1, Canada
| | - Marina Cefis
- Meakins-Christie Laboratories, Department of Medicine, Faculty of Medicine, McGill University, Montréal, QC H4A 3J1, Canada
- Département des sciences de l’activité physique, Faculté des sciences, Université du Québec à Montréal (UQAM), Montréal, QC H2X 1Y4, Canada
| | - Julie Faitg
- Département des sciences de l’activité physique, Faculté des sciences, Université du Québec à Montréal (UQAM), Montréal, QC H2X 1Y4, Canada
- Amazentis SA, EPFL Innovation Park, 1015 Lausanne, Switzerland
| | - Alaa Moamer
- Meakins-Christie Laboratories, Department of Medicine, Faculty of Medicine, McGill University, Montréal, QC H4A 3J1, Canada
| | - Tomer Jordi Chaffer
- Department of Critical Care and Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Centre (MUHC), Montréal, QC H3H 2R9, Canada
- Meakins-Christie Laboratories, Department of Medicine, Faculty of Medicine, McGill University, Montréal, QC H4A 3J1, Canada
| | - Olivier Reynaud
- Département des sciences de l’activité physique, Faculté des sciences, Université du Québec à Montréal (UQAM), Montréal, QC H2X 1Y4, Canada
| | - Felipe E. Broering
- Department of Critical Care and Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Centre (MUHC), Montréal, QC H3H 2R9, Canada
- Meakins-Christie Laboratories, Department of Medicine, Faculty of Medicine, McGill University, Montréal, QC H4A 3J1, Canada
| | - Anwar Shams
- Department of Pharmacology, Faculty of Medicine, Taif University, P.O.BOX 11099, Taif 21944, Saudi Arabia
| | - Dominique Mayaki
- Department of Critical Care and Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Centre (MUHC), Montréal, QC H3H 2R9, Canada
- Meakins-Christie Laboratories, Department of Medicine, Faculty of Medicine, McGill University, Montréal, QC H4A 3J1, Canada
| | - Laurent Huck
- Department of Critical Care and Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Centre (MUHC), Montréal, QC H3H 2R9, Canada
- Meakins-Christie Laboratories, Department of Medicine, Faculty of Medicine, McGill University, Montréal, QC H4A 3J1, Canada
| | - Marco Sandri
- Meakins-Christie Laboratories, Department of Medicine, Faculty of Medicine, McGill University, Montréal, QC H4A 3J1, Canada
- Veneto Institute of Molecular Medicine (VIMM) and Department of Biomedical Science, Università di Padova, 35129 Padova, Italy
| | - Gilles Gouspillou
- Meakins-Christie Laboratories, Department of Medicine, Faculty of Medicine, McGill University, Montréal, QC H4A 3J1, Canada
- Département des sciences de l’activité physique, Faculté des sciences, Université du Québec à Montréal (UQAM), Montréal, QC H2X 1Y4, Canada
| | - Sabah N.A. Hussain
- Department of Critical Care and Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Centre (MUHC), Montréal, QC H3H 2R9, Canada
- Meakins-Christie Laboratories, Department of Medicine, Faculty of Medicine, McGill University, Montréal, QC H4A 3J1, Canada
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Murooka Y, Sasabuchi Y, Takazawa T, Matsui H, Yasunaga H, Saito S. Long-Term Prognosis Following Early Rehabilitation in the ICU: A Retrospective Cohort Study. Crit Care Med 2023; 51:1054-1063. [PMID: 36988323 PMCID: PMC10335737 DOI: 10.1097/ccm.0000000000005862] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
OBJECTIVES Critically ill patients often have residual functional disabilities. Studies have shown that early rehabilitation improves short-term physical function. However, it remains unknown whether early rehabilitation affects long-term prognosis and healthcare resource utilization. DESIGN Retrospective cohort study. SETTING This study used an administrative claims database in Kumamoto Prefecture, Japan, from April 2012 to February 2017. PATIENTS We identified patients who were admitted to the ICU and received rehabilitation. Eligible patients were divided into those who underwent rehabilitation within 3 days (early rehabilitation group) and after 4 or more days of ICU admission (delayed rehabilitation group). Propensity score matching analyses were conducted to compare the number of outpatient consultations within 1 year and 3 years after discharge from the index hospitalization, total duration of hospitalization after discharge, healthcare costs, and survival. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 6,679 patients were included in the study. Propensity score matching created 2,245 pairs. No difference was observed in the number of outpatient consultations 1 year after discharge, although there were differences between the groups 3 years after discharge. Long-term observation revealed a shorter overall duration of hospitalization (1.9 vs 2.6 mo; p < 0.001) and lower total costs ($28,159 vs $38,272; p < 0.001), as well as lower average costs per month ($1,690 vs $1,959; p = 0.001) in the early compared with the delayed rehabilitation group. No differences in survival were observed (log-rank test; p = 0.18). CONCLUSIONS Starting rehabilitation within 3 days of ICU admission was associated with shorter durations of future hospitalization and lower healthcare costs. Early rehabilitation for ICU patients might be associated with reduced healthcare resource utilization.
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Affiliation(s)
- Yukie Murooka
- Intensive Care Unit, Gunma University Hospital, Gunma, Japan
| | | | | | - Hiroki Matsui
- Data Science Center, Jichi Medical University, Tochigi, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hideo Yasunaga
- Data Science Center, Jichi Medical University, Tochigi, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Shigeru Saito
- Department of Anesthesiology, Gunma University Graduate School of Medicine, Gunma, Japan
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10
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Diaphragm function in patients with sepsis and septic shock: A longitudinal ultrasound study. Aust Crit Care 2023; 36:239-246. [PMID: 35272911 DOI: 10.1016/j.aucc.2022.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 12/23/2021] [Accepted: 01/13/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Previous literature on the determinants of diaphragm dysfunction in septic patients is limited. The goal of this study is to assess diaphragm dysfunction in terms of its prevalence and its potential associated factors in septic intensive care unit (ICU) patients. METHODS This prospective and observational study was conducted between June 2015 and July 2019. Ultrasound measures of diaphragm thickness were performed daily on septic patients. The primary outcome was the prevalence of diaphragm dysfunction at baseline and during the ICU stay. The secondary outcome was the diaphragm thickness. Possible associated factors were prospectively recorded. RESULTS Fifty patients were enrolled in the study. The prevalence of diaphragm dysfunction was 58%. No diaphragm atrophy was found during the ICU stay. Diaphragm dysfunction was associated with the alteration of consciousness, intra-abdominal sepsis, hypnotics and opioids, and mechanical ventilation. Administration of hypnotics, opioids, and steroids was associated with a decreased diaphragm thickening fraction. Diaphragm dysfunction had no impact on patient outcomes. CONCLUSIONS Our data reveal a high prevalence of diaphragm dysfunction in septic patients at the onset of sepsis. Administration of hypnotics, opioids, and steroids was associated with the alteration of diaphragm function as well as intra-abdominal sepsis.
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11
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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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12
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Yang Z, Wang X, Wang F, Peng Z, Fan Y. A systematic review and meta-analysis of risk factors for intensive care unit acquired weakness. Medicine (Baltimore) 2022; 101:e31405. [PMID: 36316900 PMCID: PMC9622703 DOI: 10.1097/md.0000000000031405] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The aim of this meta-analysis is to systematically evaluate and summarize the risk factors of intensive care unit acquired weakness (ICU-AW), to provide evidence-based evidence for the formulation of prevention strategies for ICU-AW. METHODS PubMed, EMBASE, Web of Science, CBM (China Biology Medicine, China), Chinese National Knowledge Infrastructure, Chinese WANFANG, and VIP will be searched to define relevant risk factors for ICU-AW. The databases search period is from January 1, 2005 to August 13, 2021. The Newcastle Ottawa Scale (NOS) is used to evaluate the quality of the included studies. RevMan 5.3 analysis software will be used for meta-analysis. RESULTS This systematic review and meta-analysis included a total of 12 cohort studies, including 9 international journals and 3 Chinese journals, with a total of 1950 patients, of which 856 had ICU-AW. The results showed that the significant risk factors for ICU-AW included female (odds ratio [OR] = 1.34, 95% confidence interval [CI]: 1.06-1.71; P = .02), mechanical ventilation days (OR = 3.04, 95% CI: 1.82-4.26; P < .00001), age (OR = 6.33, 95% CI: 5.05-7.61; P < .00001), length of intensive care unit (ICU) stay (OR = 3.78, 95% CI: 2.06-5.51; P < .0001), infectious disease (OR = 1.67, 95% CI: 1.20-2.33; P = .002), renal replacement therapy (OR = 1.59, 95% CI: 1.11-2.28; P = .01), use of aminoglucoside drugs (OR = 2.51, 95% CI: 1.54-4.08; P = .0002), sepsis related organ failure assessment (SOFA) score (OR = 1.07, 95% CI: 0.24-1.90; P = .01), hyperglycemia (OR = 2.95, 95% CI: 1.70-5.11; P = .0001). CONCLUSION This meta-analysis provides comprehensive evidence-based on the assessment of the risk factors for ICU-AW, their multifactorial etiology was confirmed. This study indicated that female, mechanical ventilation days, age, length of ICU stay, infectious disease, renal replacement therapy, use of aminoglucoside drugs, SOFA score, and hyperglycemia are independent risk factors for ICU-AW. We have not found consistent evidence that corticosteroids, neuromuscular blockers, sepsis have any effect on ICU-AW risk.
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Affiliation(s)
- Zi Yang
- Clinical Nursing Teaching Department, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
- School of Nursing, Harbin Medical University, Harbin, China
| | - Xiaohui Wang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Faying Wang
- Clinical Nursing Teaching Department, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
- School of Nursing, Harbin Medical University, Harbin, China
| | - Zeyu Peng
- Clinical Nursing Teaching Department, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
- School of Nursing, Harbin Medical University, Harbin, China
| | - Yuying Fan
- Clinical Nursing Teaching Department, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
- School of Nursing, Harbin Medical University, Harbin, China
- *Correspondence: Yuying Fan, Harbin Medical University, Heilongjiang Province, 150081, China (e-mail: )
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13
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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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14
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Multimodal assessment of intensive care unit-acquired weakness in severe stroke patients. Acta Neurol Belg 2022; 122:1313-1321. [PMID: 35790678 DOI: 10.1007/s13760-022-02009-9] [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: 12/06/2021] [Accepted: 06/16/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Intensive care unit-acquired weakness (ICUAW) defines generalized muscle weakness seen in critically ill patients in the absence of other causative factors. Herein, we aimed to evaluate ICUAW in stroke patients by electrodiagnostic testing, histopathology, and assessment of respiratory complex activities (RCA), to define the frequency of ICUAW in this patient group, and to reach new parameters for early prediction and diagnosis. METHODS We prospectively recruited twenty-four severe acute stroke patients during a sixteen-month period. In addition to serial nerve conduction studies (NCS), we performed muscle biopsy and RCA analysis on the non-paretic side when ICUAW developed. Patients undergoing orthopedic surgery without metabolic and neuromuscular diseases constituted the control group for RCA. Survival and longitudinal data were analyzed by joint modeling to determine the relationship between electrophysiological parameters and ICUAW diagnosis. RESULTS Eight patients (33%) developed ICUAW, and six of them within the first two weeks. Extensor digitorum brevis, abductor digiti minimi (ADM), rectus femoris and vastus medialis (VM) compound muscle action potential (CMAP) amplitudes showed a significant decrease in the ICUAW group. VM CMAP amplitude (BIC = 358.1574) and ADM CMAP duration (BIC = 361.1028) were the best-correlated parameters with ICUAW diagnosis. The most informative electrophysiological findings during the entire study were obtained within the first 11 days. Muscle biopsies revealed varying degrees of type 2 fiber atrophy. Complex I (p = 0.003) and IV (p = 0.018) activities decreased in patients with ICUAW compared to controls. CONCLUSION VM CMAP amplitude and ADM CMAP duration correlate well with ICUAW diagnosis, and may aid in the early diagnosis.
