ICU acquired weaknes..
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October 26, 2022 Stanford University Medical Center ICU-acquired Weakness Ronald Jou
Transcript of ICU acquired weaknes..
April 12, 2023Stanford University Medical Center
ICU-acquired Weakness
Ronald Jou
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ICU-acquired Weakness
• Examples• Case study• Incidence rate• Risk factors• Current understanding• Practical implications
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Ms. KK
• 59F c Ao stenosis, sm bowel AVMs• PMH: DM, HTN, dyslipidemia, CAD
• Laparoscopic LOA• Double-balloon enteroscopy
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Ms. KK
• POD #2: abd pain and distension• EX LAP: two enterotomies
• ICU admission• Severe sepsis• Adrenal insufficiency
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Ms. KK
• Sepsis resolved• Prolonged mechanical ventilation
• ICU #14• Sedation discontinued• Patient unable to move arms or legs
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Early Observations
• MacFarlane, et al. Severe myopathy after status asthmaticus. Lancet. 1977.
• Zochodne, et al. Critical illness polyneuropathy. Brain. 1987.
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Differential Diagnosis
• Spinal cord injury• Amyotrophic lateral sclerosis• West Nile virus• Chronic myelopathy• Myasthenia gravis• Rhabdomyolysis• Hypo K+/phos
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ICU-acquired Weakness
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Clinical Syndrome
• Acquired during critical illness• Tetraparesis• Impaired DTRs• Ventilator dependence
• Abnormal electrophysiologic studies• Abnormal histologic examination
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Studies
• Population• Observational• Risk factors• Natural history
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Incidence Rate
• ~2% of mechanically ventilated patients• ~10% of mechanical ventilation 7 days• ~60-85% of patients with severe sepsis
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Risk Factors?
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Pathogenesis?
Axonopathy
UMN lesion
Neuropathy
NMJ
Myopathy
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ICU-acquired Weakness
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Practical Implications
• Common• May not be avoidable• Prolongs critical illness
• Clinical suspicion• Treatment?• Prognosis?
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Ms. KK Revisited
• Severe sepsis• NMBA• Steroids
• Strength improved to 2/5• Extubated ICU #18• Transferred to ward ICU #22
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References
• De Jonghe B, Cook D, Sharshar T, Lefaucheur JP, Carlet J, Outin H. Acquired neuromuscular disorders in critically ill patients: a systematic review. Groupe de Reflexion et d'Etude sur les Neuromyopathies En Reanimation. Intensive Care Med 1998;24(12):1242-50.
• De Jonghe B, Sharshar T, Lefaucheur JP, et al. Paresis acquired in the intensive care unit: a prospective multicenter study. Jama 2002;288(22):2859-67.
• de Letter MA, Schmitz PI, Visser LH, et al. Risk factors for the development of polyneuropathy and myopathy in critically ill patients. Crit Care Med 2001;29(12):2281-6.
• De Letter MA, van Doorn PA, Savelkoul HF, et al. Critical illness polyneuropathy and myopathy (CIPNM): evidence for local immune activation by cytokine-expression in the muscle tissue. J Neuroimmunol 2000;106(1-2):206-13.
• Deem S. Intensive-care-unit-acquired muscle weakness. Respir Care 2006;51(9):1042-52; discussion 52-3.
• Garnacho-Montero J, Amaya-Villar R, Garcia-Garmendia JL, Madrazo-Osuna J, Ortiz-Leyba C. Effect of critical illness polyneuropathy on the withdrawal from mechanical ventilation and the length of stay in septic patients. Crit Care Med 2005;33(2):349-54.
• Garnacho-Montero J, Madrazo-Osuna J, Garcia-Garmendia JL, et al. Critical illness polyneuropathy: risk factors and clinical consequences. A cohort study in septic patients. Intensive Care Med 2001;27(8):1288-96.
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