Effects of early treatment with immunoglobulin on critical illness polyneuropathy following multiple organ failure and gram-negative sepsis

ICU-acquired weakness: Critical illness myopathy and polyneuropathy

Critical illness myopathy (CIM) and critical illness polyneuropathy (CIP) are significant complications in intensive care unit (ICU) patients, first identified in the late 20th century. These conditions often present as flaccid paralysis and respiratory muscle weakness, making it challenging for patients to wean off ventilatory support. The incidence of ICU-acquired weakness, which includes CIM and CIP, ranges from 25 % to 84 % among long-term ventilated patients, with higher rates observed in those with sepsis or systemic inflammatory response syndrome. CIM is characterized by muscle wasting and can be confirmed using electromyography and muscle biopsy. The pathogenesis of CIM involves the loss of thick myosin filaments, while the proposed etiology of CIP centers around increased permeability of nerve axons, leading to axonal degeneration. Risk factors for developing these conditions include prolonged ICU length of stay, sepsis, multi-system organ dysfunction, hyperglycemia, as well as exposure to steroids and neuromuscular blocking agents. Emerging diagnostic tools including muscle ultrasound, magnetic resonance imaging (MRI), and biomarkers such as interleukin-6 (IL-6) and growth differentiation factor-15 (GDF-15) show promise in early detection and differentiation of CIM and CIP. Preventative and therapeutic treatment focuses on early mobilization, minimizing sedation, optimizing nutritional support, and use of intensive insulin therapy to prevent prolonged hyperglycemia. Despite these advancements, CIM and CIP continue to pose significant challenges, emphasizing the need for ongoing research to improve patient outcomes and develop effective treatments.

Critical illness-associated weakness and related motor disorders

Weakness of limb and respiratory muscles that occurs in the course of critical illness has become an increasingly common and serious complication of adult and pediatric intensive care unit patients and a cause of prolonged ventilatory support, morbidity, and prolonged hospitalization. Two motor disorders that occur singly or together, namely critical illness polyneuropathy and critical illness myopathy, cause weakness of limb and of breathing muscles, making it difficult to be weaned from ventilatory support, commencing rehabilitation, and extending the length of stay in the intensive care unit, with higher rates of morbidity and mortality. Recovery can take weeks or months and in severe cases, and may be incomplete or absent. Recent findings suggest an improved prognosis of critical illness myopathy compared to polyneuropathy. Prevention and treatment are therefore very important. Its management requires an integrated team approach commencing with neurologic consultation, creatine kinase (CK) measurement, detailed electrodiagnostic, respiratory and neuroimaging studies, and potentially muscle biopsy to elucidate the etiopathogenesis of the weakness in the peripheral and/or central nervous system, for which there may be a variety of causes. These tenets of care are being applied to new cases and survivors of the coronavirus-2 disease pandemic of 2019. This chapter provides an update to the understanding and approach to critical illness motor disorders.

High-dose intravenous immunoglobulins as a therapeutic option in critical illness polyneuropathy accompanying SARS-CoV-2 infection: A case-based review of the literature (Review)

The still ongoing COVID-19 pandemic has exposed the medical community to a number of major challenges. A significant number of patients require admission to intensive care unit (ICU) services due to severe respiratory, thrombotic and septic complications and require long-term hospitalization. Neuromuscular weakness is a common complication in critically ill patients who are treated in ICUs and are mechanically ventilated. This complication is frequently caused by critical illness myopathy (CIM) or critical illness polyneuropathy (CIP) and leads to difficulty in weaning from the ventilator. It is thought to represent an important neurologic manifestation of the systemic inflammatory response syndrome (SIRS). COVID-19 infection is known to trigger strong immune dysregulation, with an intense cytokine storm, as a result, the frequency of CIP is expected to be higher in this setting. The mainstay in the diagnosis of this entity beside the high level of clinical awareness is the electrophysiological examination that provides evidence of axonal motor and sensory polyneuropathy. The present article presents the case of a 54-year-old woman with severe COVID 19 infection who developed neuromuscular weakness, which turned out to be secondary to CIP and was treated successfully with a high dose of human intravenous immunoglobulins. Related to this case, we reviewed the relevant literature data regarding the epidemiology, pathophysiology and clinical features of this important complication and discussed also the treatment options and prognosis.

Pathophysiology and management of critical illness polyneuropathy and myopathy

Critical illness-associated weakness (CIAW) is an umbrella term used to describe a group of neuromuscular disorders caused by severe illness. It can be subdivided into three major classifications based on the component of the neuromuscular system (i.e. peripheral nerves or skeletal muscle or both) that are affected. This includes critical illness polyneuropathy (CIP), critical illness myopathy (CIM), and an overlap syndrome, critical illness polyneuromyopathy (CIPNM). It is a common complication observed in people with critical illness requiring intensive care unit (ICU) admission. Given CIAW is found in individuals experiencing grave illness, it can be challenging to study from a practical standpoint. However, over the past 2 decades, many insights into the pathophysiology of this condition have been made. Results from studies in both humans and animal models have found that a profound systemic inflammatory response and factors related to bioenergetic failure as well as microvascular, metabolic, and electrophysiological alterations underlie the development of CIAW. Current management strategies focus on early mobilization, achieving euglycemia, and nutritional optimization. Other interventions lack sufficient evidence, mainly due to a dearth of large trials. The goal of this Physiology in Medicine article is to highlight important aspects of the pathophysiology of these enigmatic conditions. It is hoped that improved understanding of the mechanisms underlying these disorders will lead to further study and new investigations for novel pharmacologic, nutritional, and exercise-based interventions to optimize patient outcomes.

Aminoglycoside use and intensive care unit-acquired weakness: A systematic review and meta-analysis

Background

The relationship between aminoglycoside use and intensive care unit (ICU)-acquired weakness remains controversial. In the present study, we performed a systematic review and meta-analysis to examine the relationship between aminoglycoside use and ICU-acquired weakness in critically ill patients.

Methods

The PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials and Cumulative Index of Nursing and Allied Health Literature databases were searched from the earliest available date to July 10, 2019. Randomized controlled trials and prospective cohort studies examining the relationship between aminoglycosides and ICU-acquired weakness in adult ICU patients were included. Two authors independently screened titles/abstracts, reviewed full text and extracted data from the included studies. We performed the Meta-analysis using Stata version 15.0 and used the DerSimonian-Laird random effects model for data analyses. Heterogeneity was evaluated using the χ² statistic and I² statistic. Publication bias was evaluated with funnel plots qualitatively, the Begg’s test and Egger’s test quantitatively.