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15
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Chhetri I, Hunt JEA, Mendis JR, Forni LG, Kirk-Bayley J, White I, Cooper J, Somasundaram K, Shah N, Patterson SD, Puthucheary ZA, Montgomery HE, Creagh-Brown BC. Safety and Feasibility Assessment of Repetitive Vascular Occlusion Stimulus (RVOS) Application to Multi-Organ Failure Critically Ill Patients: A Pilot Randomised Controlled Trial. J Clin Med 2022; 11:3938. [PMID: 35887701 PMCID: PMC9316533 DOI: 10.3390/jcm11143938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 11/17/2022] Open
Abstract
Muscle wasting is implicated in the pathogenesis of intensive care unit acquired weakness (ICU-AW), affecting 40% of patients and causing long-term physical disability. A repetitive vascular occlusion stimulus (RVOS) limits muscle atrophy in healthy and orthopaedic subjects, thus, we explored its application to ICU patients. Adult multi-organ failure patients received standard care +/- twice daily RVOS {4 cycles of 5 min tourniquet inflation to 50 mmHg supra-systolic blood pressure, and 5 min complete deflation} for 10 days. Serious adverse events (SAEs), tolerability, feasibility, acceptability, and exploratory outcomes of the rectus femoris cross-sectional area (RFCSA), echogenicity, clinical outcomes, and blood biomarkers were assessed. Only 12 of the intended 32 participants were recruited. RVOS sessions (76.1%) were delivered to five participants and two could not tolerate it. No SAEs occurred; 75% of participants and 82% of clinical staff strongly agreed or agreed that RVOS is an acceptable treatment. RFCSA fell significantly and echogenicity increased in controls (n = 5) and intervention subjects (n = 4). The intervention group was associated with less frequent acute kidney injury (AKI), a greater decrease in the total sequential organ failure assessment score (SOFA) score, and increased insulin-like growth factor-1 (IGF-1), and reduced syndecan-1, interleukin-4 (IL-4) and Tumor necrosis factor receptor type II (TNF-RII) levels. RVOS application appears safe and acceptable, but protocol modifications are required to improve tolerability and recruitment. There were signals of possible clinical benefit relating to RVOS application.
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Affiliation(s)
- Ismita Chhetri
- Intensive Care Unit, Royal Surrey County Hospital, NHS Foundation Trust, Guildford GU2 7XX, UK; (I.C.); (L.G.F.); (J.K.-B.)
- Faculty of Health and Medical Sciences, School of Biosciences & Medicine, University of Surrey, Guildford GU2 7XH, UK; (J.E.A.H.); (J.R.M.)
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London SW7 2BX, UK
| | - Julie E. A. Hunt
- Faculty of Health and Medical Sciences, School of Biosciences & Medicine, University of Surrey, Guildford GU2 7XH, UK; (J.E.A.H.); (J.R.M.)
| | - Jeewaka R. Mendis
- Faculty of Health and Medical Sciences, School of Biosciences & Medicine, University of Surrey, Guildford GU2 7XH, UK; (J.E.A.H.); (J.R.M.)
| | - Lui G. Forni
- Intensive Care Unit, Royal Surrey County Hospital, NHS Foundation Trust, Guildford GU2 7XX, UK; (I.C.); (L.G.F.); (J.K.-B.)
- Faculty of Health and Medical Sciences, School of Biosciences & Medicine, University of Surrey, Guildford GU2 7XH, UK; (J.E.A.H.); (J.R.M.)
| | - Justin Kirk-Bayley
- Intensive Care Unit, Royal Surrey County Hospital, NHS Foundation Trust, Guildford GU2 7XX, UK; (I.C.); (L.G.F.); (J.K.-B.)
| | - Ian White
- Intensive Care Unit, Ashford and St Peter’s Hospitals NHS Foundation Trust, Chertsey KT16 0PZ, UK; (I.W.); (J.C.); (K.S.); (N.S.)
| | - Jonathan Cooper
- Intensive Care Unit, Ashford and St Peter’s Hospitals NHS Foundation Trust, Chertsey KT16 0PZ, UK; (I.W.); (J.C.); (K.S.); (N.S.)
| | - Karthik Somasundaram
- Intensive Care Unit, Ashford and St Peter’s Hospitals NHS Foundation Trust, Chertsey KT16 0PZ, UK; (I.W.); (J.C.); (K.S.); (N.S.)
| | - Nikunj Shah
- Intensive Care Unit, Ashford and St Peter’s Hospitals NHS Foundation Trust, Chertsey KT16 0PZ, UK; (I.W.); (J.C.); (K.S.); (N.S.)
| | - Stephen D. Patterson
- Faculty of Sport, Allied Health & Performance Sciences, St Mary’s University, London TW1 4SX, UK;
| | - Zudin A. Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London E1 4NS, UK;
- Institute for Sport, Exercise and Health, University College London, London W1T 7HA, UK
- Centre for Human Health and Performance, Department of Medicine, University College London, London W1T 7HA, UK;
- Intensive Care Unit, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Centre for Human and Applied Physiological Sciences, King’s College London, London WC2R 2LS, UK
| | - Hugh E. Montgomery
- Centre for Human Health and Performance, Department of Medicine, University College London, London W1T 7HA, UK;
| | - Benedict C. Creagh-Brown
- Intensive Care Unit, Royal Surrey County Hospital, NHS Foundation Trust, Guildford GU2 7XX, UK; (I.C.); (L.G.F.); (J.K.-B.)
- Faculty of Health and Medical Sciences, School of Biosciences & Medicine, University of Surrey, Guildford GU2 7XH, UK; (J.E.A.H.); (J.R.M.)
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Hirotsu A, Miyao M, Tatsumi K, Tanaka T. Sepsis-associated neuroinflammation in the spinal cord. PLoS One 2022; 17:e0269924. [PMID: 35696412 PMCID: PMC9191735 DOI: 10.1371/journal.pone.0269924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 05/31/2022] [Indexed: 11/19/2022] Open
Abstract
Septic patients commonly present with central nervous system (CNS) disorders including impaired consciousness and delirium. Today, the main mechanism regulating sepsis-induced cerebral disorders is believed to be neuroinflammation. However, it is unknown how another component of the CNS, the spinal cord, is influenced during sepsis. In the present study, we intraperitoneally injected mice with lipopolysaccharide (LPS) to investigate molecular and immunohistochemical changes in the spinal cord of a sepsis model. After LPS administration in the spinal cord, pro-inflammatory cytokines including interleukin (IL)-1β, IL-6, and tumor necrosis factor alpha mRNA were rapidly and drastically induced. Twenty-four-hour after the LPS injection, severe neuronal ischemic damage spread into gray matter, especially around the anterior horns, and the anterior column had global edematous changes. Immunostaining analyses showed that spinal microglia were significantly activated and increased, but astrocytes did not show significant change. The current results indicate that sepsis induces acute neuroinflammation, including microglial activation and pro-inflammatory cytokine upregulation in the spinal cord, causing drastic neuronal ischemia and white matter edema in the spinal cord.
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Affiliation(s)
- Akiko Hirotsu
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Mariko Miyao
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | | | - Tomoharu Tanaka
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
- * E-mail:
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17
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Dang K, Jiang S, Gao Y, Qian A. The role of protein glycosylation in muscle diseases. Mol Biol Rep 2022; 49:8037-8049. [DOI: 10.1007/s11033-022-07334-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/23/2022] [Accepted: 03/02/2022] [Indexed: 12/14/2022]
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18
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Early Neuromuscular Electrical Stimulation in Addition to Early Mobilization Improves Functional Status and Decreases Hospitalization Days of Critically Ill Patients. Crit Care Med 2022; 50:1116-1126. [PMID: 35412472 DOI: 10.1097/ccm.0000000000005557] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To evaluate the impact of the additional use of early neuromuscular electrical stimulation (NMES) on an early mobilization (EM) protocol. DESIGN Randomized controlled trial. SETTING ICU of the Clinical Hospital of Ribeirão Preto, University of São Paulo, Brazil. PATIENTS One hundred and thirty-nine consecutive mechanically ventilated patients were included in the first 48 hours of ICU admission. INTERVENTIONS The patients were divided into two groups: EM and EM+NMES. Both groups received EM daily. In the EM+NMES group, patients additionally received NMES 5 days a week, for 60 minutes, starting in the first 48 hours of ICU admission until ICU discharge. MEASUREMENTS AND MAIN RESULTS Functional status, muscle strength, ICU and hospital length of stay (LOS), frequency of delirium, days on mechanical ventilation, mortality, and quality of life were assessed. Patients in the EM+NMES group presented a significant higher score of functional status measured by the Functional Status Score for the ICU scale when compared with the EM group in the first day awake: 22 (15-26) versus 12 (8-22) (p = 0.019); at ICU discharge: 28 (21-33) versus 18 (11-26) (p = 0.004); and hospital discharge: 33 (27-35) versus 25 (17-33) (p = 0.014), respectively. They also had better functional status measured by the Physical Function Test in the ICU scale, took less days to stand up during the ICU stay, and had a significant shorter hospital LOS, lower frequency of ICU-acquired weakness, and better global muscle strength. CONCLUSIONS The additional application of early NMES promoted better functional status outcomes on the first day awake and at ICU and hospital discharge. The patients in the EM+NMES group also took fewer days to stand up and had shorter hospital LOS, lower frequency of ICU-acquired weakness, and better muscle strength. Future studies are still necessary to clarify the effects of therapies associated with EM, especially to assess long-term outcomes.
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19
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Maramattom BV. Screening Power of Short Tau Inversion Recovery Muscle Magnetic Resonance Imaging in Critical Illness Myo-neuropathy and Guillain–Barre Syndrome in the Intensive Care Unit. Indian J Crit Care Med 2022; 26:204-209. [PMID: 35712739 PMCID: PMC8857722 DOI: 10.5005/jp-journals-10071-24122] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Critical illness myoneuropathy (CIMN) or intensive care unit (ICU)-acquired weakness (AW) is a common cause of weakness in ICU patients. Guillain–Barre syndrome (GBS) is also a common cause of acute neurological weakness in the ICU. It is diagnosed by clinical features, nerve conduction studies (NCS), and muscle/nerve biopsies. Methods The short tau inversion recovery (STIR) muscle magnetic resonance (MR) images of seven patients with suspected CIMN and seven GBS patients over a 5-year period from February 2015 till May 2020 were analyzed. Results All seven patients with CIMN showed diffuse muscle edema, predominating in the lower limbs. Only one patient with GBS showed abnormal magnetic resonance imaging (MRI) changes (14%) and MRI was normal in 86%. The sensitivity of MRI to detect CIMN was 100%, whereas the specificity was 85.7%. Thus, the positive predictive value (PPV) of MRI in this situation was 87.5% and the negative predictive value (NPV) was 100%. Conclusion Muscle STIR imaging may help to differentiate between CIMN and GBS. How to cite this article Maramattom BV. Screening Power of Short Tau Inversion Recovery Muscle Magnetic Resonance Imaging in Critical Illness Myoneuropathy and Guillain–Barre Syndrome in the Intensive Care Unit. Indian J Crit Care Med 2022;26(2):204–209.
