ICU acquired weakness Ron Jou

ICU-acquired Weakness: 

ICU-acquired Weakness Ronald Jou

ICU-acquired Weakness: 

ICU-acquired Weakness Examples Case study Incidence rate Risk factors Current understanding Practical implications

Ms. KK: 

Ms. KK 59F c Ao stenosis, sm bowel AVMs PMH: DM, HTN, dyslipidemia, CAD Laparoscopic LOA Double-balloon enteroscopy

Ms. KK: 

Ms. KK POD #2: abd pain and distension EX LAP: two enterotomies ICU admission Severe sepsis Adrenal insufficiency

Ms. KK: 

Ms. KK Sepsis resolved Prolonged mechanical ventilation ICU #14 Sedation discontinued Patient unable to move arms or legs

Early Observations: 

Early Observations MacFarlane, et al. Severe myopathy after status asthmaticus. Lancet. 1977. Zochodne, et al. Critical illness polyneuropathy. Brain. 1987.

Differential Diagnosis: 

Differential Diagnosis Spinal cord injury Amyotrophic lateral sclerosis West Nile virus Chronic myelopathy Myasthenia gravis Rhabdomyolysis Hypo K+/phos

ICU-acquired Weakness: 

ICU-acquired Weakness

Clinical Syndrome: 

Clinical Syndrome Acquired during critical illness Tetraparesis Impaired DTRs Ventilator dependence Abnormal electrophysiologic studies Abnormal histologic examination

Studies: 

Studies Population Observational Risk factors Natural history

Incidence Rate: 

Incidence Rate ~2% of mechanically ventilated patients ~10% of mechanical ventilation  7 days ~60-85% of patients with severe sepsis

Risk Factors?: 

Risk Factors?

Pathogenesis?: 

Pathogenesis? Axonopathy UMN lesion Neuropathy NMJ Myopathy

ICU-acquired Weakness: 

ICU-acquired Weakness

Practical Implications: 

Practical Implications Common May not be avoidable Prolongs critical illness Clinical suspicion Treatment? Prognosis?

Ms. KK Revisited: 

Ms. KK Revisited Severe sepsis NMBA Steroids Strength improved to 2/5 Extubated ICU #18 Transferred to ward ICU #22

References: 

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.