Results

Ten prospective cohort studies were included and analysed in this review. The overall effect sizes of the studies revealed a statistically significant relationship between aminoglycoside use and ICU-acquired weakness (OR, 2.06; 95%CI, 1.33–3.21; I² = 56%). Subgroup and sensitivity analyses suggested a significant association between aminoglycoside use and studies limited to patients with clinical weakness (OR, 2.74; 95%CI, 1.83–4.10; I² = 0%), and not to studies limited to patients with abnormal electrophysiology (OR, 1.78; 95%CI, 0.94–3.39; I² = 59%), a large sample size (OR, 1.81; 95%CI, 0.97–3.39; I² = 75%), or low risk of bias (OR, 1.59; 95%CI, 0.97–2.60; I² = 56%); however, statistical heterogeneity was obvious. There were no significant publication biases found in the review.

Conclusions

The review revealed a significant relationship between aminoglycoside use and ICU-acquired weakness.

An Unusual Case of Critical Illness Polyneuromyopathy

Critical illness myopathy (CIM), critical illness polyneuropathy (CIP), and critical illness polyneuromyopathy (CIPNM) are the group of disorders that are commonly presented as neuromuscular weakness in intensive care unit (ICU) settings. They are responsible for prolonged ICU stay and failure to wean off from mechanical ventilation. We report a case of young female who was admitted with undiagnosed type I diabetes mellitus with diabetic ketoacidosis, severe hypokalemia, sepsis developed acute onset quadriplegia, and diaphragmatic palsy within 72 hours of ICU admission. On detailed investigation, CIPNM was diagnosed. In view of high morbidity, mortality, and poor prognosis, a guided approach to diagnose and treat in earliest possible duration might give better improvement and outcome of the illness. Despite all the odds, our patient showed good clinical improvement and finally got discharged.

How to cite this article

Mahashabde M, Chaudhary G, Kanchi G, Rohatgi S, Rao P, Patil R, et al. An Unusual Case of Critical Illness Polyneuromyopathy. Indian J Crit Care Med 2020;24(2):133-135.

Muscle weakness: Understanding the principles of myopathy and neuropathy in the critically ill patient and the management options

Myo-neuropathy of the critically ill patient is a difficult nosological entity to understand and manage. It appears soon after injury, and it is estimated that 20-30% of patients admitted to Intensive Care Units will develop it in some degree. Although muscular and nervous involvement are related, the former has a better prognosis. Myo-neuropathy associates to more morbidity, longer stay in Intensive Care Unit and in hospital, and also to higher costs and mortality. It is considered part of the main determinants of the new entities: the Chronic Critical Patient and the Post Intensive Care Syndrome. This update focuses on aetiology, pathophysiology, diagnosis and strategies that can prevent, alleviate and/or improve muscle (or muscle-nerve) weakness.

[Critical illness myopathy and polyneuropathy]

An average of 50-80% of patients treated in the intensive care unit is affected by disturbances of neuromuscular functions due to damage to the nerves and muscles, which has led to the terms critical illness polyneuropathy and myopathy. Both components occur in 30-50% of patients, while the others predominantly show a pure myopathy, while pure neuropathy is rare. Meanwhile, the descriptive term of the concept as intensive care unit-acquired weakness (ICUAW) is preferred. The most significant risk factors for the development of ICUAW are sepsis, multiorgan dysfunction and acute respiratory distress syndrome (ARDS). In at least one third of patients, persistent impairment by paralysis, sensory disturbances and balance problems persist when they leave the ICU. At approximately 10%, these leg-accentuated and highly everyday relevant disorders persist over the first year after ICU therapy. Pure myopathy rarely leads to residual disturbances, while the neuropathic component is responsible for long-term impairments.

Pharmacological Therapy for the Prevention and Treatment of Weakness After Critical Illness: A Systematic Review

OBJECTIVES

ICU-acquired weakness is a common complication of critical illness and can have significant effects upon functional status and quality of life. As part of preliminary work to inform the design of a randomized trial of a complex intervention to improve recovery from critical illness, we sought to identify pharmacological interventions that may play a role in this area.

DATA SOURCES

We systematically reviewed the published literature relating to pharmacological intervention for the treatment and prevention of ICU-acquired weakness.

STUDY SELECTION

We searched MEDLINE, EMBASE, CINAHL+, Web of Science, and both U.S. and European trial registries up to July 2014 alongside reviews and reference lists from populations with no age or language restrictions. We included studies that reported a measure of muscle structure or physical function as an outcome measure.

DATA EXTRACTION

We estimated pooled odds ratios and 95% CI using data extracted from published articles or where available, original data provided by the authors. Assessment of bias was performed using the Cochrane Collaboration's risk of bias tool.

DATA SYNTHESIS

Ten studies met the inclusion criteria. The current body of evidence does not support the use of any pharmacological agent in this setting, although maintaining euglycemia may reduce the prevalence of critical illness polyneuropathy.

CONCLUSIONS

At present, no pharmacological intervention can be recommended to prevent or treat ICU-acquired weakness. Further research is required into this field to include more novel agents such as myostatin inhibitors. Challenges in the conduct of research in this area are highlighted.

Neuroprotective effects of intravenous immunoglobulin are mediated through inhibition of complement activation and apoptosis in a rat model of sepsis

Background

Intravenous (IV) immunoglobulin (Ig) treatment is known to alleviate behavioral deficits and increase survival in the experimentally induced model of sepsis. To delineate the mechanisms by which IVIg treatment prevents neuronal dysfunction, an array of immunological and apoptosis markers was investigated.

Methods

Sepsis was induced by cecal ligation perforation (CLP) in rats. The animals were divided into five groups: sham, control, CLP + saline, CLP + immunoglobulin G (IgG) (250 mg/kg, iv), and CLP + immunoglobulins enriched with immunoglobulin M (IgGAM) (250 mg/kg, iv). Blood and brain samples were taken in two sets of experiments to see the early (24 h) and late (10 days) effects of treatment. Total complement activity, complement 3 (C3), and soluble complement C5b-9 levels were measured in the sera of rats using ELISA-based methods. Cerebral complement, complement receptor, NF-κB, Bax, and Bcl-2 expressions were analyzed by western blot and/or RT-PCR methods. Immune cell infiltration and gliosis were examined by immunohistochemistry using CD3, CD4, CD8, CD11b, CD19, and glial fibrillary acidic protein antibodies. Apoptotic neuronal death was investigated by TUNEL staining.

Results

IVIgG and IgGAM administration significantly reduced systemic complement activity and cerebral C5a and C5a receptor expression. Likewise, both treatment methods reduced proapoptotic NF-κB and Bax expressions in the brain. IVIgG and IgGAM treatment induced considerable amelioration in glial cell proliferation and neuronal apoptosis which were increased in non-treated septic rats.