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Affiliation(s)
- Boby Varkey Maramattom
- Boby Varkey Maramattom, Department of Neurology, Division of Neurocritical Care, Aster Medcity, Kochi, Kerala, India, Phone: +91 484 2234242, e-mail:
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20
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Qin ES, Hough CL, Andrews J, Bunnell AE. Intensive Care Unit-Acquired Weakness and the COVID-19 Pandemic: A Clinical Review. PM R 2022; 14:227-238. [PMID: 35014183 DOI: 10.1002/pmrj.12757] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 12/08/2021] [Accepted: 12/28/2021] [Indexed: 01/08/2023]
Abstract
Patients with severe cases of coronavirus disease 2019 (COVID-19) often become critically ill requiring intensive care unit (ICU) management. These individuals are at risk for developing ICU-acquired weakness (ICUAW), a multifactorial condition in which polyneuropathy, myopathy, and/or disuse muscle atrophy result in motor weakness. This weakness is thought to contribute to the long-term functional disability frequently observed in survivors of critical illness. This review discusses the current evidence regarding the epidemiology, pathophysiology, evaluation, risk factors, and rehabilitation-specific management of ICUAW in patients with COVID-19. Due to the novelty of COVID-19, the exact prevalence of ICUAW is not well delineated among COVID-19 patients. However, ICUAW has been reported in this population with retrospective studies showing weakness occurring in up to 45.5% of patients with severe COVID-19. There are multiple risk factors for developing ICUAW among COVID-19 patients which include premorbid health status, sepsis, multiple organ failure, mechanical ventilation, immobilization, neuromuscular blockade, corticosteroid use, and glycemic control. ICUAW is more likely to occur after prolonged mechanical ventilation and long hospital stays and can be diagnosed with manual muscle and electrodiagnostic testing. While the long-term sequela of COVID-19 after ICU stays is not fully studied, increasing evidence indicates significant risk for this population developing long-term functional impairments. Establishing post-acute rehabilitation programs for COVID-19 survivors will be important for recovery of endurance, mobility, and function. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Evelyn S Qin
- Department of Rehabilitation Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Catherine L Hough
- Department of Pulmonary and Critical Care Medicine, Oregon Health Science University, Portland, OR
| | - James Andrews
- Department of Medicine, University of Washington, Seattle, WA 325 9th Ave., Seattle, WA, USA
| | - Aaron E Bunnell
- Department of Rehabilitation Medicine, Harborview Medical Center, University of Washington, Seattle, WA
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21
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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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22
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Bertorini TE, Finder JD, Bassam BA. Perioperative Management of Patients With Neuromuscular Disorders. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00010-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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23
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Schick B, Schmid S, Mayer B, Wagner D, Walter S, Gruss S, Jungwirth B, Barth E. [Potential effect of the stimulus threshold level of the nociceptive flexion reflex (NFRT) on mortality and delirium incidence in the critically ill patient: a retrospective cohort analysis]. DIE ANAESTHESIOLOGIE 2022; 71:921-929. [PMID: 36166064 PMCID: PMC9514181 DOI: 10.1007/s00101-022-01206-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/05/2022] [Accepted: 08/25/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Mortality and delirium in critically ill patients are affected by the provided analgesics and sedatives. The deeper the sedation and the higher the dose of analgesics applied, the more difficult it is to assess pain and the depth of sedation. Therefore, instrumental measurement methods, such as the measurement of the stimulus threshold of the nociceptive flexion reflex (NFRT), are becoming increasingly more important. OBJECTIVE The aim of the present study is to investigate a potential association between the level of the nociceptive flexion reflex, mortality, and the occurrence of delirium. MATERIAL AND METHODS By retrospectively analyzing a pilot data set of 57 ICU patients from the interdisciplinary surgical ICU of Ulm University Hospital surveyed between 11/2018 and 03/2020, a possible association between the NFRT, mortality, and the occurrence of delirium was calculated in an adjusted logistic regression model. Depending on the cut-off value, the stimulus threshold corridors result in the following comparison pairs: < 20 mA vs. 20-40 mA/20-50 mA/20-60 mA, > 40 mA vs. 20-40 mA, > 50 mA vs. 20-50 mA and > 60 mA vs. 20-60 mA. Results are presented as odds ratios (OR) adjusted for age, sex, height, TISS-28, SAPS II, RASS, BPS, and applied analgesics. Pain assessment was performed, in addition to the Behavioral Pain scale, ≥ 3 times daily by measuring NFRT. RESULTS A statistically nonsignificant tendency for an increase in mortality incidence occurred with an NFRT > 50 mA, versus a stimulus threshold corridor of 20-50 mA (OR 3.3, CI: 0.89-12.43, p = 0.07). A trend toward a reduction in delirium incidence occurred at an NFRT < 20 mA, versus a stimulus threshold corridor of 20-40 mA (OR 0.40, CI: 0.18-0.92, p = 0.03). CONCLUSION Based on the level of the NFRT, no recommendation can be made at this point to adjust the analgesic regimen of critically ill patients, who are unable to communicate. The observation of a tendency towards an increase in mortality at high stimulus thresholds or a reduction in the occurrence of delirium at low stimulus thresholds of the NFRT must be verified in standardized studies.
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Affiliation(s)
- B. Schick
- grid.410712.10000 0004 0473 882XKlinik für Anästhesiologie und Intensivmedizin, Sektion Interdisziplinäre Operative Intensivmedizin, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Deutschland
| | - S. Schmid
- grid.410712.10000 0004 0473 882XKlinik für Anästhesiologie und Intensivmedizin, Sektion Interdisziplinäre Operative Intensivmedizin, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Deutschland
| | - B. Mayer
- grid.6582.90000 0004 1936 9748Institut für Epidemiologie und Medizinische Biometrie, Universität Ulm, Schwabstr. 13, 89075 Ulm, Deutschland
| | - D. Wagner
- grid.410712.10000 0004 0473 882XKlinik für Anästhesiologie und Intensivmedizin, Sektion Interdisziplinäre Operative Intensivmedizin, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Deutschland
| | - S. Walter
- grid.6582.90000 0004 1936 9748Klinik für Psychosomatische Medizin und Psychotherapie, Sektion medizinische Psychologie, Universität Ulm, Frauensteige 6, 89075 Ulm, Deutschland
| | - S. Gruss
- grid.6582.90000 0004 1936 9748Klinik für Psychosomatische Medizin und Psychotherapie, Sektion medizinische Psychologie, Universität Ulm, Frauensteige 6, 89075 Ulm, Deutschland
| | - B. Jungwirth
- grid.410712.10000 0004 0473 882XKlinik für Anästhesiologie und Intensivmedizin, Sektion Interdisziplinäre Operative Intensivmedizin, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Deutschland
| | - E. Barth
- grid.410712.10000 0004 0473 882XKlinik für Anästhesiologie und Intensivmedizin, Sektion Interdisziplinäre Operative Intensivmedizin, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Deutschland
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24
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Bocci T, Campiglio L, Zardoni M, Botta S, Coppola S, Groppo E, Chiumello D, Priori A. Critical illness neuropathy in severe COVID-19: a case series. Neurol Sci 2021; 42:4893-4898. [PMID: 34477990 PMCID: PMC8414960 DOI: 10.1007/s10072-021-05471-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/07/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Neurological complications of SARS-CoV-2 disease have received growing attention, but only few studies have described to date clinical and neurophysiological findings in COVID patients during their stay in intensive care units (ICUs). Here, we neurophysiologically assessed the presence of either critical illness neuropathy (CIP) or myopathy (CIM) in ICU patients. MATERIALS AND METHODS Patients underwent a neurophysiological assessment, including bilateral examination of the median, ulnar, deep peroneal and tibial motor nerves and of the median, ulnar, radial and sural sensory nerves. Needle electromyography (EMG) was performed for both distal and proximal muscles of the lower and upper limbs. In order to differentiate CIP from CIM, Direct Muscle Stimulation (DMS) was applied either to the deltoid or tibialis anterior muscles. Peak to peak amplitudes and onset latencies of the responses evoked by DMS (DMSamp, DMSlat) or by motor nerve stimulation (MNSamp, MNSlat) were compared. The ratio MNSamp to DMSamp (NMR) and the MNSlat to DMSlat difference (NMD: MNSlat - DMSlat) were also evaluated. RESULTS Nerve conduction studies showed a sensory-motor polyneuropathy with axonal neurogenic pattern, as confirmed by needle EMG. Both MNSamp and NMR were significantly reduced when compared to controls (p < 0.0001), whereas MNSlat and NMD were markedly increased (p = 0.0049). CONCLUSIONS We have described COVID patients in the ICU with critical illness neuropathy (CIP). COVID-related CIP could have implications for the functional recovery and rehabilitation strategies.
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Affiliation(s)
- Tommaso Bocci
- Aldo Ravelli" Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences, University of Milan, Milan, Italy.,Clinical Neurology Unit, ASST Santi Paolo & Carlo, Milan, Italy
| | - Laura Campiglio
- Clinical Neurology Unit, ASST Santi Paolo & Carlo, Milan, Italy
| | - Manuela Zardoni
- Clinical Neurology Unit, ASST Santi Paolo & Carlo, Milan, Italy
| | - Stefano Botta
- Clinical Neurology Unit, ASST Santi Paolo & Carlo, Milan, Italy
| | - Silvia Coppola
- Intensive Care, Anesthesia and Resuscitation Unit, ASST Santi Paolo & Carlo, Milan, Italy.,Department of Health Sciences, University of Milan, Milan, Italy
| | | | - Davide Chiumello
- Intensive Care, Anesthesia and Resuscitation Unit, ASST Santi Paolo & Carlo, Milan, Italy.,Department of Health Sciences, University of Milan, Milan, Italy
| | - Alberto Priori
- Aldo Ravelli" Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences, University of Milan, Milan, Italy. .,Clinical Neurology Unit, ASST Santi Paolo & Carlo, Milan, Italy. .,Struttura Complessa Di Neurologia I, Ospedale Universitario San Paolo, Via Antonio di Rudinì 8, 20142, Milan, Italy.
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25
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Abstract
Sepsis and septic shock are considered major factors in the development of myopathy in critically ill patients, which is correlated with increased morbidity rates and ICU length of stay. The underlying pathophysiology is complex, involving mitochondrial dysfunction, increased protein breakdown and muscle inexcitability. Sepsis induced myopathy is characterized by several electrophysiological and histopathological abnormalities of the muscle, also has clinical consequences such as flaccid weakness and failure to wean from ventilator. In order to reach definite diagnosis, clinical assessment, electrophysiological studies and muscle biopsy must be performed, which can be challenging in daily practice. Ultrasonography as a screening tool can be a promising alternative, especially in the ICU setting. Sepsis and mechanical ventilation have additive effects leading to diaphragm dysfunction thus complicating the patient's clinical course and recovery. Here, we summarize the effects of the septic syndrome on the muscle tissue based on the existing literature.
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26
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Barbariol F, Deana C, Guadagnin GM, Cammarota G, Vetrugno L, Bassi F. Ultrasound diaphragmatic excursion during non-invasive ventilation in ICU: a prospective observational study. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021269. [PMID: 34212900 PMCID: PMC8343726 DOI: 10.23750/abm.v92i3.11609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 04/18/2021] [Indexed: 11/26/2022]
Abstract
Background and Aim: Diaphragmatic dysfunction is seen in up to 60% of critically ill patients with respiratory failure, and it is associated with worse outcomes. The functionality of the diaphragm can be studied with simple and codified bedside ultrasound evaluation. Diaphragm excursion is one of the most studied parameters. The aim of this study was to assess the prevalence of diaphragmatic dysfunction in critically ill non-intubated patients admitted to a general intensive care unit with acute respiratory failure. Methods: We collected data, including ultrasound diaphragm excursion, at 2 time points: at T0 (at the time of recruitment, just before starting NIV) and at T1 (after one hour of NIV). Results: A total of 47 patients were enrolled. The prevalence of diaphragm dysfunction was 42.5% (95% CI 28, 3 - 57,8). Surgical patients showed a higher incidence (relative risk of 1.97) than medical patients. Mean DE was not significantly different between NIV responders (1,35 ± 0.78 cm) and non-responders (1.21 ± 0.85 cm, p 0,6). Patients with diaphragmatic dysfunction responded positively to NIV in 60% (95% CI 36.0 - 80.9%) of cases, while patients without diaphragmatic dysfunction responded positively to the NIV trial in 70.4% (95% CI 49.8 - 86.2%) of cases (p = 0.54). Taking the use of ultrasound diaphragm excursion as a potential predictor of NIV response, the corresponding ROC curve had an area under the curve of 0.53; the best balance between sensitivity (58.1%) and specificity (62.5%) was obtained with a cut-off diaphragm excursion of 1.37 cm. Conclusions: Diaphragm dysfunction is particularly frequent in critically ill patients with respiratory failure. The functionality of the diaphragm can be effectively and easily tested by bedside ultrasound examination. Overall, our results point towards tentative evidence of a trend of a different response to NIV in patients with vs without diaphragmatic dysfunction. (www.actabiomedica.it)
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Affiliation(s)
- Federico Barbariol
- Department of Anesthesia and Intensive Care, Academic Hospital of Udine, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy..
| | - Cristian Deana
- Anesthesia and Intensive Care Unit 1, Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy..
| | - Giovanni Maria Guadagnin
- Anesthesia and Intensive Care, Palmanova Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy..
| | | | - Luigi Vetrugno
- Department of Medical Area, University of Udine, Udine, Italy..
| | - Flavio Bassi
- Department of Anesthesia and Intensive Care, Academic Hospital of Udine, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy..
