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critical illness weakness; critical illness neuromyopathy

Critically ill patients with multiorgan system failure may develop severe muscle weakness associated with respiratory failure. Classification: distinct syndromes 1) critical illness polyneuropathy 2) critical illness myopathy a) focal myosin-deficient myopathy b) diffuse myosin-deficit myopathy 3) vencuronium-induced prolonged neuromuscular blockade Etiology: 1) prolonged (> 7 day) stay in ICU 2) administration of pharmaceutical agents may contribute a) glucocorticoids b) aminoglycosides c) neuromuscular blocking agents 3) other factors a) sepsis b) malnutrition c) muscle catabolism d) disuse e) hyperglycemia f) systemic inflammatory response syndrome g) multiple organ dysfunction Clinical manifestations: - if critical illness is prolonged, weakness may progress out of proportion to deconditioning expected from immobility - inability to extubate - flaccid predominantly proximal muscle weakness - areflexia may be present - not associated with cognitive impairment Laboratory: - serum creatine kinase elevated - plasma glucose may be elevated Special laboratory: - Medical Research Council muscle scale 1st step in evalutating critical illness weakness [1] (rarely used [1]) - electromyoagraphy (EMG) - absent or dimininished sensory responses - low-amplitude motor units Complications: - inability to wean patient from mechanical ventilation - prolonged post-hospital muscle weakness Management: 1) respiratory support 2) appropriate glycemic control; wean off glucocorticoids [1] 3) early moblization & therapy - physical therapy & occupational therapy 4) prognosis a) vencuronium-induced neuromuscular blockade improves rapidly when agent is stopped b) recovery from other syndromes may take weeks to months or may persist indefinitely

Related

critical illness neuropsychiatric impairment (post-ICU neuropsychiatric impairment) ICU-acquired weakness

Specific

critical illness myopathy critical illness polyneuropathy

General

critical illness syndrome neuromuscular disease; myoneural disease

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018, 2021 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Griffiths RD, Hall JB. Intensive care unit-acquired weakness. Crit Care Med. 2010 Mar;38(3):779-87. PMID: 20048676
  3. Wieske L, Harmsen RE, Schultz MJ, Horn J. Is critical illness neuromyopathy and duration of mechanical ventilation decreased by strict glucose control? Neurocrit Care. 2011 Jun;14(3):475-81 PMID: 21267673
  4. Kress JP, Hall JB. ICU-acquired weakness and recovery from critical illness. N Engl J Med. 2014 Jul 17;371(3):287-8 PMID: 25014703