Conclusions

We suggest that IVIgG and IgGAM administration ameliorates neuronal dysfunction and behavioral deficits by reducing apoptotic cell death and glial cell proliferation. In both treatment methods, these beneficial effects might be mediated through reduction of anaphylatoxic C5a activity and subsequent inhibition of inflammation and apoptosis pathways.

Electronic supplementary material

The online version of this article (doi:10.1186/s40635-016-0114-1) contains supplementary material, which is available to authorized users.

Review of Critical Illness Myopathy and Neuropathy

Critical illness myopathy (CIM) and neuropathy are underdiagnosed conditions within the intensive care setting and contribute to prolonged mechanical ventilation and ventilator wean failure and ultimately lead to significant morbidity and mortality. These conditions are often further subdivided into CIM, critical illness polyneuropathy (CIP), or the combination-critical illness polyneuromyopathy (CIPNM). In this review, we discuss the epidemiology and pathophysiology of CIM, CIP, and CIPNM, along with diagnostic considerations such as detailed clinical examination, electrophysiological studies, and histopathological review of muscle biopsy specimens. We also review current available treatments and prognosis. Increased awareness and early recognition of CIM, CIP, and CIPNM in the intensive care unit setting may lead to earlier treatments and rehabilitation, improving patient outcomes.

Intravenous immunoglobulin in critically ill adults: When and what is the evidence?

Intravenous immunoglobulin (IVIg) use is growing dramatically internationally due to the increasing numbers of acute and chronic conditions that may benefit from IVIg. Patients with conditions that may benefit from IVIg might require intensive care unit (ICU) admission, supporting the need to review IVIg use in the critical care setting. The most common clinical indications for IVIg in adults that may require ICU admission and are commonly supported under clinical practice guidelines are Guillain-Barré syndrome, myasthenia gravis and Lambert-Eaton myasthenic syndrome, inflammatory myopathies, and primary or secondary immunodeficiency diseases complicated by severe bacterial sepsis. Other emerging indications include necrotizing fasciitis, toxic epidermal necrolysis/Stevens-Johnson syndrome, and toxic shock syndrome. The evidence for IVIg use in sepsis and septic shock remains controversial and insufficient to recommend its routine use. Intravenous immunoglobulin is expensive and also carries risks of adverse effects, including common and benign infusion-related reactions, as well as relatively rare and more serious problems, such as thromboembolic events, renal failure, and aseptic meningitis. In this article, we review the literature on conditions requiring ICU admission and IVIg, and we classify them as supported, emerging, or unsupported indications based on the available evidence and guidelines for clinical use of IVIg.

Intensive care unit-related generalized neuromuscular weakness due to critical illness polyneuropathy/myopathy in critically ill patients

Thirty to fifty percent of critically ill patients admitted to the intensive care unit suffer from generalized neuromuscular weakness due to critical illness polyneuropathy, critical illness myopathy, or a combination of them, thus prolonging mechanical ventilation and their intensive care unit stay. A distinction between these syndromes and other neuromuscular abnormalities beginning either before or after ICU admission is necessary. These intensive care unit-related diseases are associated with both elevated mortality rates and increased morbidity rates. Generally, over 50 % of patients will completely recover. Most of them recover after 4-12 weeks, but some patients have been reported to keep on suffering from muscle weakness for at least 4 months. Prevention has a key role in the management of critical illness neuromuscular disorders, as no specific therapy has been suggested. Either prevention or aggressive treatment of sepsis can prevent critical illness polyneuropathy and critical illness myopathy. The dose and duration of the administration of neuromuscular blocking drugs should be limited, and their concurrent administration with corticosteroids should be avoided. Intensive insulin therapy has also been proven to reduce their incidence. Finally, early mobilization via active exercise or electrical muscle stimulation plays a significant role in their prevention.

The incidence of intensive care unit-acquired weakness syndromes: A systematic review

We conducted a literature review of the intensive care unit-acquired weakness syndromes (critical illness polyneuropathy, critical illness myopathy and critical illness neuromyopathy) with the primary objective of determining their incidence as a combined group. Studies were identified through MEDLINE, Embase, Cochrane Database and article reference list searches and were included if they evaluated the incidence of one or more of these conditions in an adult intensive care unit population. The incidence of an intensive care unit-acquired weakness syndrome in the included studies was 40% (1080/2686 patients, 95% confidence interval 38-42%). The intensive care unit populations included were heterogeneous though largely included patients receiving mechanical ventilation for seven or more days. Additional prespecified outcomes identified that the incidence of intensive care unit-acquired weakness varied with the diagnostic technique used, being lower with clinical (413/1276, 32%, 95% CI 30-35%) compared to electrophysiological techniques (749/1591, 47%, 95% CI 45-50%). Approximately a quarter of patients were not able to comply with clinical evaluation and this may be responsible for potential underreporting of this condition.

Critical illness polyneuropathy and myopathy: a systematic review

Critical illness polyneuropathy and critical illness myopathy are frequent complications of severe illness that involve sensorimotor axons and skeletal muscles, respectively. Clinically, they manifest as limb and respiratory muscle weakness. Critical illness polyneuropathy/myopathy in isolation or combination increases intensive care unit morbidity via the inability or difficulty in weaning these patients off mechanical ventilation. Many patients continue to suffer from decreased exercise capacity and compromised quality of life for months to years after the acute event. Substantial progress has been made lately in the understanding of the pathophysiology of critical illness polyneuropathy and myopathy. Clinical and ancillary test results should be carefully interpreted to differentiate critical illness polyneuropathy/myopathy from similar weaknesses in this patient population. The present review is aimed at providing the latest knowledge concerning the pathophysiology of critical illness polyneuropathy/myopathy along with relevant clinical, diagnostic, differentiating, and treatment information for this debilitating neurological disease.

Neuromuscular complications of critical illness

Neuromuscular sequelae are common in the critically ill. Critical illness polyneuropathy and critical illness myopathy are neuromuscular complications of sepsis or iatrogenic complications of treatments required in intensive care. This article discusses the diagnosis, treatment, and prognosis of these disorders based on a literature review. This review found that glycemic control, early mobilization, and judicious use of steroids and neuromuscular blocking agents are the primary approaches to reduce the incidence and severity of neuromuscular complications in affected patients.

Neurologic complications of sepsis

PURPOSE OF REVIEW

This article reviews the current understanding of sepsis, a critical and often fatal illness that results from infection and multiorgan failure and impacts the brain, peripheral nervous system, and muscle.

RECENT FINDINGS

Encephalopathy occurs early in association with sepsis, and its severity correlates with mortality. Neuroimaging in patients with CNS manifestations is typically normal. EEG is nonspecific. EMG is commonly diagnostic, showing a combination of nerve and muscle injury already early in the clinical course. Rapid recognition and correction of reversible causes of encephalopathy and avoidance of risk factors for intensive care unit-acquired weakness may limit sequelae. Major deficiencies in our understanding of the complications of sepsis remain. Studies to improve the recognition and rehabilitation of these patients are imperative in a clinical syndrome affecting countless patients each year.