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27
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Goossens C, Weckx R, Derde S, Van Helleputte L, Schneidereit D, Haug M, Reischl B, Friedrich O, Van Den Bosch L, Van den Berghe G, Langouche L. Impact of prolonged sepsis on neural and muscular components of muscle contractions in a mouse model. J Cachexia Sarcopenia Muscle 2021; 12:443-455. [PMID: 33465304 PMCID: PMC8061378 DOI: 10.1002/jcsm.12668] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/19/2020] [Accepted: 12/16/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Prolonged critically ill patients frequently develop debilitating muscle weakness that can affect both peripheral nerves and skeletal muscle. In-depth knowledge on the temporal contribution of neural and muscular components to muscle weakness is currently incomplete. METHODS We used a fluid-resuscitated, antibiotic-treated, parenterally fed murine model of prolonged (5 days) sepsis-induced muscle weakness (caecal ligation and puncture; n = 148). Electromyography (EMG) measurements were performed in two nerve-muscle complexes, combined with histological analysis of neuromuscular junction denervation, axonal degeneration, and demyelination. In situ muscle force measurements distinguished neural from muscular contribution to reduced muscle force generation. In myofibres, imaging and biomechanics were combined to evaluate myofibrillar contractile calcium sensitivity, sarcomere organization, and fibre structural properties. Myosin and actin protein content and titin gene expression were measured on the whole muscle. RESULTS Five days of sepsis resulted in increased EMG latency (P = 0.006) and decreased EMG amplitude (P < 0.0001) in the dorsal caudal tail nerve-tail complex, whereas only EMG amplitude was affected in the sciatic nerve-gastrocnemius muscle complex (P < 0.0001). Myelin sheath abnormalities (P = 0.2), axonal degeneration (number of axons; P = 0.4), and neuromuscular junction denervation (P = 0.09) were largely absent in response to sepsis, but signs of axonal swelling [higher axon area (P < 0.0001) and g-ratio (P = 0.03)] were observed. A reduction in maximal muscle force was present after indirect nerve stimulation (P = 0.007) and after direct muscle stimulation (P = 0.03). The degree of force reduction was similar with both stimulations (P = 0.2), identifying skeletal muscle, but not peripheral nerves, as the main contributor to muscle weakness. Myofibrillar calcium sensitivity of the contractile apparatus was unaffected by sepsis (P ≥ 0.6), whereas septic myofibres displayed disorganized sarcomeres (P < 0.0001) and altered myofibre axial elasticity (P < 0.0001). Septic myofibres suffered from increased rupturing in a passive stretching protocol (25% more than control myofibres; P = 0.04), which was associated with impaired myofibre active force generation (P = 0.04), linking altered myofibre integrity to function. Sepsis also caused a reduction in muscle titin gene expression (P = 0.04) and myosin and actin protein content (P = 0.05), but not the myosin-to-actin ratio (P = 0.7). CONCLUSIONS Prolonged sepsis-induced muscle weakness may predominantly be related to a disruption in myofibrillar cytoarchitectural structure, rather than to neural abnormalities.
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Affiliation(s)
- Chloë Goossens
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Ruben Weckx
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Sarah Derde
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lawrence Van Helleputte
- Experimental Neurology and Leuven Brain Institute, Department of Neurosciences, KU Leuven, Leuven, Belgium.,Laboratory of Neurobiology, VIB Center for Brain & Disease Research, Leuven, Belgium
| | - Dominik Schneidereit
- Institute of Medical Biotechnology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Haug
- Institute of Medical Biotechnology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Barbara Reischl
- Institute of Medical Biotechnology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Oliver Friedrich
- Institute of Medical Biotechnology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Ludo Van Den Bosch
- Experimental Neurology and Leuven Brain Institute, Department of Neurosciences, KU Leuven, Leuven, Belgium.,Laboratory of Neurobiology, VIB Center for Brain & Disease Research, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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28
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Testosterone improves muscle function of the extensor digitorum longus in rats with sepsis. Biosci Rep 2021; 40:221929. [PMID: 31967292 PMCID: PMC7000367 DOI: 10.1042/bsr20193342] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/05/2020] [Accepted: 01/20/2020] [Indexed: 02/06/2023] Open
Abstract
Among patients with intensive care unit-acquired weakness (ICUAW), skeletal muscle strength often decreases significantly. The present study aimed to explore the effects of testosterone propotionate on skeletal muscle using rat model of sepsis. Male SD rats were randomly divided into experimental group, model control group, sham operation group and blank control group. Rats in experimental group were given testosterone propionate two times a week, 10 mg/kg for 3 weeks. Maximal contraction force, fatigue index and cross-sectional area of the extensor digitorum longus (EDL) were measured. Myosin, IGF-1, p-AKT and p-mTOR levels in EDL were detected by Western blot. Histological changes of the testis and prostate were detected by hematoxylin and eosin staining. We found that maximal contraction force and fatigue index of EDL in experimental group were significantly higher than in model control group. Cross-sectional area of fast MHC muscle fiber of EDL in group was significantly higher than in model control group. The levels of myosin, IGF-1, p-AKT and p-mTOR of EDL in experimental group were significantly higher than in model control group. In addition, no testicle atrophy and prostate hyperplasia were detected in experimental group. In conclusion, these results suggest that testosterone propionate can significantly improve skeletal muscle strength, endurance and volume of septic rats, and the mechanism may be related to the activation of IGF-1/AKT pathway. Moreover, testosterone propionate with short duration does not cause testicular atrophy and prostate hyperplasia in septic rats. Therefore, testosterone propionate is a potential treatment for muscle malfunction in ICUAW patients.
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29
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Deana C, Verriello L, Pauletto G, Corradi F, Forfori F, Cammarota G, Bignami E, Vetrugno L, Bove T. Insights into neurological dysfunction of critically ill COVID-19 patients. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021; 36:30-38. [PMID: 38620281 PMCID: PMC7490585 DOI: 10.1016/j.tacc.2020.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/06/2020] [Accepted: 09/09/2020] [Indexed: 12/29/2022]
Abstract
Novel coronavirus spread rapidly around the world infecting millions of people. It was thus declared a pandemic. This new virus damages the lungs. In the most severe cases, it leads to acute respiratory failure that requires intensive care treatment. However, many clinical reports have listed different neurological symptoms, leading to increased interest in the neurological involvement of COVID-19. Various pathophysiological mechanisms have been proposed to explain these neurological aspects. Direct viral invasion of the nervous system, systemic cytokine storm and severe hypoxemia are key factors in the development of symptoms. Critically ill patients present several additional risk factors for nervous system damage. Reasons for these include deep sedation and extended muscular paralysis, bed rest for several days, and the inability to receive proper physical rehabilitation. After ICU treatment, COVID-19 patients generally require an extensive rehabilitation program. However, distancing restrictions mean that in many cases physiotherapists are unable to enter ICUs, delaying the process of rehabilitation. The role of telemedicine should be considered as an adjunctive tool in the rehabilitation of critically ill COVID-19 patients.
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Affiliation(s)
- Cristian Deana
- Anesthesia and Intensive Care Department, Santa Maria della Misericordia Academic Hospital, ASUFC, Udine, Italy
| | - Lorenzo Verriello
- Neurology Unit, Department of Neurosciences, Santa Maria della Misericordia Academic Hospital, ASUFC, Udine, Italy
| | - Giada Pauletto
- Neurology Unit, Department of Neurosciences, Santa Maria della Misericordia Academic Hospital, ASUFC, Udine, Italy
| | - Francesco Corradi
- Department of Anesthesiology, Ente Ospedaliero Ospedali Galliera, Genova, Italy
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Francesco Forfori
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Gianmaria Cammarota
- Department of Anesthesia and Intensive Care, Maggiore della Carità University Hospital, Novara, Italy
| | - Elena Bignami
- Anesthesia, Intensive Care and Pain Therapy Service, University-Hospital of Parma, Parma, Italy
| | - Luigi Vetrugno
- Anesthesia and Intensive Care Department, Santa Maria della Misericordia Academic Hospital, ASUFC, Udine, Italy
- Department of Medical Area, University of Udine, Udine, Italy
| | - Tiziana Bove
- Anesthesia and Intensive Care Department, Santa Maria della Misericordia Academic Hospital, ASUFC, Udine, Italy
- Department of Medical Area, University of Udine, Udine, Italy
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30
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Wang W, Xu C, Ma X, Zhang X, Xie P. Intensive Care Unit-Acquired Weakness: A Review of Recent Progress With a Look Toward the Future. Front Med (Lausanne) 2020; 7:559789. [PMID: 33330523 PMCID: PMC7719824 DOI: 10.3389/fmed.2020.559789] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/11/2020] [Indexed: 12/16/2022] Open
Abstract
Intensive care unit-acquired weakness (ICU-AW), a common neuromuscular complication associated with patients in the ICU, is a type of skeletal muscle dysfunction that commonly occurs following sepsis, mobility restriction, hyperglycemia, and the use of glucocorticoids or neuromuscular blocking agents. ICU-AW can lead to delayed withdrawal of mechanical ventilation and extended hospitalization. Patients often have poor prognosis, limited mobility, and severely affected quality of life. Currently, its pathogenesis is uncertain, with unavailability of specific drugs or targeted therapies. ICU-AW has gained attention in recent years. This manuscript reviews the current research status of the epidemiology, pathogenesis, diagnosis, and treatment methods for ICU-AW and speculates the novel perspectives for future research.
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Affiliation(s)
- Wenkang Wang
- Department of Critical Care Medicine of the Third Affiliated Hospital (The First People's Hospital of Zunyi), Zunyi Medical University, Zunyi, China
| | - Chuanjie Xu
- Department of Critical Care Medicine of the Third Affiliated Hospital (The First People's Hospital of Zunyi), Zunyi Medical University, Zunyi, China
| | - Xinglong Ma
- Department of Critical Care Medicine of the Third Affiliated Hospital (The First People's Hospital of Zunyi), Zunyi Medical University, Zunyi, China
| | - Xiaoming Zhang
- Department of Molecular and Cellular Biology, Baylor College of Medicine Houston, Houston, TX, United States
| | - Peng Xie
- Department of Critical Care Medicine of the Third Affiliated Hospital (The First People's Hospital of Zunyi), Zunyi Medical University, Zunyi, China
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31
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Kasinathan A, Sharawat IK, Singhi P, Jayashree M, Sahu JK, Sankhyan N. Intensive Care Unit-Acquired Weakness in Children: A Prospective Observational Study Using Simplified Serial Electrophysiological Testing (PEDCIMP Study). Neurocrit Care 2020; 34:927-934. [PMID: 33025545 PMCID: PMC7538369 DOI: 10.1007/s12028-020-01123-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/21/2020] [Indexed: 12/02/2022]
Abstract
Background To study the incidence and time of onset of intensive care unit—acquired weakness in a prospective cohort of children (2–12 years) by serial simplified electrophysiological assessment (Pediatric Critical Illness Myopathy Polyneuropathy study, PEDCIMP). Methods A single-center, prospective cohort study (Trial Registry Number: NCT02763709; PEDCIMP2016) was conducted at the pediatric intensive care unit of a tertiary care hospital in North India. A complete electrophysiological evaluation (4 motor nerves and 2 sensory nerves) was performed at baseline in children (2–12 years) admitted to the ICU with a pediatric risk of mortality (PRISM) of > 20 with more than 24-h stay. Following the entry evaluation, a minimal alternate day simplified electrophysiological testing of the unilateral common peroneal nerve and the sural nerve was assessed. A 25% reduction in compound muscle action potential (CMAP) and sensory nerve action potential from baseline was considered significant for ICUAW and was confirmed by complete electrophysiological re-evaluation. Results Of the total 481 children assessed for eligibility, 97 were enrolled. The median age of the cohort was 7 years. Sepsis (81%); need for vasoactive support (43%); multiorgan dysfunction (26%) were the common reasons for admission. Of the 433 eligible patient ICU days, 380 electrophysiological observations were done. A significant decrease of > 25% in CMAP of common peroneal nerve was not detected in any of the 380 observations. However, two children unfit for inclusion were diagnosed with ICUAW during the study period. Conclusions Children admitted with PRISM > 20 have a very low incidence of intensive care unit—acquired weakness by serial clinical and abbreviated electrophysiological evaluation. Electronic supplementary material The online version of this article (10.1007/s12028-020-01123-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ananthanarayanan Kasinathan
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India.,Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006, India
| | - Indar Kumar Sharawat
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India.,Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, 249203, India
| | - Pratibha Singhi
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India.,Pediatric Neurology and Neurodevelopment, Medanta, The Medicity, Gurugram, Haryana, India, 122001
| | - Muralidharan Jayashree
- Pediatric Intensive Care and Emergency Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Jitendra Kumar Sahu
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India
| | - Naveen Sankhyan
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India.
