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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Cabañes-Martínez L, Villadóniga M, González-Rodríguez L, Araque L, Díaz-Cid A, Ruz-Caracuel I, Pian H, Sánchez-Alonso S, Fanjul S, Del Álamo M, Regidor I. Neuromuscular involvement in COVID-19 critically ill patients. Clin Neurophysiol 2020; 131:2809-2816. [PMID: 33137571 PMCID: PMC7558229 DOI: 10.1016/j.clinph.2020.09.017] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Coronavirus disease 2019 (COVID-19) has a high incidence of intensive care admittance due to the severe acute respiratory syndrome (SARS). Intensive care unit (ICU)-acquired weakness (ICUAW) is a common complication of ICU patients consisting of symmetric and generalised weakness. The aim of this study was to determine the presence of myopathy, neuropathy or both in ICU patients affected by COVID-19 and whether ICUAW associated with COVID-19 differs from other aetiologies. METHODS Twelve SARS CoV-2 positive patients referred with the suspicion of critical illness myopathy (CIM) or polyneuropathy (CIP) were included between March and May 2020. Nerve conduction and concentric needle electromyography were performed in all patients while admitted to the hospital. Muscle biopsies were obtained in three patients. RESULTS Four patients presented signs of a sensory-motor axonal polyneuropathy and seven patients showed signs of myopathy. One muscle biopsy showed scattered necrotic and regenerative fibres without inflammatory signs. The other two biopsies showed non-specific myopathic findings. CONCLUSIONS We have not found any distinctive features in the studies of the ICU patients affected by SARS-CoV-2 infection. SIGNIFICANCE Further studies are needed to determine whether COVID-19-related CIM/CIP has different features from other aetiologies. Neurophysiological studies are essential in the diagnosis of these patients.
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Affiliation(s)
- Lidia Cabañes-Martínez
- Clinical Neurophysiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - Marta Villadóniga
- Clinical Neurophysiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Lesly Araque
- Clinical Neurophysiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Alba Díaz-Cid
- Clinical Neurophysiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Ignacio Ruz-Caracuel
- Pathology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Research Group in Muscle Regeneration, University of Cordoba, Córdoba, Spain
| | - Héctor Pian
- Pathology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Samira Fanjul
- Neurology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Marta Del Álamo
- Neurosurgery Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Ignacio Regidor
- Clinical Neurophysiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Abstract
Intensive care unit-acquired weakness (ICUAW) is a substantial contributor to long-term disability in survivors of critical illness. Critical illness polyneuropathy, critical illness myopathy, and muscle atrophy from disuse contribute in various proportions to ICUAW. ICUAW is a clinical diagnosis supported by electrophysiology and newer diagnostic tests, such as muscle ultrasound. Risk factor reduction, including the aggressive treatment of sepsis and early mobilization, improves outcome. Although some patients with ICUAW experience a full recovery, for others improvement is slow and incomplete and quality of life is adversely affected. This article examines aspects of ICUAW and identifies potential areas of further study.
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Affiliation(s)
- Christopher L Kramer
- Department of Neurology, University of Chicago, 5841 South Maryland Avenue, MC 2050, Chicago, IL 60637, USA.
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Witteveen E, Sommers J, Wieske L, Doorduin J, van Alfen N, Schultz MJ, van Schaik IN, Horn J, Verhamme C. Diagnostic accuracy of quantitative neuromuscular ultrasound for the diagnosis of intensive care unit-acquired weakness: a cross-sectional observational study. Ann Intensive Care 2017; 7:40. [PMID: 28382599 PMCID: PMC5382120 DOI: 10.1186/s13613-017-0263-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 03/27/2017] [Indexed: 02/07/2023] Open
Abstract
Background Neuromuscular ultrasound is a noninvasive investigation, which can be easily performed at the bedside on the ICU. A reduction in muscle thickness and increase in echo intensity over time have been described in ICU patients, but the relation to ICU-acquired weakness (ICU-AW) is unknown. We hypothesized that quantitative assessment of muscle and nerve parameters with ultrasound can differentiate between patients with and without ICU-AW. The aim of this cross-sectional study was to investigate the diagnostic accuracy of neuromuscular ultrasound for diagnosing ICU-AW. Methods Newly admitted ICU patients, mechanically ventilated for at least 48 h, were included. As soon as patients were awake and attentive, an ultrasound was made of four muscles and two nerves (index test) and ICU-AW was evaluated using muscle strength testing (reference standard; ICU-AW defined as mean Medical Research Council score <4). Diagnostic accuracy of muscle thickness, echo intensity and homogeneity (echo intensity standard deviation) as well as nerve cross-sectional area, thickness and vascularization were evaluated with the area under the curve of the receiver operating characteristic curve (ROC–AUC). We also evaluated diagnostic accuracy of z-scores of muscle thickness, echo intensity and echo intensity standard deviation. Results Seventy-one patients were evaluated of whom 41 had ICU-AW. Ultrasound was done at a median of 7 days after admission in patients without ICU-AW and 9 days in patients with ICU-AW. Diagnostic accuracy of all muscle and nerve parameters was low. ROC–AUC ranged from 51.3 to 68.0% for muscle parameters and from 51.0 to 66.7% for nerve parameters. Conclusion Neuromuscular ultrasound does not discriminate between patients with and without ICU-AW at the time the patient awakens and is therefore not able to reliably diagnose ICU-AW in ICU patients relatively early in the disease course. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0263-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Esther Witteveen
- Department of Intensive Care Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Laboratory of Experimental Anesthesiology and Intensive Care (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands. .,Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands.
| | - Juultje Sommers
- Department of Rehabilitative Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Luuk Wieske
- Department of Intensive Care Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Laboratory of Experimental Anesthesiology and Intensive Care (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands.,Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jonne Doorduin
- Department of Neurology and Clinical Neurophysiology, Donders Center for Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nens van Alfen
- Department of Neurology and Clinical Neurophysiology, Donders Center for Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Laboratory of Experimental Anesthesiology and Intensive Care (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, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Laboratory of Experimental Anesthesiology and Intensive Care (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
| | - Camiel Verhamme
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
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