SUMMARY

The risk of later cognitive and physical disability may be increased after sepsis; therefore, attention to neurologic complications is urgent.

Interventions for preventing critical illness polyneuropathy and critical illness myopathy

BACKGROUND

Critical illness polyneuropathy or myopathy (CIP/CIM) is a frequent complication in the intensive care unit (ICU) and is associated with prolonged mechanical ventilation, longer ICU stay and increased mortality. This is an interim update of a review first published in 2009 (Hermans 2009). It has been updated to October 2011, with further potentially eligible studies from a December 2013 search characterised as awaiting assessment.

OBJECTIVES

To systematically review the evidence from RCTs concerning the ability of any intervention to reduce the incidence of CIP or CIM in critically ill individuals.

SEARCH METHODS

On 4 October 2011, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, and EMBASE. We checked the bibliographies of identified trials and contacted trial authors and experts in the field. We carried out an additional search of these databases on 6 December 2013 to identify recent studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs), examining the effect of any intervention on the incidence of CIP/CIM in people admitted to adult medical or surgical ICUs. The primary outcome was the incidence of CIP/CIM in ICU, based on electrophysiological or clinical examination. Secondary outcomes included duration of mechanical ventilation, duration of ICU stay, death at 30 and 180 days after ICU admission and serious adverse events from the treatment regimens.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data and assessed the risk of bias in included studies.

MAIN RESULTS

We identified five trials that met our inclusion criteria. Two trials compared intensive insulin therapy (IIT) to conventional insulin therapy (CIT). IIT significantly reduced CIP/CIM in the screened (n = 825; risk ratio (RR) 0.65, 95% confidence interval (CI) 0.55 to 0.77) and total (n = 2748; RR 0.70, 95% CI 0.60 to 0.82) population randomised. IIT reduced duration of mechanical ventilation, ICU stay and 180-day mortality, but not 30-day mortality compared with CIT. Hypoglycaemia increased with IIT but did not cause early deaths.One trial compared corticosteroids with placebo (n = 180). The trial found no effect of treatment on CIP/CIM (RR 1.27, 95% CI 0.77 to 2.08), 180-day mortality, new infections, glycaemia at day seven, or episodes of pneumonia, but did show a reduction of new shock events.In the fourth trial, early physical therapy reduced CIP/CIM in 82/104 evaluable participants in ICU (RR 0.62. 95% CI 0.39 to 0.96). Statistical significance was lost when we performed a full intention-to-treat analysis (RR 0.81, 95% CI 0.60 to 1.08). Duration of mechanical ventilation but not ICU stay was significantly shorter in the intervention group. Hospital mortality was not affected but 30- and 180-day mortality results were not available. No adverse effects were noticed.The last trial found a reduced incidence of CIP/CIM in 52 evaluable participants out of a total of 140 who were randomised to electrical muscle stimulation (EMS) versus no stimulation (RR 0.32, 95% CI 0.10 to 1.01). These data were prone to bias due to imbalances between treatment groups in this subgroup of participants. After we imputed missing data and performed an intention-to-treat analysis, there was still no significant effect (RR 0.94, 95% CI 0.78 to 1.15). The investigators found no effect on duration of mechanical ventilation and noted no difference in ICU mortality, but did not report 30- and 180-day mortality.We updated the searches in December 2013 and identified nine potentially eligible studies that will be assessed for inclusion in the next update of the review.

AUTHORS' CONCLUSIONS

There is moderate quality evidence from two large trials that intensive insulin therapy reduces CIP/CIM, and high quality evidence that it reduces duration of mechanical ventilation, ICU stay and 180-day mortality, at the expense of hypoglycaemia. Consequences and prevention of hypoglycaemia need further study. There is moderate quality evidence which suggests no effect of corticosteroids on CIP/CIM and high quality evidence that steroids do not affect secondary outcomes, except for fewer new shock episodes. Moderate quality evidence suggests a potential benefit of early rehabilitation on CIP/CIM which is accompanied by a shorter duration of mechanical ventilation but without an effect on ICU stay. Very low quality evidence suggests no effect of EMS, although data are prone to bias. Strict diagnostic criteria for CIP/CIM are urgently needed for research purposes. Large RCTs need to be conducted to further explore the role of early rehabilitation and EMS and to develop new preventive strategies.

Interventions for preventing critical illness polyneuropathy and critical illness myopathy

BACKGROUND

Critical illness polyneuropathy or myopathy (CIP/CIM) is a frequent complication in the intensive care unit (ICU) and is associated with prolonged mechanical ventilation, longer ICU stay and increased mortality. This is an interim update of a review first published in 2009 (Hermans 2009). It has been updated to October 2011, with further potentially eligible studies from a December 2013 search characterised as awaiting assessment.

OBJECTIVES

To systematically review the evidence from RCTs concerning the ability of any intervention to reduce the incidence of CIP or CIM in critically ill individuals.

SEARCH METHODS

On 4 October 2011, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, and EMBASE. We checked the bibliographies of identified trials and contacted trial authors and experts in the field. We carried out an additional search of these databases on 6 December 2013 to identify recent studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs), examining the effect of any intervention on the incidence of CIP/CIM in people admitted to adult medical or surgical ICUs. The primary outcome was the incidence of CIP/CIM in ICU, based on electrophysiological or clinical examination. Secondary outcomes included duration of mechanical ventilation, duration of ICU stay, death at 30 and 180 days after ICU admission and serious adverse events from the treatment regimens.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data and assessed the risk of bias in included studies.

MAIN RESULTS

We identified five trials that met our inclusion criteria. Two trials compared intensive insulin therapy (IIT) to conventional insulin therapy (CIT). IIT significantly reduced CIP/CIM in the screened (n = 825; risk ratio (RR) 0.65, 95% confidence interval (CI) 0.55 to 0.77) and total (n = 2748; RR 0.70, 95% CI 0.60 to 0.82) population randomised. IIT reduced duration of mechanical ventilation, ICU stay and 180-day mortality, but not 30-day mortality compared with CIT. Hypoglycaemia increased with IIT but did not cause early deaths.One trial compared corticosteroids with placebo (n = 180). The trial found no effect of treatment on CIP/CIM (RR 1.27, 95% CI 0.77 to 2.08), 180-day mortality, new infections, glycaemia at day seven, or episodes of pneumonia, but did show a reduction of new shock events.In the fourth trial, early physical therapy reduced CIP/CIM in 82/104 evaluable participants in ICU (RR 0.62. 95% CI 0.39 to 0.96). Statistical significance was lost when we performed a full intention-to-treat analysis (RR 0.81, 95% CI 0.60 to 1.08). Duration of mechanical ventilation but not ICU stay was significantly shorter in the intervention group. Hospital mortality was not affected but 30- and 180-day mortality results were not available. No adverse effects were noticed.The last trial found a reduced incidence of CIP/CIM in 52 evaluable participants out of a total of 140 who were randomised to electrical muscle stimulation (EMS) versus no stimulation (RR 0.32, 95% CI 0.10 to 1.01). These data were prone to bias due to imbalances between treatment groups in this subgroup of participants. After we imputed missing data and performed an intention-to-treat analysis, there was still no significant effect (RR 0.94, 95% CI 0.78 to 1.15). The investigators found no effect on duration of mechanical ventilation and noted no difference in ICU mortality, but did not report 30- and 180-day mortality.We updated the searches in December 2013 and identified nine potentially eligible studies that will be assessed for inclusion in the next update of the review.