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32
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Li Z, Zhang Q, Zhang P, Sun R, Jiang H, Wan J, Wu F, Wang X, Tao X. Prevalence and risk factors for intensive care unit acquired weakness: A protocol for a systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e22013. [PMID: 32899052 PMCID: PMC7478796 DOI: 10.1097/md.0000000000022013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] 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. We will systematically summarize and incorporate the important risk factors and prevalence from previously published multivariate analyses for ICU-AW. METHODS We will search the PubMed, Embase, Web of Science, and the Cochrane library to identify the relevant studies about the prevalence and risk factors for ICU-AW. Two reviewers will independently review the studies for eligibility according to the inclusion criteria. Two reviewers will independently assess the quality of studies by using the Newcastle-Ottawa scale for nonrandomized studies. Heterogeneity among studies will be estimated by the I statistic. RESULTS This systematic review and meta-analysis will provide an evidence of prevalence and risk factors for the ICU-AW. CONCLUSION We hope that our research will contribute to clinicians and public decision making about the ICU-AW.
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Affiliation(s)
- Zheng Li
- Graduate College, Wannan Medical College, Wuhu
| | - 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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33
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McClafferty B, Umer I, Fye G, Kepko D, Kalayanamitra R, Shahid Z, Ramgobin D, Cai A, Groff A, Bhandari A, Aggarwal CS, Patel R, Bhatt D, Polimera H, Sahu N, Vunnam R, Golamari R, Kumar A, Jain R. Approach to critical illness myopathy and polyneuropathy in the older SARS-CoV-2 patients. J Clin Neurosci 2020; 79:241-245. [PMID: 33070904 PMCID: PMC7380205 DOI: 10.1016/j.jocn.2020.07.058] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/08/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022]
Abstract
One of the major concerns of the health care community and the public surrounding the SARS-CoV-2 pandemic is the availability and use of ventilators. Unprecedented surges of patients presented to intensive care units across the country, with older adults making up a large proportion of the patient population. This paper illustrates contemporary approaches to critical illness myopathy (CIM), critical illness polyneuropathy (CIP), and critical illness polyneuromyopathy (CIPNM) in older patients, including incidence, risk factors, mechanisms for pathology, diagnosis, contemporary treatment approaches, and outcomes. We hope that the following analysis may help educate clinicians and ultimately decrease the duration of the mechanical ventilation required by these patients, resulting in improved clinical outcomes and an increase in ventilator availability for other patients in need.
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Affiliation(s)
| | - Ibrahim Umer
- Lake Erie College of Osteopathic Medicine, United States
| | - Gary Fye
- Lake Erie College of Osteopathic Medicine, United States
| | - Douglas Kepko
- Lake Erie College of Osteopathic Medicine, United States
| | | | - Zainab Shahid
- Lake Erie College of Osteopathic Medicine, United States
| | | | - Alice Cai
- Penn State College of Medicine, United States
| | | | - Abani Bhandari
- Department of Internal Medicine, KISTMC, Tribhuvan University, Nepal, India
| | | | - Ravi Patel
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - Dhirisha Bhatt
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - Hyma Polimera
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - Nitasa Sahu
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - Ramarao Vunnam
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - Reshma Golamari
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - Ashutosh Kumar
- Department of Pediatrics and Neurology, Penn State Milton S. Hershey Medical Center, United States
| | - Rohit Jain
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
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Teixeira C, Rosa RG, Maccari JG, Savi A, Rotta FT. Association between electromyographical findings and intensive care unit mortality among mechanically ventilated acute respiratory distress syndrome patients under profound sedation. Rev Bras Ter Intensiva 2020; 31:497-503. [PMID: 31967224 PMCID: PMC7009005 DOI: 10.5935/0103-507x.20190087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 08/05/2019] [Indexed: 12/23/2022] Open
Abstract
Objective To evaluate whether electromyographical findings could predict intensive care unit mortality among mechanically ventilated septic patients under profound sedation. Methods A prospective cohort study that consecutively enrolled moderate-severe acute respiratory distress syndrome (partial pressure of oxygen/fraction of inspired oxygen < 200) patients who were ≥ 18 years of age, dependent on mechanical ventilation for ≥ 7 days, and under profound sedation (Richmond Agitation Sedation Scale ≤ -4) was conducted. Electromyographic studies of the limbs were performed in all patients between the 7th and the 10th day of mechanical ventilation. Sensory nerve action potentials were recorded from the median and sural nerves. The compound muscle action potentials were recorded from the median (abductor pollicis brevis muscle) and common peroneal (extensor digitorum brevis muscle) nerves. Results Seventeen patients were enrolled during the seven months of the study. Nine patients (53%) had electromyographic signs of critical illness myopathy or neuropathy. The risk of death during the intensive care unit stay was increased in patients with electromyographical signs of critical illness myopathy or neuropathy in comparison to those without these diagnostics (77.7% versus 12.5%, log-rank p = 0.02). Conclusion Electromyographical signs of critical illness myopathy or neuropathy between the 7th and the 10th day of mechanical ventilation may be associated with intensive care unit mortality among moderate-severe acute respiratory distress syndrome patients under profound sedation, in whom clinical strength assessment is not possible.
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Affiliation(s)
- Cassiano Teixeira
- Departamento de Clínica Médica e Reabilitação, Universidade Federal de Ciências da Saúde de Porto Alegre - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Régis Goulart Rosa
- Unidade de Terapia Intensiva, Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
| | | | - Augusto Savi
- Unidade de Terapia Intensiva, Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
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Parkin Overexpression Attenuates Sepsis-Induced Muscle Wasting. Cells 2020; 9:cells9061454. [PMID: 32545383 PMCID: PMC7349807 DOI: 10.3390/cells9061454] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 12/11/2022] Open
Abstract
Sepsis elicits skeletal muscle weakness and fiber atrophy. The accumulation of injured mitochondria and depressed mitochondrial functions are considered as important triggers of sepsis-induced muscle atrophy. It is unclear whether mitochondrial dysfunctions in septic muscles are due to the inadequate activation of quality control processes. We hypothesized that overexpressing Parkin, a protein responsible for the recycling of dysfunctional mitochondria by the autophagy pathway (mitophagy), would confer protection against sepsis-induced muscle atrophy by improving mitochondrial quality and content. Parkin was overexpressed for four weeks in the limb muscles of four-week old mice using intramuscular injections of adeno-associated viruses (AAVs). The cecal ligation and perforation (CLP) procedure was used to induce sepsis. Sham operated animals were used as controls. All animals were studied for 48 h post CLP. Sepsis resulted in major body weight loss and myofiber atrophy. Parkin overexpression prevented myofiber atrophy in CLP mice. Quantitative two-dimensional transmission electron microscopy revealed that sepsis is associated with the accumulation of enlarged and complex mitochondria, an effect which was attenuated by Parkin overexpression. Parkin overexpression also prevented a sepsis-induced decrease in the content of mitochondrial subunits of NADH dehydrogenase and cytochrome C oxidase. We conclude that Parkin overexpression prevents sepsis-induced skeletal muscle atrophy, likely by improving mitochondrial quality and contents.
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Chen WT, Sun C, Zhou YB, Liu DH, Peng ZL, Chen J, Xu N, Lei YY, He J, Tang CZ, Lin XF, Xu NG, Xian SX, Lu LM. Evaluation on the effect of acupuncture on patients with sepsis-induced myopathy (ACU-SIM pilot study): A single center, propensity-score stratified, assessor-blinded, prospective pragmatic controlled trial. Medicine (Baltimore) 2020; 99:e20233. [PMID: 32481297 PMCID: PMC7249879 DOI: 10.1097/md.0000000000020233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Sepsis-induced myopathy (SIM) is a disease that causes motor dysfunction in patients with sepsis. There is currently no targeted treatment for this disease. Acupuncture has shown considerable efficacy in the treatment of sepsis and muscle weakness. Therefore, our research aims to explore the effects of acupuncture on the improvement of muscle structure and function in SIM patients and on activities of daily living. METHODS The ACU-SIM pilot study is a single-center, propensity-score stratified, assessor-blinded, prospective pragmatic controlled trial (pCT) with a 1-year follow-up period. This study will be deployed in a multi-professional critical care department at a tertiary teaching hospital in Guangzhou, China. Ninety-eight intensive care unit subjects will be recruited and assigned to either the control group or the acupuncture group. Both groups will receive basic treatment for sepsis, and the acupuncture group will additionally receive acupuncture treatment. The primary outcomes will be the rectus femoris cross-sectional area, the Medical Research Council sum-score and time-to-event (defined as all-cause mortality or unplanned readmission to the intensive care unit due to invasive ventilation). The activities of daily living will be accessed by the motor item of the Functional Independence Measure. Recruitment will last for 2 years, and each patient will have a 1-year follow-up after the intervention. DISCUSSION There is currently no research on the therapeutic effects of acupuncture on SIM. The results of this study may contribute to new knowledge regarding early muscle atrophy and the treatment effect of acupuncture in SIM patients, and the results may also direct new approaches and interventions in these patients. This trial will serve as a pilot study for an upcoming multicenter real-world study. TRIAL REGISTRATION Chinese Clinical Trials Registry: ChiCTR-1900026308, registered on September 29th, 2019.
