SICU Research Meeting

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SICU Research Meeting

• Critical Illness Myopathy and Neuropathy
• Present by Ri ???

2006/3/13
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Case

• 78 y/o man, a case of asthma, HTN, CVA, gout
• Left incarcerated hernia s/p herniorrhaphy and
  segmental resection of jejunum, 20 cm, on
  2005/12/20
• Intubated and admitted to ICU due to septic shock
• Primary adrenal insufficiency s/p steroid
  supplement

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• Dormicum was DC on 12/27
• Consciousness not improved after 24 hrs
• NE gag reflex (), doll eye sign (-)
• Brain CT (12/29) multiple insults, old
• 1/3 E4M1VT
• 1/5 E2M3-4VT, Muscle flaccid
• 1/9 Muscle power remain weakness, unable to move
  limbs

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• Neurologist consultation (1/10)
• Cons drowsy but easily arousable
• MP upper limb 2-3 Lower limb 2
• DTR bilateral
• Muscle tone? and atrophy
• Symmetric response to pain stimuli on both
  side
• Impression Critical illness myopathy and
  neuropathy
• Suggestion supportive care, inform family of
  delayed recovery of muscle strength

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• 1/22 Extubation, inform family high risk of
  re-on endo
• 1/31 Poor gag reflex and cough reflex, family
  refused tracheostomy
• 2/11 CXR RML, RLL infiltration?
• 2/22 Reintubation and tracheostomy

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• His condition became chronic stable
• 3/7 Transferred to nursing home with E4M5-6VT

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Neuromuscular Sequelae of Critical Illness

• Current Opinion in Critical Care
• 2005 11381-390

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Definition

• Critical illness polyneuropathy (CIP)
• Acute axonal sensory-motor polyneuropathy
• Lower limb of critically ill patients
• Gold diagnostic standard Electroneurography

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Fig. Major electroneurographic features in axonal
and demyelinating neuropathy
Critical illness myopathy and neuropathy Current
Opinion in Critical Care 2005 11126-132
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• Critical illness myopathy (CIM)
• Acute primary myopathy
• Spectrum from pure functional impairment with
  normal histology to muscle atrophy and necrosis
• Diagnosis Electrophysiological investigation or
  muscle biopsy

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Short-term Outcome

• Approach to the comatose patient
• Acute neuromuscular respiratory failure

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Approach to the comatose patient

• GCS motor reflex
• Disappearance of motor reflexes ?Extensive CNS
  damage ?Inappropriate pessimistic prognoses
• Predicted outcome alters treatment

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Acute neuromuscular respiratory failure

• Difficult weaning from ventilator
• Duration of weaning from mechanical ventilation
  is 2-7 times greater in patients with CIP
• De Jonghe et al. 6 days vs 3 days
• Garnacho-Montero et al. 15 days vs 2 days

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Long-term Outcome

• 263 patients, mean duration of follow-up 3-6
  months (2 days to 8 years)
• Profound muscle weakness
• Improvement upper limbs and proximal lower limbs
  ?respiratory system ?distal lower limbs
• CIP is a lesion of terminal motor axons

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• Complete functional recovery 68.4 (180/263)
• Regaining the ability to breathe spontaneously
  and to walk independently
• Severe disability 28.1 (74/263)
• Tetraparesis, tetraplegia, or paraplegia

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• Persisting milder disabilities
• Reduced or absent DTR
• Stocking and glove sensory loss
• Muscle atrophy
• Painful hyperesthesia
• Foot drop

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Prevention and Treatment

• Damage muscle
• Several electrolyte abnormalities
• Hypokalemia
• Hyperkalemia
• Hypophosphatemia

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• Damage muscle
• Propofol propofol infusion syndrome (when gt5
  mg/kg/h for gt48 hrs)
• Severe metabolic acidosis
• Rhabdomyolysis
• Renal failure
• Fatal cardiac failure
• Catecholamines
• Chronic corticosteroid use

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• No specific treatments exist for CIP and CIM

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Conclusion

• Only limited evidence is available suggesting
  that CIP increases ICU and hospital mortality in
  critically ill patients.
• Data are insufficient to demonstrate any
  association with long-term mortality.

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Thanks for Your Attention!!