AUTHORS' CONCLUSIONS

There is moderate quality evidence from two large trials that intensive insulin therapy reduces CIP/CIM, and high quality evidence that it reduces duration of mechanical ventilation, ICU stay and 180-day mortality, at the expense of hypoglycaemia. Consequences and prevention of hypoglycaemia need further study. There is moderate quality evidence which suggests no effect of corticosteroids on CIP/CIM and high quality evidence that steroids do not affect secondary outcomes, except for fewer new shock episodes. Moderate quality evidence suggests a potential benefit of early rehabilitation on CIP/CIM which is accompanied by a shorter duration of mechanical ventilation but without an effect on ICU stay. Very low quality evidence suggests no effect of EMS, although data are prone to bias. Strict diagnostic criteria for CIP/CIM are urgently needed for research purposes. Large RCTs need to be conducted to further explore the role of early rehabilitation and EMS and to develop new preventive strategies.

Early treatment with IgM-enriched intravenous immunoglobulin does not mitigate critical illness polyneuropathy and/or myopathy in patients with multiple organ failure and SIRS/sepsis: a prospective, randomized, placebo-controlled, double-blinded trial

Introduction

Critical illness polyneuropathy and/or myopathy (CIPNM) is a severe complication of critical illness. Retrospective data suggest that early application of IgM-enriched intravenous immunoglobulin (IVIG) may prevent or mitigate CIPNM. Therefore, the primary objective was to assess the effect of early IgM-enriched IVIG versus placebo to mitigate CIPNM in a prospective setting.

Methods

In this prospective, randomized, double-blinded and placebo-controlled trial, 38 critically ill patients with multiple organ failure (MOF), systemic inflammatory response syndrome (SIRS)/sepsis, and early clinical signs of CIPNM were included. Patients were randomly assigned to be treated either with IgM-enriched IVIG or placebo over a period of three days. CIPNM was measured by the CIPNM severity sum score based on electrophysiological stimulation of the median, ulnar, and tibial nerves on days 0, 4, 7, 14 and on the histological evaluation of muscle biopsies on days 0 and 14 and ranged from 0 (no CIPNM) to 8 (very severe CIPNM).

Results

A total of 38 critically ill patients were included and randomized to receive either IgM-enriched IVIG (n = 19) or placebo (n = 19). Baseline characteristics were similar between the two groups. CIPNM could not be improved by IVIG treatment, represented by similar CIPNM severity sum scores on day 14 (IVIG vs. placebo: 4.8 ± 2.0 vs. 4.5 ± 1.8; P = 0.70). CIPNM severity sum score significantly increased from baseline to day 14 (3.5 ± 1.6 vs. 4.6 ± 1.9; P = 0.002). After an interim analysis the study was terminated early due to futility in reaching the primary endpoint.

Conclusions

Early treatment with IVIG did not mitigate CIPNM in critically ill patients with MOF and SIRS/sepsis.

Trial registration

Clinicaltrials.gov: NCT01867645

Unusual presentation of Guillain-Barré syndrome following traumatic bone injuries: report of two cases

OBJECTIVE

To report two cases of Guillain-Barré syndrome (GBS) which occurred following traumatic bone injuries.

PRESENTATION AND INTERVENTION

Two patients presented with traumatic bone injuries. The first was a 47-year-old female who was admitted with fracture of both tibial bones sustained during a road traffic accident. One week after surgical fixation of the fracture, she developed areflexic weakness of all four limbs and respiratory muscle weakness. The nerve conduction study was consistent with GBS. She was administered intravenous immunoglobulins which was repeated after 2 weeks. She recovered gradually. The second patient was a 31-year-old male who was admitted with 4-days history of severe back pain which occurred when he lifted a heavy weight. He then developed ascending areflexic weakness of all four limbs and bifacial weakness. X-ray and magnetic resonance imaging of the lumbosacral spine revealed fracture of L1 and L2 vertebrae. Nerve conduction studies confirmed the diagnosis of GBS. He was given mechanical ventilatory support and was treated with intravenous immunoglobulins and later plasmapheresis. However, his condition gradually deteriorated as he developed aspiration pneumonia and sepsis with multi-organ failure and finally expired.

CONCLUSION

These cases highlight the importance of considering GBS as a differential diagnosis when patients with traumatic bone injuries develop acute neuromuscular weakness. Early diagnosis and treatment may prevent morbidity and mortality.

Critical illness polyneuropathy and myopathy: a major cause of muscle weakness and paralysis

Critical illness polyneuropathy (CIP) and myopathy (CIM) are complications of critical illness that present with muscle weakness and failure to wean from the ventilator. In addition to prolonging mechanical ventilation and hospitalisation, CIP and CIM increase hospital mortality in patients who are critically ill and cause chronic disability in survivors of critical illness. Structural changes associated with CIP and CIM include axonal nerve degeneration, muscle myosin loss, and muscle necrosis. Functional changes can cause electrical inexcitability of nerves and muscles with reversible muscle weakness. Microvascular changes and cytopathic hypoxia might disrupt energy supply and use. An acquired sodium channelopathy causing reduced muscle membrane and nerve excitability is a possible unifying mechanism underlying CIP and CIM. The diagnosis of CIP, CIM, or combined CIP and CIM relies on clinical, electrophysiological, and muscle biopsy investigations. Control of hyperglycaemia might reduce the severity of these complications of critical illness, and early rehabilitation in the intensive care unit might improve the functional recovery and independence of patients.

[Critical illness myopathy and neuropathy (CRIMYN). Electroneurographic classification]

BACKGROUND

Critical Illness Myopathy and Neuropathy (CRIMYN) frequently coexist with severe sepsis and is associated with prolonged weaning from mechanical ventilation and prolonged ICU length of stay. We aimed to classify different levels as well as patterns of impairment with regard to electrophysiological disturbances in CRIMYN patients by cluster analysis.