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Affiliation(s)
- Wei-Tao Chen
- Intensive Care Unit, The First Affiliated Hospital of Guangzhou University of Chinese Medicine
- Ling-Nan Medical Research Center, Guangzhou University of Chinese Medicine
- The First Clinical School of Guangzhou University of Chinese Medicine, Guangzhou
| | - Ce Sun
- Meizhou Hospital of Traditional Chinese Medicine, Meizhou
| | - Ying-Bin Zhou
- The First Clinical School of Guangzhou University of Chinese Medicine, Guangzhou
| | - Dong-Hua Liu
- The First Clinical School of Guangzhou University of Chinese Medicine, Guangzhou
| | - Zhi-Long Peng
- The First Clinical School of Guangzhou University of Chinese Medicine, Guangzhou
| | - Jing Chen
- Intensive Care Unit, The First Affiliated Hospital of Guangzhou University of Chinese Medicine
- Ling-Nan Medical Research Center, Guangzhou University of Chinese Medicine
- The First Clinical School of Guangzhou University of Chinese Medicine, Guangzhou
| | - Nuo Xu
- The university of Alabama at Birmingham, Birmingham, USA
| | - Yan-Yan Lei
- Intensive Care Unit, The First Affiliated Hospital of Guangzhou University of Chinese Medicine
- School of economics and management, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jun He
- Department of Acupuncture and Rehabilitation, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | | | - Xin-Feng Lin
- Intensive Care Unit, The First Affiliated Hospital of Guangzhou University of Chinese Medicine
| | | | - Shao-Xiang Xian
- Ling-Nan Medical Research Center, Guangzhou University of Chinese Medicine
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine
| | - Li-Ming Lu
- Medical College of Acupuncture and Rehabilitation
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Nwafor DC, Chakraborty S, Brichacek AL, Jun S, Gambill CA, Wang W, Engler-Chiurazzi EB, Dakhlallah D, Pinkerton AB, Millán JL, Benkovic SA, Brown CM. Loss of tissue-nonspecific alkaline phosphatase (TNAP) enzyme activity in cerebral microvessels is coupled to persistent neuroinflammation and behavioral deficits in late sepsis. Brain Behav Immun 2020; 84:115-131. [PMID: 31778743 PMCID: PMC7010562 DOI: 10.1016/j.bbi.2019.11.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 11/12/2019] [Accepted: 11/20/2019] [Indexed: 12/13/2022] Open
Abstract
Sepsis is a host response to systemic inflammation and infection that may lead to multi-organ dysfunction and eventual death. While acute brain dysfunction is common among all sepsis patients, chronic neurological impairment is prevalent among sepsis survivors. The brain microvasculature has emerged as a major determinant of sepsis-associated brain dysfunction, yet the mechanisms that underlie its associated neuroimmune perturbations and behavioral deficits are not well understood. An emerging body of data suggests that inhibition of tissue-nonspecific alkaline phosphatase (TNAP) enzyme activity in cerebral microvessels may be associated with changes in endothelial cell barrier integrity. The objective of this study was to elucidate the connection between alterations in cerebrovascular TNAP enzyme activity and brain microvascular dysfunction in late sepsis. We hypothesized that the disruption of TNAP enzymatic activity in cerebral microvessels would be coupled to the sustained loss of brain microvascular integrity, elevated neuroinflammatory responses, and behavioral deficits. Male mice were subjected to cecal ligation and puncture (CLP), a model of experimental sepsis, and assessed up to seven days post-sepsis. All mice were observed daily for sickness behavior and underwent behavioral testing. Our results showed a significant decrease in brain microvascular TNAP enzyme activity in the somatosensory cortex and spinal cord of septic mice but not in the CA1 and CA3 hippocampal regions. Furthermore, we showed that loss of cerebrovascular TNAP enzyme activity was coupled to a loss of claudin-5 and increased perivascular IgG infiltration in the somatosensory cortex. Analyses of whole brain myeloid and T-lymphoid cell populations also revealed a persistent elevation of infiltrating leukocytes, which included both neutrophil and monocyte myeloid derived suppressor cells (MDSCs). Regional analyses of the somatosensory cortex, hippocampus, and spinal cord revealed significant astrogliosis and microgliosis in the cortex and spinal cord of septic mice that was accompanied by significant microgliosis in the CA1 and CA3 hippocampal regions. Assessment of behavioral deficits revealed no changes in learning and memory or evoked locomotion. However, the hot plate test uncovered a novel anti-nociceptive phenotype in our septic mice, and we speculate that this phenotype may be a consequence of sustained GFAP astrogliosis and loss of TNAP activity in the somatosensory cortex and spinal cord of septic mice. Taken together, these results demonstrate that the loss of TNAP enzyme activity in cerebral microvessels during late sepsis is coupled to sustained neuroimmune dysfunction which may underlie, in part, the chronic neurological impairments observed in sepsis survivors.
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Affiliation(s)
- Divine C. Nwafor
- Department of Neuroscience, West Virginia University Health Science Center, Morgantown, WV 26506, USA
| | - Sreeparna Chakraborty
- Department of Microbiology, Immunology, and Cell Biology, School of Medicine, West Virginia University Health Science Center, Morgantown, WV 26506, USA
| | - Allison L. Brichacek
- Department of Microbiology, Immunology, and Cell Biology, School of Medicine, West Virginia University Health Science Center, Morgantown, WV 26506, USA
| | - Sujung Jun
- Wilmer Eye Institute, John Hopkins University School of Medicine, Baltimore, MD 21231, USA.
| | - Catheryne A. Gambill
- Department of Microbiology, Immunology, and Cell Biology, School of Medicine, West Virginia University Health Science Center, Morgantown, WV 26506, USA
| | - Wei Wang
- Department of Neuroscience, West Virginia University Health Science Center, Morgantown, WV 26506, USA.
| | | | - Duaa Dakhlallah
- Department of Neuroscience, West Virginia University Health Science Center, Morgantown, WV 26506, USA; Cancer Institute, West Virginia University Health Science Center, Morgantown, WV 26506, USA.
| | | | - José Luis Millán
- Sanford-Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA.
| | - Stanley A. Benkovic
- Department of Neuroscience, West Virginia University Health Science Center, Morgantown, WV 26506, USA
| | - Candice M. Brown
- Department of Neuroscience, West Virginia University Health Science Center, Morgantown, WV 26506, USA,Department of Microbiology, Immunology, and Cell Biology, School of Medicine, West Virginia University Health Science Center, Morgantown, WV 26506, USA,Corresponding Author: Candice M. Brown, Ph.D., Assistant Professor, Neuroscience, 108 Biomedical Road, Box 9303, Center for Basic and Translational Stroke Research, Rockefeller Neuroscience Institute, West Virginia University Health Sciences, Morgantown, WV 26506, Phone: 304-293-0589,
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Schmidt D, Coelho AC, Vieira FN, Torres VF, Savi A, Vieira SRR. Critical illness polyneuromyopathy in septic patients: Is it possible to diagnose it in a bedside clinical examination? ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:33-38. [PMID: 30758440 DOI: 10.1590/0004-282x20180144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 10/04/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To determine the sensitivity and specificity of peripheral and respiratory muscle strength tests in diagnosing critical illness polyneuromyopathy (CIPNM), compared with an electrophysiological examination. METHODS Fifty septic patients who required mechanical ventilation for at least five days, and without a previous history of muscle weakness, were included. Peripheral muscle strength was assessed using the Medical Research Council (MRC) score, handgrip strength by dynamometry, and respiratory muscle strength with maximum respiratory pressures. Diagnosis of CIPNM was either confirmed or rejected by an electrophysiological examination. Receiver operating characteristic curve analysis was performed to determine the cut-off values with the best sensitivity (SN) and specificity (SP) of the studied variables in the presence or absence of CIPNM. RESULTS Patients with CIPNM were older, more critical (APACHE IV/SAPS 3), had a longer hospitalization, required mechanical ventilation for longer, and had a higher rate of intensive care unit readmission. Cutoff values identified CIPNM patients using MRC scores, dynamometry according to sex, maximal expiratory and inspiratory pressures, as well as being confirmed by the electrophysiological examination, with good sensitivity and specificity: < 40 (SN: 0.893; SP: 0.955); < 7 kg (SN: 1; SP: 0.909) for men, < 4 kg (SN: 0.882; SP: 1) for women; < 34 cmH2O (SN: 0.808; SP: 0.909) and > -40 cmH2O (SN: 0.846; SP: 0.909), respectively. CONCLUSION The MRC score, dynamometry or maximum respiratory pressures can be used to identify patients with CIPNM at the intensive care bedside assessment. The healthcare professional can choose any of the methods studied to evaluate the patient, based on his experience and the resource available.
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Affiliation(s)
- Débora Schmidt
- Hospital de Clínicas de Porto Alegre, Porto Alegre RS, Brasil.,Hospital Nossa Senhora da Conceição, Porto Alegre RS, Brasil
| | - Ana Cláudia Coelho
- Hospital de Clínicas de Porto Alegre, Porto Alegre RS, Brasil.,Hospital Nossa Senhora da Conceição, Porto Alegre RS, Brasil
| | - Fernando Nataniel Vieira
- Hospital de Clínicas de Porto Alegre, Porto Alegre RS, Brasil.,Hospital Nossa Senhora da Conceição, Porto Alegre RS, Brasil
| | | | - Augusto Savi
- Hospital de Clínicas de Porto Alegre, Porto Alegre RS, Brasil
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Carpenter KC, Hakenjos JM, Fry CD, Nemzek JA. The Influence of Pain and Analgesia in Rodent Models of Sepsis. Comp Med 2019; 69:546-554. [PMID: 31213216 PMCID: PMC6935706 DOI: 10.30802/aalas-cm-19-000004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 02/15/2019] [Accepted: 04/01/2019] [Indexed: 12/17/2022]
Abstract
Sepsis is a multifaceted host response to infection that dramatically affects patient outcomes and the cost of health care. Animal models are necessary to replicate the complexity and heterogeneity of clinical sepsis. However, these models entail a high risk of pain and distress due to tissue trauma, inflammation, endotoxin-mediated hyperalgesia, and other mechanisms. Several recent studies and initiatives address the need to improve the welfare of animals through analgesics and standardize the models used in preclinical sepsis research. Ultimately, the goal is to provide high-fidelity, humane animal models that better replicate the clinical course of sepsis, to provide more effective translation and advance therapeutic discovery. The purpose of this review is to discuss the current understanding of the roles of pain and analgesia in rodent models of sepsis. The current definitions of sepsis along with an overview of pain in human sepsis are described. Finally, welfare concerns associated with animal models of sepsis and the most recent considerations for relief of pain and distress are reviewed.
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Affiliation(s)
- Kelsey C Carpenter
- Unit for Laboratory Animal Medicine, University of Michigan, Ann Arbor, Michigan
| | - John M Hakenjos
- Unit for Laboratory Animal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Christopher D Fry
- Unit for Laboratory Animal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jean A Nemzek
- Unit for Laboratory Animal Medicine, University of Michigan, Ann Arbor, Michigan;,
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40
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Mitobe Y, Morishita S, Ohashi K, Sakai S, Uchiyama M, Abeywickrama H, Yamada E, Kikuchi Y, Nitta M, Honda T, Endoh H, Kimura S, Sakano S, Koyama Y. Skeletal Muscle Index at Intensive Care Unit Admission Is a Predictor of Intensive Care Unit-Acquired Weakness in Patients With Sepsis. J Clin Med Res 2019; 11:834-841. [PMID: 31803328 PMCID: PMC6879036 DOI: 10.14740/jocmr4027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 11/11/2019] [Indexed: 01/06/2023] Open
Abstract
Background Intensive care unit-acquired weakness (ICU-AW) can be diagnosed using the Medical Research Council (MRC) score. However, such scoring may not be possible in ICU patients who may be sedated or delirious or have encephalopathy. Currently, a quantitative assessment of the cross-sectional area of the muscle is available to assess changes in skeletal muscle mass using computed tomography (CT) images. This assessment calculates the skeletal muscle index (SMI) (cm2/m2) by dividing the cross-sectional area (cm2) of the skeletal muscle at the level of the third lumbar vertebra by the square of the patient’s height (m2) on CT. This study assessed the effectiveness of SMI, as measured by abdominal CT scans, in predicting the onset of ICU-AW in patients with sepsis admitted to the ICU. Methods We examined septic ICU patients admitted to the Niigata University Hospital ICU during 2012 - 2017 under mechanical ventilation. Patients were retrospectively divided into two groups by MRC score at ICU discharge: group AW comprised patients with an MRC score < 48, and group non-AW (NAW) comprised the remaining patients. Clinicopathological factors at ICU admission such as age, gender, underlying disease, body mass index, and SMI were compared between the two groups. Statistical analyses were performed using the Mann-Whitney U test, Fisher’s exact test, receiver operator characteristic (ROC) analysis and multivariate analysis. Results A total of 31 septic patients were examined, and 23 patients met the criteria for ICU-AW. The prevalence of women was significantly higher in group AW (P < 0.05). All clinical factors, except for gender, were not significantly different between the two groups. SMI was significantly lower in group AW than in group NAW (P < 0.05). ROC analysis revealed that the cut-off value of SMI for predicting ICU-AW was 44.1, and the multivariate analysis revealed that only low SMI was a significant factor in predicting ICU-AW (P < 0.05). Conclusions Our results show that SMI measurement at ICU admission is a valid predictive factor for ICU-AW progression in septic patients.
