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ICU acquired weaknes..

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ICU acquired weaknes..

  1. 1. ICU-acquired Weakness Ronald Jou
  2. 2. ICU-acquired Weakness <ul><li>Examples </li></ul><ul><li>Case study </li></ul><ul><li>Incidence rate </li></ul><ul><li>Risk factors </li></ul><ul><li>Current understanding </li></ul><ul><li>Practical implications </li></ul>
  3. 8. Ms. KK <ul><li>59F c Ao stenosis, sm bowel AVMs </li></ul><ul><li>PMH: DM, HTN, dyslipidemia, CAD </li></ul><ul><li>Laparoscopic LOA </li></ul><ul><li>Double-balloon enteroscopy </li></ul>
  4. 9. Ms. KK <ul><li>POD #2: abd pain and distension </li></ul><ul><li>EX LAP: two enterotomies </li></ul><ul><li>ICU admission </li></ul><ul><li>Severe sepsis </li></ul><ul><li>Adrenal insufficiency </li></ul>
  5. 10. Ms. KK <ul><li>Sepsis resolved </li></ul><ul><li>Prolonged mechanical ventilation </li></ul><ul><li>ICU #14 </li></ul><ul><li>Sedation discontinued </li></ul><ul><li>Patient unable to move arms or legs </li></ul>
  6. 11. Early Observations <ul><li>MacFarlane, et al . Severe myopathy after status asthmaticus. Lancet. 1977. </li></ul><ul><li>Zochodne, et al. Critical illness polyneuropathy. Brain. 1987. </li></ul>
  7. 12. Differential Diagnosis <ul><li>Spinal cord injury </li></ul><ul><li>Amyotrophic lateral sclerosis </li></ul><ul><li>West Nile virus </li></ul><ul><li>Chronic myelopathy </li></ul><ul><li>Myasthenia gravis </li></ul><ul><li>Rhabdomyolysis </li></ul><ul><li>Hypo K+/phos </li></ul>
  8. 13. ICU-acquired Weakness
  9. 14. Clinical Syndrome <ul><li>Acquired during critical illness </li></ul><ul><li>Tetraparesis </li></ul><ul><li>Impaired DTRs </li></ul><ul><li>Ventilator dependence </li></ul><ul><li>Abnormal electrophysiologic studies </li></ul><ul><li>Abnormal histologic examination </li></ul>
  10. 15. Studies <ul><li>Population </li></ul><ul><li>Observational </li></ul><ul><li>Risk factors </li></ul><ul><li>Natural history </li></ul>
  11. 16. Incidence Rate <ul><li>~2% of mechanically ventilated patients </li></ul><ul><li>~10% of mechanical ventilation  7 days </li></ul><ul><li>~60-85% of patients with severe sepsis </li></ul>
  12. 17. Risk Factors?
  13. 18. Pathogenesis? Axonopathy UMN lesion Neuropathy NMJ Myopathy
  14. 19. ICU-acquired Weakness
  15. 20. Practical Implications <ul><li>Common </li></ul><ul><li>May not be avoidable </li></ul><ul><li>Prolongs critical illness </li></ul><ul><li>Clinical suspicion </li></ul><ul><li>Treatment? </li></ul><ul><li>Prognosis? </li></ul>
  16. 21. Ms. KK Revisited <ul><li>Severe sepsis </li></ul><ul><li>NMBA </li></ul><ul><li>Steroids </li></ul><ul><li>Strength improved to 2/5 </li></ul><ul><li>Extubated ICU #18 </li></ul><ul><li>Transferred to ward ICU #22 </li></ul>
  17. 22. References <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>Deem S. Intensive-care-unit-acquired muscle weakness. Respir Care 2006;51(9):1042-52; discussion 52-3. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>

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