METHODS

A total of 30 patients with sepsis/SIRS were studied prospectively. Motor and sensory conduction studies were performed from six motor and four sensory nerves on a weekly basis from admission until discharge and finally after 6 months. A control group of 63 healthy persons was examined simultaneously using the same criteria. Different patterns of electrophysiological disturbances were classified by cluster analysis based on differences to reference values of 20 parameters, compound muscle action potential (CMAP), sensory nerve action potential (SNAP) and motor and sensor conduction velocity (NCV).

RESULTS

Four different clusters were identified: cluster 1 showing normal values for CMAP, SNAP and NCV in all nerves (3 patients and all test persons), cluster 2 showing pathological values for CMAP in the lower extremities and the other parameters were normal (5 patients), cluster 3 showing moderately pathological values for CMAP, SNAP and sensory NCV in upper and lower extremities and motor NCV in lower extremities (12 patients) and cluster 4 showing severe disturbances of CMAP, SNAP and NCV in upper and lower extremities (10 patients).

CONCLUSION

A total of four different clusters of electrophysiological impairment can be identified in patients with sepsis/SIRS, which enables further differentiation of the severity of neuromuscular disturbances in sepsis-associated organ failure. This might be useful as a prognostic parameter and can be correlated with additional clinical and paraclinical parameters related to sepsis.

Neuromuscular disorders in critically ill patients: review and update

Neuromuscular disorders that are diagnosed in the intensive care unit (ICU) usually cause substantial limb weakness and contribute to ventilatory dysfunction. Although some lead to ICU admission, ICU-acquired disorders, mainly critical illness myopathy (CIM) and critical illness polyneuropathy (CIP), are more frequent and are associated with considerable morbidity. Approximately 25% to 45% of patients admitted to the ICU develop CIM, CIP, or both. Their clinical features often overlap; therefore, nerve conduction studies and electromyography are particularly helpful diagnostically, and more sophisticated electrodiagnostic studies and histopathologic evaluation are required in some circumstances. A number of prospective studies have identified risk factors for CIP and CIM, but their limitations often include the inability to separate CIM from CIP. Animal models reveal evidence of a channelopathy in both CIM and CIP, and human studies also identified axonal degeneration in CIP and myosin loss in CIM. Outcomes are variable. They tend to be better with CIM, and some patients have longstanding disabilities. Future studies of well-characterized patients with CIP and CIM should refine our understanding of risk factors, outcomes, and pathogenic mechanisms, leading to better interventions.

Management of critical illness polyneuropathy and myopathy

A syndrome of generalized weakness, areflexia, and difficulty with weaning from a ventilator is a common clinical presentation in the critically ill patient, especially in the setting of sepsis, multiorgan failure, and hyperglycemia. At first believed to be a manifestation of nerve (critical illness neuropathy, CIN) or muscle (critical illness myopathy, CIM) dysfunction, our current conceptualization is as a spectrum (critical illness neuromuscular abnormalities, CINMA) that varies in extent and site(s) of involvement, but often a similar clinical presentation. Signs and symptoms of CINMA must be identified early to foster recovery and limit morbidity and mortality. The medical history is crucial in excluding preexisting neuromuscular conditions and electrodiagnostic testing helps to establish the diagnosis and prognostication. A stepwise approach to the management of a patient with CINMA is outlined, but avoiding potential medications, and ensuring supportive care are the primary interventions to consider. Recently intensive insulin therapy for hyperglycemia has been shown to lower the risk of CINMA and decrease the time of ventilatory support, but with a greater risk of hypoglycemia. Future therapeutic interventions will require a better understanding of disease pathogenesis, but may target proinflammatory cytokine and free-radical pathways, muscle gene expression, ion channel function, or proteolytic muscle protein mechanisms. Rehabilitation is an equally essential component in a patient's management. Although prognosis depends on the extent of the underlying muscle and nerve damage, mild persistent deficits are common and severe disability may be persistent.

Evidence for the use of intravenous immunoglobulins--a review of the literature

Intravenous immunoglobulins (IVIg) were first introduced in the middle of the twentieth century for the treatment of primary immunodeficiencies. In 1981, Paul Imbach noticed an improvement of immune-mediated thrombocytopenia, in patients receiving IVIg for immunodeficiencies. This opened a new era for the treatment of autoimmune conditions with IVIg. Since then, IVIg has become an important treatment option in a wide spectrum of diseases, including autoimmune and acute inflammatory conditions, most of them off-label (not included in the US Food and Drug Administration recommendation). A panel of immunologists and internists with experience in IVIg therapy reviewed the medical literature for published data concerning treatment with IVIg. The quality of evidence was assessed, and a summary of the available relevant literature in each disease was given. To our knowledge, this is the first all-inclusive comprehensive review, developed to assist the clinician when considering the use of IVIg in autoimmune diseases, immune deficiencies, and other conditions.

Intensive care unit-acquired weakness: risk factors and prevention

Intensive care unit-acquired weakness, the main clinical sign of critical illness neuromyopathy, is an increasingly recognized cause of prolonged mechanical ventilation and delayed return to physical self-sufficiency. Identifying risk factors and developing preventive measures are therefore important goals. Several studies on risk factors for critical illness neuromyopathy including prospective observational studies with a multivariate analysis of potential risk factors were conducted over the last decade. A large body of data is also available from two large prospective randomized trials comparing the effect of strict vs. conventional blood-glucose control on intensive care unit mortality and on secondary outcomes including the occurrence of critical illness neuromyopathy. Five central risk factors and their related potential measures to prevent intensive care unit-acquired weakness can be identified including multiple organ failure, muscle inactivity, hyperglycemia, and use of corticosteroids and neuromuscular blockers. Although strong evidence regarding the efficacy of preventive measures is still lacking, the results of available studies are promising and cast doubt on the widespread belief that the treatment of intensive care unit-acquired weakness is essentially supportive. Early identifying and treating conditions leading to multiple organ failure, especially severe sepsis and septic shock, avoiding unnecessary deep sedation and excessive blood glucose levels, promoting early mobilization, and carefully weighing the risks and benefits of corticosteroids might contribute to reduce the incidence and severity of intensive care unit-acquired weakness.

Critical illness polyneuromyopathy in a patient with disseminated cryptococcal infection

Critical illness polyneuromyopathy is frequent in patients in intensive care units. We report a case of critical illness polyneuromyopathy in a patient with disseminated cryptococcal infection in an intensive care unit.

Interventions for preventing critical illness polyneuropathy and critical illness myopathy

BACKGROUND

Critical illness polyneuro-and/or myopathy (CIP/CIM) is an important and frequent complication in the intensive care unit (ICU), causing delayed weaning from mechanical ventilation. It may increase ICU stay and mortality.