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Affiliation(s)
- Yuta Mitobe
- Department of Nursing, Faculty of Medical Technology, Teikyo University, 2-11-1 Kaga, Itabashi, Tokyo 173-8605, Japan
| | - Shinichiro Morishita
- Department of Physical Therapy, Niigata University of Health and Welfare, Shimami-cho 1398, Kita-ku, Niigata 950-3198, Japan
| | - Kazuki Ohashi
- Department of Nursing, Sapporo University of Health Science, 2-1-15, Nakanumanishi 4-jo, Sapporo Shi Higashi Ku, Hokkaido 007-0894, Japan
| | - Sayuri Sakai
- Department of Nursing, Niigata University Graduate School of Health Sciences, 2-746 Asahimachi, Niigata, Niigata 951-8518, Japan
| | - Mieko Uchiyama
- Department of Nursing, Niigata University Graduate School of Health Sciences, 2-746 Asahimachi, Niigata, Niigata 951-8518, Japan
| | - Hansani Abeywickrama
- Department of Nursing, Niigata University Graduate School of Health Sciences, 2-746 Asahimachi, Niigata, Niigata 951-8518, Japan
| | - Etsuko Yamada
- Department of Nursing, Niigata University Graduate School of Health Sciences, 2-746 Asahimachi, Niigata, Niigata 951-8518, Japan
| | - Yuko Kikuchi
- Department of Nursing, Niigata University Graduate School of Health Sciences, 2-746 Asahimachi, Niigata, Niigata 951-8518, Japan
| | - Masakazu Nitta
- Advanced Emergency and Critical Care Center, Niigata University Medical and Dental Hospital, 1-754 Asahimachi, Niigata, Niigata 951-8520, Japan
| | - Tadayuki Honda
- Division of Emergency and Critical Care Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Niigata, Niigata 951-8510, Japan
| | - Hiroshi Endoh
- Division of Emergency and Critical Care Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi, Niigata, Niigata 951-8510, Japan
| | - Shinji Kimura
- Rehabilitation Center, Niigata University Medical and Dental Hospital, 1-754 Asahimachi, Niigata, Niigata 951-8520, Japan
| | - Shuhei Sakano
- Rehabilitation Center, Niigata University Medical and Dental Hospital, 1-754 Asahimachi, Niigata, Niigata 951-8520, Japan
| | - Yu Koyama
- Department of Nursing, Niigata University Graduate School of Health Sciences, 2-746 Asahimachi, Niigata, Niigata 951-8518, Japan
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Vetrugno L, Guadagnin GM, Barbariol F, Langiano N, Zangrillo A, Bove T. Ultrasound Imaging for Diaphragm Dysfunction: A Narrative Literature Review. J Cardiothorac Vasc Anesth 2019; 33:2525-2536. [DOI: 10.1053/j.jvca.2019.01.003] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Indexed: 12/15/2022]
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Chhetri I, Hunt JEA, Mendis JR, Patterson SD, Puthucheary ZA, Montgomery HE, Creagh-Brown BC. Repetitive vascular occlusion stimulus (RVOS) versus standard care to prevent muscle wasting in critically ill patients (ROSProx):a study protocol for a pilot randomised controlled trial. Trials 2019; 20:456. [PMID: 31340849 PMCID: PMC6657179 DOI: 10.1186/s13063-019-3547-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 06/29/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Forty per cent of critically ill patients are affected by intensive care unit-acquired weakness (ICU-AW), to which skeletal muscle wasting makes a substantial contribution. This can impair outcomes in hospital, and can cause long-term physical disability after hospital discharge. No effective mitigating strategies have yet been identified. Application of a repetitive vascular occlusion stimulus (RVOS) a limb pressure cuff inducing brief repeated cycles of ischaemia and reperfusion, can limit disuse muscle atrophy in both healthy controls and bed-bound patients recovering from knee surgery. We wish to determine whether RVOS might be effective in mitigating against muscle wasting in the ICU. Given that RVOS can also improve vascular function in healthy controls, we also wish to assess such effects in the critically ill. We here describe a pilot study to assess whether RVOS application is safe, tolerable, feasible and acceptable for ICU patients. METHODS This is a randomised interventional feasibility trial. Thirty-two ventilated adult ICU patients with multiorgan failure will be recruited within 48 h of admission and randomised to either the intervention arm or the control arm. Intervention participants will receive RVOS twice daily (except only once on day 1) for up to 10 days or until ICU discharge. Serious adverse events and tolerability (pain score) will be recorded; feasibility of trial procedures will be assessed against pre-specified criteria and acceptability by semi-structured interview. Together with vascular function, muscle mass and quality will be assessed using ultrasound and measures of physical function at baseline, on days 6 and 11 of study enrolment, and at ICU and hospital discharge. Blood and urine biomarkers of muscle metabolism, vascular function, inflammation and DNA damage/repair mechanism will also be analysed. The Health questionnaire will be completed 3 months after hospital discharge. DISCUSSION If this study demonstrates feasibility, the derived data will be used to inform the design (and sample size) of an appropriately-powered prospective trial to clarify whether RVOS can help preserve muscle mass/improve vascular function in critically ill patients. TRIAL REGISTRATION ISRCTN Registry, ISRCTN44340629. Registered on 26 October 2017.
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Affiliation(s)
- Ismita Chhetri
- Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, GU2 7XX UK
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Julie E. A. Hunt
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Jeewaka R. Mendis
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | | | - Zudin A. Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Institute for Sport, Exercise and Health, University College London, London, UK
- Department of Medicine, Centre for Human Health and Performance, University College London, London, UK
- Intensive Care Unit, Royal Free London NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King’s College London, London,, UK
| | - Hugh E. Montgomery
- Institute for Sport, Exercise and Health, University College London, London, UK
- Department of Medicine, Centre for Human Health and Performance, University College London, London, UK
| | - Benedict C. Creagh-Brown
- Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, GU2 7XX UK
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
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Lu Z, Ge H, Xu L, Guo F, Zhang G, Wu Y. Alterations in diaphragmatic function assessed by ultrasonography in mechanically ventilated patients with sepsis. JOURNAL OF CLINICAL ULTRASOUND : JCU 2019; 47:206-211. [PMID: 30671990 DOI: 10.1002/jcu.22690] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 12/01/2018] [Accepted: 12/25/2018] [Indexed: 06/09/2023]
Abstract
PURPOSE To assess alteration of diaphragmatic function by ultrasonography in a population of mechanically ventilated patients with or without sepsis. METHODS We performed a prospective, 6-month, single-center, observational cohort study. Mechanically ventilated septic and nonseptic patients were studied within 24 hours following intubation and before the moment of ventilator liberation. Diaphragm thickness and contractile activity (quantified by diaphragmatic thickening fraction, DTF) were measured by ultrasonography at the zone of apposition. Intraobserver and interobserver reproducibility were measured. RESULTS Fifty-two critically ill patients were included, 28 with sepsis and 24 without sepsis. Upon initiation of ventilation, DTF was lower in septic than that in nonseptic patients (P = 0.03). No difference was observed between septic and nonseptic patients for diaphragm thickness. Mean 188 ± 111 hours after the first measurement, both diaphragm thickness and DTF decreased significantly compared with first measurements in septic and nonseptic patients, all P < 0.001. Diaphragm thickness decreased by 9.1 ± 10.7% in nonseptic and by 16.0 ± 13.5% in septic patients, P = 0.049. DTF decreased by 15.2 ± 21.3% in nonseptic and by 30.7 ± 22.0% in septic patients, P = 0.013. CONCLUSIONS Mechanically ventilated patients with sepsis were associated with an earlier and more severe diaphragm dysfunction compared with patients without sepsis.
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Affiliation(s)
- Zhihua Lu
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Huiqing Ge
- Department of Respiratory Care, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lilong Xu
- Department of Diagnostic Ultrasound, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Feng Guo
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ge Zhang
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yinshan Wu
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Shible AA, Ramadurai D, Gergen D, Reynolds PM. Dry Beriberi Due to Thiamine Deficiency Associated with Peripheral Neuropathy and Wernicke's Encephalopathy Mimicking Guillain-Barré syndrome: A Case Report and Review of the Literature. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:330-334. [PMID: 30862772 PMCID: PMC6429982 DOI: 10.12659/ajcr.914051] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Beriberi due to thiamine (vitamin B1) deficiency has two clinical presentations. Patients with dry beriberi present with neuropathy, and patients with wet beriberi present with heart failure, with or without neuropathy. Dry beriberi can mimic the most common form of Guillain-Barre syndrome (GBS), an acute inflammatory demyelinating polyradiculoneuropathy (AIDP). Severe thiamine deficiency results in Wernicke's encephalopathy. This report of a case of dry beriberi and Wernicke's encephalopathy due to thiamine deficiency includes a review of the literature. CASE REPORT A 56-year old woman with a history of gallstone pancreatitis and protein-calorie malnutrition was treated six months previously with total parenteral nutrition (TPN). She initially presented at another hospital with paresthesia of the lower limbs, arms, and neck, and symptoms of encephalopathy. Initial diagnosis of GBS was made, based on magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) findings. Despite five days of intravenous immunoglobulin (IVIG) treatment, her encephalopathy worsened, requiring transfer to our hospital, where she required intubation and treatment with vasopressors. A repeat MRI of her brain showed changes consistent with Wernicke's encephalopathy. Following treatment with high-dose intravenous thiamine, her mental status improved within 48 hours, and by the third hospital day, she no longer required intubation. CONCLUSIONS Symptoms and signs of dry beriberi due to thiamine deficiency can mimic those of acute or chronic GBS. However, thiamine repletion leads to rapid clinical improvement and can prevent irreversible neurologic sequelae, including Korsakoff syndrome. Clinicians should consider thiamine deficiency in malnourished patients presenting with symptoms and signs of GBS.
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Affiliation(s)
- Ahmed A Shible
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA.,Department of Pharmacy, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Deepa Ramadurai
- University of Colorado Internal Medicine Residency Training Program, University of Colorado, Aurora, CO, USA
| | - Daniel Gergen
- University of Colorado Internal Medicine Residency Training Program, University of Colorado, Aurora, CO, USA
| | - Paul M Reynolds
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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Witteveen E, Wieske L, Manders E, Verhamme C, Ottenheijm CAC, Schultz MJ, van Schaik IN, Horn J. Muscle weakness in a S. pneumoniae sepsis mouse model. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:9. [PMID: 30788356 DOI: 10.21037/atm.2018.12.45] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The pathophysiology of intensive care unit-acquired weakness (ICU-AW), which affects peripheral nerves, limb muscles and respiratory muscles, is complex and incompletely understood. This illustrates the need for an ICU-AW animal model. However, a translatable and easily applicable ICU-AW animal model does not exist. The objective of this study was to investigate whether induction of a S. pneumoniae sepsis could serve as a model for ICU-AW. Methods A total of 24 C57BL/6J mice were infected intranasally with viable S. pneumoniae. Control mice (n=8) received intranasal saline and mice of the blank group (n=4) were not inoculated. Ceftriaxone was administered at 24 h (n=8) or at 48h after inoculation (n=8), or as soon as mice lost 10% of their body weight (n=8). The primary endpoint, in vivo grip strength, was measured daily. At the end of the experiment, at 120 h after inoculation, electrophysiological recordings were performed and diaphragm muscle was excised to determine ex vivo muscle fiber strength and myosin/action ratio. Results Grip strength over time was similar between experimental and control groups and electrophysiological recordings did not show signs of ICU-AW. Diaphragm fiber contractility measurements showed reduced strength in the group that received ceftriaxone at 48 h after S. pneumoniae inoculation. Conclusions Ex vivo diaphragm weakness, but no in vivo limb weakness was found in the S. pneumoniae mouse model in which severe illness was induced. This does not reflect the full clinical picture of ICU-AW as seen in humans and as such this model did not fulfill our predefined requirements. However, this model may be used to study inflammation induced diaphragmatic weakness.