OBJECTIVES

To examine the ability of any intervention to prevent the occurrence of CIP/CIM.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Trials Register (October 2007), MEDLINE (January 1950 to April 2008), EMBASE (January 1980 to October 2007), checked bibliographies and contacted trial authors and experts in the field.

SELECTION CRITERIA

All randomised controlled trials (RCTs), examining the effect of any intervention on the incidence of CIP/CIM in adult medical or surgical ICU patients. The primary outcome measure was the incidence of CIP/CIM after at least seven days in ICU, based on electrophysiological or clinical examination.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data.

MAIN RESULTS

Three out of nine identified trials, provided data on our primary outcome measure. Two trials examined the effects of intensive insulin therapy versus conventional insulin therapy. Eight hundred and twenty-five out of 2748 patients randomised, were included in the analysis. The incidence of CIP/CIM was significantly reduced with intensive insulin therapy in the population screened for CIP/CIM (relative risk (RR) 0.65, 95% confidence interval (CI) 0.55 to 0.78) and in the total population randomised (RR 0.60, 95% CI 0.49 to 0.74). Duration of mechanical ventilation, duration of ICU stay and 180-day mortality but not 30-day mortality, were significantly reduced with intensive insulin therapy, in both the total and the screened population. Intensive insulin therapy significantly increased hypoglycaemic events and recurrent hypoglycaemia. Death within 24 hours of the hypoglycaemic event was not different between groups. The third trial examined the effects of corticosteroids versus placebo in 180 patients with prolonged acute respiratory distress syndrome. No significant effect of corticosteroids on CIP/CIM was found (RR 1.09, 95% CI 0.53 to 2.26). No effect on 180-day mortality, new serious infections and glycaemia at day seven was found. A trend towards fewer episodes of pneumonia and reduction of new events of shock was shown.

AUTHORS' CONCLUSIONS

Substantial evidence shows that intensive insulin therapy reduces the incidence of CIP/CIM, the duration of mechanical ventilation, duration of ICU stay and 180-day mortality. There was a significant associated increase in hypoglycaemia. Further research needs to identify the clinical impact of this and strategies need to be developed to reduce the risk of hypoglycaemia. Limited evidence shows no significant effect of corticosteroids on the incidence of CIP/CIM, or on any of the other secondary outcome measures, except for a significant reduction of new episodes of shock. Strict diagnostic criteria for the purpose of research should be defined. Other interventions should be investigated in randomised controlled trials.

Clinical review: Critical illness polyneuropathy and myopathy

Critical illness polyneuropathy (CIP) and myopathy (CIM) are major complications of severe critical illness and its management. CIP/CIM prolongs weaning from mechanical ventilation and physical rehabilitation since both limb and respiratory muscles can be affected. Among many risk factors implicated, sepsis, systemic inflammatory response syndrome, and multiple organ failure appear to play a crucial role in CIP/CIM. This review focuses on epidemiology, diagnostic challenges, the current understanding of pathophysiology, risk factors, important clinical consequences, and potential interventions to reduce the incidence of CIP/CIM. CIP/CIM is associated with increased hospital and intensive care unit (ICU) stays and increased mortality rates. Recently, it was shown in a single centre that intensive insulin therapy significantly reduced the electrophysiological incidence of CIP/CIM and the need for prolonged mechanical ventilation in patients in a medical or surgical ICU for at least 1 week. The electrophysiological diagnosis was limited by the fact that muscle membrane inexcitability was not detected. These results have yet to be confirmed in a larger patient population. One of the main risks of this therapy is hypoglycemia. Also, conflicting evidence concerning the neuromuscular effects of corticosteroids exists. A systematic review of the available literature on the optimal approach for preventing CIP/CIM seems warranted.

Role of endotoxin in the pathogenesis of critical illness polyneuropathy

Critical illness polyneuropathy (CIP) occurs in association with sepsis and multiple organ failure; however, little is known about the pathomechanisms of CIP and its therapy. In order to determine the parameters which interfere with development of CIP, electrophysiological investigations of peripheral nerves and biochemical measures were correlated to each other. The present study includes 20 consecutive patients in an intensive care unit developing severe sepsis or septic shock. Nerve conduction studies and electromyography were performed with occurring sepsis (day 1, 7, 14) and neurophysiological parameters were correlated with biochemical measures, especially indicators of infection and inflammation. It was found that all patients developed neurophysiological signs of axonal motor polyneuropathy. There was a significant correlation between serum concentrations of endotoxin and interleukin-2 receptors (IL2-R) and reduction of the amplitude of the compound motor action potentials. Other clinical and biochemical parameters showed no significant correlations with neurophysiological data. This finding apparently indicates that endotoxin damages nerve axons directly or indirectly, e.g. by activation of inflammatory cascades (IL2-R). Endotoxin appears to be an essential factor in the pathogenesis of CIP in sepsis, and therapeutic options neutralizing endotoxin may prevent development of CIP.

Neuromuscular dysfunction acquired in critical illness: a systematic review

OBJECTIVE

To determine the prevalence, risk factors, and outcomes of critical illness neuromuscular abnormalities (CINMA).

DESIGN

Systematic review.

DATA SOURCES AND STUDY SELECTION

MEDLINE, EMBASE, CINAHL, and the Cochrane Library were searched for reports on adult ICU patients who were evaluated for CINMA clinically and electrophysiologically. Studies were included if they contained sufficient data to quantify the association between CINMA and relevant exposures and/or outcome variables.

MEASUREMENTS AND RESULTS

CINMA was diagnosed in 655 of 1421 [46% (95% confidence interval 43-49%)] adult ICU patients enrolled in 24 studies, all with inclusion criteria of sepsis, multi-organ failure, or prolonged mechanical ventilation. Diagnostic criteria for CINMA were not uniform, and few reports unequivocally differentiated between polyneuropathy, myopathy, and mixed types of CINMA. The risk of CINMA was associated with hyperglycemia (and inversely associated with tight glycemic control), the systemic inflammatory response syndrome, sepsis, multiple organ dysfunction, renal replacement therapy, and catecholamine administration. Across studies, there was no consistent relationship between CINMA and patient age, gender, severity of illness, or use of glucocorticoids, neuromuscular blockers, aminoglycosides, or midazolam. Unadjusted mortality was not increased in the majority of patients with CINMA, but mechanical ventilation and ICU and hospital stay were prolonged.

CONCLUSIONS

The risk of CINMA is nearly 50% in ICU patients with sepsis, multi-organ failure, or protracted mechanical ventilation. The association of CINMA with frequently cited CINMA risk factors (glucocorticoids, neuromuscular blockers) and with short-term survival is uncertain. Available data indicate glycemic control as a potential strategy to decrease CINMA risk.

Neuromuscular dysfunction in critical illness: what are we dealing with?

Neuromuscular weakness is a very common and debilitating problem for survivors of critical illness. Neurophysiological abnormalities are almost ubiquitous in these patients, and often favour a diagnosis of axonal polyneuropathy, whereas muscle histology, where available, reveals a high incidence of atrophy and necrosis. The precise nature and aetiology of this complex disorder is not yet well understood.

Surgical critical care: from old boundaries to new frontiers

The surgical specialty of critical care has evolved into a field where the surgeon manages complex medical and surgical problems in critically ill patients. As a specialty, surgical critical care began when acutely ill surgical patients were placed in a designated area within a hospital to facilitate the delivery of medical care. As technology evolved to allow for development of increasingly intricate and sophisticated adjuncts to care, there has been recognition of the importance of physician availability and continuity of care as key factors in improving patient outcomes. Guidelines and protocols have been established to ensure quality improvement and are essential to licensing by state and national agencies. The modern ICU team provides continuous daily care to the patient in close communication with the primary operating physician. While the ultimate responsibility befalls the primary physician who performed the preoperative evaluation and operative procedure, the intensivist is expected to establish and enforce protocols, guidelines and patient care pathways for the critical care unit. It is difficult to imagine modern surgical ICU care without the surgical critical care specialist at the helm.

Guidelines on the use of intravenous immune globulin for neurologic conditions

Canada's per capita use of intravenous immune globulin (IVIG) grew by approximately 115% between 1998 and 2006, making Canada one of the world's highest per capita users of IVIG. It is believed that most of this growth is attributable to off-label usage. To help ensure IVIG use is in keeping with an evidence-based approach to the practice of medicine, the National Advisory Committee on Blood and Blood Products (NAC) and Canadian Blood Services convened a panel of national experts to develop an evidence-based practice guideline on the use of IVIG for neurologic conditions. The mandate of the expert panel was to review evidence regarding use of IVIG for 22 neurologic conditions and formulate recommendations on IVIG use for each. A panel of 6 clinical experts, one expert in practice guideline development and 4 representatives from the NAC met to review the evidence and reach consensus on the recommendations for the use of IVIG. The primary sources used by the panel were 2 recent evidence-based reviews. Recommendations were based on interpretation of the available evidence and, where evidence was lacking, consensus of expert clinical opinion. A draft of the practice guideline was circulated to neurologists in Canada for feedback. The results of this process were reviewed by the expert panel, and modifications to the draft guideline were made where appropriate. This practice guideline will provide the NAC with a basis for making recommendations to provincial and territorial health ministries regarding IVIG use management. Recommendations for use of IVIG were made for 14 conditions, including acute disseminated encephalomyelitis, chronic inflammatory demyelinating polyneuropathy, dermatomyositis, diabetic neuropathy, Guillain-Barré syndrome, Lambert-Eaton myasthenic syndrome, multifocal motor neuropathy, multiple sclerosis, myasthenia gravis, opsoclonus-myoclonus, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, polymyositis, Rasmussen's encephalitis, and stiff person syndrome; IVIG was not recommended for 8 conditions including adrenoleukodystrophy, amyotropic lateral sclerosis, autism, critical illness polyneuropathy, inclusion body, myositis, intractable childhood epilepsy, paraproteinemic neuropathy (IgM variant), and POEMS syndrome. Development and dissemination of evidence-based clinical practice guidelines may help to facilitate appropriate use of IVIG.

Critical Illness Polyneuropathy in an Obstetric Patient: A case report and review

Recently it has been found that many critically ill patients develop secondary neuromuscular disorders following admission to intensive care units (ICU). One of these is critical illness polyneuropathy (CIP), a widespread symmetrical disorder affecting the peripheral nervous system and often associated with sepsis and multi-organ dysfunction. Two percent of all intensive care patients and as many as 80% of septic patients develop critical illness polyneuropathy which leads to a considerably increased risk of in-hospital mortality. The exact etiology of the condition is not known but various risk factors, differential diagnosis, treatment, management and prognosis are discussed in this report of ci woman who, following caesarian section, developed CIP, septic shock, multi-organ failure and subsequently died.

Critical illness neuromuscular syndromes

Critical illness neuromyopathy (CINM) is the most common peripheral neuromuscular disorder encountered in the ICU. Bilateral diffuse weakness predominant in the proximal part of the limbs after improvement of the acute phase of the critical illness is highly suggestive of CINM. Although muscle and peripheral nerve are often involved in combination, muscle involvement alone is increasingly identified on electrophysiologic investigation, including direct muscle stimulation. Respiratory weakness results in delayed weaning and prolonged mechanical ventilation. Besides muscle immobilization and prolonged sepsis-induced multiorgan failure, which are risk factors for CINM, hyperglycemia and use of corticosteroids might have a deleterious effect on the neuromuscular system in critically ill patients.

Diagnosis and management of critical illness polyneuropathy and critical illness myopathy

Newly acquired neuromuscular weakness commonly develops in the setting of critical illness. This weakness delays recovery and often causes prolonged ventilator dependence. An axonal sensory-motor polyneuropathy, critical illness polyneuropathy (CIP), is seen in up to a third of critically ill patients with the systemic inflammatory response syndrome (usually due to sepsis). As frequently, or more so, an acute myopathy, critical illness myopathy (CIM), develops in a similar setting, often in association with the use of corticosteroids and/or nondepolarizing neuromuscular-blocking agents. This paper reviews the clinical features, diagnostic approach, and treatment of CIP and CIM. There are no specific pharmacologic treatments for CIP or CIM, but recognizing the presence of one of these disorders often improves management. Prevention of CIP and CIM is feasible in part by avoiding risk factors and by aggressive medical management of critically ill patients. Intensive insulin therapy in intensive care unit patients appears to reduce the likelihood of developing CIP and/or CIM. Future treatments of sepsis may further reduce the incidence of these neuromuscular consequences of critical illness.

Critical Illness Neuromuscular Syndromes

Critical illness neuromyopathy (CINM) is the most common peripheral neuromuscular disorder encountered in the ICU. Bilateral diffuse weakness predominant in the proximal part of the limbs after improvement of the acute phase of the critical illness is highly suggestive of CINM. Although muscle and peripheral nerve often are involved in combination, muscle involvement alone increasingly is identified on electrophysiological investigation, including direct muscle stimulation. Respiratory muscles also are involved, and CINM may cause delayed weaning and prolonged MV. Besides muscle immobilization and prolonged sepsis-induced multiple organ failure, which are both strong contributors to CINM, hyperglycemia and use of corticosteroids also might have a deleterious effect on the neuromuscular system in critically ill patients.