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Affiliation(s)
- Esther Witteveen
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands.,Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Luuk Wieske
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands.,Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Emmy Manders
- Department of Physiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Camiel Verhamme
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Coen A C Ottenheijm
- Department of Physiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
| | - Ivo N van Schaik
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Janneke Horn
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
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Kelmenson DA, Quan D, Moss M. What is the diagnostic accuracy of single nerve conduction studies and muscle ultrasound to identify critical illness polyneuromyopathy: a prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:342. [PMID: 30558638 PMCID: PMC6296115 DOI: 10.1186/s13054-018-2281-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 11/27/2018] [Indexed: 12/21/2022]
Abstract
Background Critical illness polyneuromyopathy (CIPNM) is a major cause of weakness in intensive care unit (ICU) patients, but current diagnostic tests are limited. We evaluated the generalizability and validity of single nerve conduction studies (NCS) and muscle ultrasound testing to identify CIPNM, and we also assessed the ability of muscle ultrasound to prognosticate patient outcomes. Methods This was a prospective cohort study of mechanically ventilated medical, cardiac, surgical, and neurosurgical ICU patients. We performed weekly strength testing, NCS, electromyography (EMG), and muscle ultrasound. We calculated the sensitivity, specificity, and other test characteristics of single NCS and muscle ultrasound, and we used multivariable regression models to assess the prognostic ability of muscle ultrasound. Results Ninety-five patients were enrolled. The incidence of probable CIPNM was 18% and did not differ significantly by type of ICU (p = 0.49). For diagnosing probable CIPNM, the peroneal motor NCS had a sensitivity of 94% (95% confidence interval (CI) 71–100%) and specificity of 91% (95% CI 82–96%), the sural sensory NCS had a sensitivity of 100% (95% CI 80–100%) and specificity of 42% (95% CI 31–54%), and abnormal muscle ultrasound echogenicity had a sensitivity of 82% (95% CI 48–98%) and specificity of 57% (95% CI 43–70%). Abnormal echogenicity was associated with reduced likelihood of discharge to home (9% vs 50%, p = 0.0001), fewer ICU-free days (median 3 (interquartile range 0–15) days vs 16 (9.3–19.3) days, p = 0.0002), and increased ICU mortality (42% vs 12%, p = 0.004). Conclusions In a diverse cohort of critically ill patients, single NCS and muscle ultrasound achieved diagnostic accuracy for patients at risk for CIPNM. The routine utilization of these tests could be beneficial for all critically ill patients at risk for CIPNM. Electronic supplementary material The online version of this article (10.1186/s13054-018-2281-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel A Kelmenson
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado School of Medicine, RM 9023, Mail Stop C272, 12700 East 19th Avenue, Aurora, CO, 80045, USA.
| | - Dianna Quan
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Marc Moss
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado School of Medicine, RM 9023, Mail Stop C272, 12700 East 19th Avenue, Aurora, CO, 80045, USA
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Kubiak CA, Ranganathan K, Matusko N, Jacobson JA, Wang SC, Park PK, Levi BL. Computed Tomography Evidence of Psoas Muscle Atrophy Without Concomitant Tendon Wasting in Early Sepsis. J Surg Res 2018; 234:210-216. [PMID: 30527476 DOI: 10.1016/j.jss.2018.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 08/22/2018] [Accepted: 09/06/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Morphomic studies have demonstrated a correlation between sarcopenia and clinical outcomes in septic patients. However, tendon morphomics has not yet been studied in this context. The purpose of the present study was to evaluate tendon morphology in septic patients through analytic morphomics. We hypothesized that morphomic analyses would reveal concomitant muscle and tendon wasting in sepsis patients. The results of this study may help to implement different rehabilitation modalities for critically ill patients. MATERIALS AND METHODS The volume and fat content of bilateral psoas muscles and tendons were measured on abdominal computed tomography scans of 25 ICU septic and 25 control trauma patients admitted to the University of Michigan between 2011 and 2012. Univariate and multivariate analyses were performed to determine the relationship between psoas muscle and tendon morphometric data, and the association with clinical variables such as smoking and comorbidities. RESULTS Average psoas muscle volume was 12.21 ± 5.6 cm3 for control patients and 9.318 ± 3.3 cm3 in septic patients (P = 0.0023). The average psoas muscle/fat ratio for septic patients was 0.0288 ± 0.071 cm3, compared with 0.0107 ± 0.008 cm3 in the control group (P = 0.075). Average tendon volume in the septic population (0.508 ± 0.191 cm3) was not different than the control cohort (0.493 ± 0.182 cm3) (P = 0.692). CONCLUSIONS Our results demonstrate significantly smaller psoas muscle volume in septic patients than in age-, gender-, and BMI-matched trauma patients but no demonstrable change in tendon morphology between patient groups. These findings begin to define the boundaries of clinical application within the field of morphomics.
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Affiliation(s)
- Carrie A Kubiak
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Niki Matusko
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jon A Jacobson
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Stewart C Wang
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Pauline K Park
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Benjamin L Levi
- Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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Diaphragm Weakness in the Critically Ill: Basic Mechanisms Reveal Therapeutic Opportunities. Chest 2018; 154:1395-1403. [PMID: 30144420 DOI: 10.1016/j.chest.2018.08.1028] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 07/23/2018] [Accepted: 08/01/2018] [Indexed: 12/11/2022] Open
Abstract
The diaphragm is the primary muscle of inspiration. Its capacity to respond to the load imposed by pulmonary disease is a major determining factor both in the onset of ventilatory failure and in the ability to successfully separate patients from ventilator support. It has recently been established that a very large proportion of critically ill patients exhibit major weakness of the diaphragm, which is associated with poor clinical outcomes. The two greatest risk factors for the development of diaphragm weakness in critical illness are the use of mechanical ventilation and the presence of sepsis. Loss of force production by the diaphragm under these conditions is caused by a combination of defective contractility and reduced diaphragm muscle mass. Importantly, many of the same molecular mechanisms are implicated in the diaphragm dysfunction associated with both mechanical ventilation and sepsis. This review outlines the primary cellular mechanisms identified thus far at the nexus of diaphragm dysfunction associated with mechanical ventilation and/or sepsis, and explores the potential for treatment or prevention of diaphragm weakness in critically ill patients through therapeutic manipulation of these final common pathway targets.
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Yang T, Li Z, Jiang L, Xi X. Corticosteroid use and intensive care unit-acquired weakness: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:187. [PMID: 30075789 PMCID: PMC6091087 DOI: 10.1186/s13054-018-2111-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 06/29/2018] [Indexed: 01/15/2023]
Abstract
Background The association between corticosteroid use and intensive care unit (ICU)-acquired weakness remains unclear. We evaluated the relationship between corticosteroid use and ICU-acquired weakness in critically ill adult patients. Methods The PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and Cumulative Index of Nursing and Allied Health Literature databases were searched from database inception until October 10, 2017. Two authors independently screened the titles/abstracts and reviewed full-text articles. Randomized controlled trials and prospective cohort studies evaluating the association between corticosteroids and ICU-acquired weakness in adult ICU patients were selected. Data extraction from the included studies was accomplished by two independent reviewers. Meta-analysis was performed using Stata version 12.0. The results were analyzed using odds ratios (ORs) and 95% confidence intervals (CIs). Data were pooled using a random effects model, and heterogeneity was evaluated using the χ2 and I2 statistics. Publication bias was qualitatively analyzed with funnel plots, and quantitatively analyzed with Begg’s test and Egger’s test. Results One randomized controlled trial and 17 prospective cohort studies were included in this review. After a meta-analysis, the effect sizes of the included studies indicated a statistically significant association between corticosteroid use and ICU-acquired weakness (OR 1.84; 95% CI 1.26–2.67; I2 = 67.2%). Subgroup analyses suggested a significant association between corticosteroid use and studies limited to patients with clinical weakness (OR 2.06; 95% CI 1.27–3.33; I2 = 60.6%), patients with mechanical ventilation (OR 2.00; 95% CI 1.23–3.27; I2 = 66.0%), and a large sample size (OR 1.61; 95% CI 1.02–2.53; I2 = 74.9%), and not studies limited to patients with abnormal electrophysiology (OR 1.65; 95% CI 0.92–2.95; I2 = 70.6%) or patients with sepsis (OR 1.96; 95% CI 0.61–6.30; I2 = 80.8%); however, statistical heterogeneity was obvious. No significant publication biases were found in the review. The overall quality of the evidence was high for the randomized controlled trial and very low for the included prospective cohort studies. Conclusions The review suggested a significant association between corticosteroid use and ICU-acquired weakness. Thus, exposure to corticosteroids should be limited, or the administration time should be shortened in clinical practice to reduce the risk of ICU-acquired weakness. Electronic supplementary material The online version of this article (10.1186/s13054-018-2111-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tao Yang
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, 20A Fu Xing Men Wai Da Jie, Xicheng District, Beijing, 100038, China
| | - Zhiqiang Li
- Department of Critical Care Medicine, North China University of Science and Technology Affiliated Hospital, Tangshan, China
| | - Li Jiang
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, 20A Fu Xing Men Wai Da Jie, Xicheng District, Beijing, 100038, China
| | - Xiuming Xi
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, 20A Fu Xing Men Wai Da Jie, Xicheng District, Beijing, 100038, China.
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Marchioni A, Castaniere I, Tonelli R, Fantini R, Fontana M, Tabbì L, Viani A, Giaroni F, Ruggieri V, Cerri S, Clini E. Ultrasound-assessed diaphragmatic impairment is a predictor of outcomes in patients with acute exacerbation of chronic obstructive pulmonary disease undergoing noninvasive ventilation. Crit Care 2018; 22:109. [PMID: 29703214 PMCID: PMC5921560 DOI: 10.1186/s13054-018-2033-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 04/09/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Ultrasound (US) evaluation of diaphragmatic dysfunction (DD) has proved to be a reliable technique in critical care. In this single-center prospective study, we investigated the impact of US-assessed DD on noninvasive ventilation (NIV) failure in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and its correlation with the transdiaphragmatic pressure assessed using the invasive sniff maneuver (Pdi sniff). METHODS A population of 75 consecutive patients with AECOPD with hypercapnic acidosis admitted to our respiratory intensive care unit (RICU) were enrolled. Change in diaphragm thickness (ΔTdi) < 20% during tidal volume was the predefined cutoff for identifying DD+/- status. Correlations between ΔTdi < 20% NIV failure and other clinical outcomes were investigated. Correlation between ΔTdi and Pdi sniff values was analyzed in a subset of ten patients. RESULTS DD+ patients had a higher risk for NIV failure than DD- patients (risk ratio, 4.4; p < 0.001), and this finding was significantly associated with higher RICU, in-hospital, and 90-day mortality rates; longer mechanical ventilation duration; higher tracheostomy rate; and longer RICU stay. Huge increases in NIV failure (HR, 6.2; p < 0.0001) and 90-day mortality (HR, 4.7; p = 0.008) in DD+ patients were found by Kaplan-Meier analysis. ΔTdi highly correlated with Pdi sniff (Pearson's r = 0.81; p = 0.004). ΔTdi < 20% showed better accuracy in predicting NIV failure than baseline pH value and early change in both arterial blood pH and partial pressure of carbon dioxide following NIV start (AUCs 0.84 to DTdi < 20%, 0.51 to pH value at baseline, 0.56 to early change in arterial blood pH following NIV start, and 0.54 to early change in partical pressure of carbon dioxide following NIV start, respectively; p < 0.0001). CONCLUSIONS Early and noninvasive US assessment of DD during severe AECOPD is reliable and accurate in identifying patients at major risk for NIV failure and worse prognosis.
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Affiliation(s)
- Alessandro Marchioni
- Respiratory Diseases Unit and Centre for Rare Lung Diseases, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, University Hospital of Modena, Modena, Italy
| | - Ivana Castaniere
- Respiratory Diseases Unit and Centre for Rare Lung Diseases, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, University Hospital of Modena, Modena, Italy
| | - Roberto Tonelli
- Respiratory Diseases Unit and Centre for Rare Lung Diseases, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, University Hospital of Modena, Modena, Italy
| | - Riccardo Fantini
- Respiratory Diseases Unit and Centre for Rare Lung Diseases, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, University Hospital of Modena, Modena, Italy
| | - Matteo Fontana
- Respiratory Diseases Unit and Centre for Rare Lung Diseases, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, University Hospital of Modena, Modena, Italy
| | - Luca Tabbì
- Respiratory Diseases Unit and Centre for Rare Lung Diseases, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, University Hospital of Modena, Modena, Italy
| | - Andrea Viani
- University Hospital of Modena, School of Medicine, University of Modena Reggio Emilia, Modena, Italy
| | - Francesco Giaroni
- University Hospital of Modena, School of Medicine, University of Modena Reggio Emilia, Modena, Italy
| | - Valentina Ruggieri
- Respiratory Diseases Unit and Centre for Rare Lung Diseases, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, University Hospital of Modena, Modena, Italy
| | - Stefania Cerri
- Respiratory Diseases Unit and Centre for Rare Lung Diseases, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, University Hospital of Modena, Modena, Italy
| | - Enrico Clini
- Respiratory Diseases Unit and Centre for Rare Lung Diseases, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, University Hospital of Modena, Modena, Italy
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