scholarly journals Acquired neuromuscular weakness In Intensive Care Unit: Review article

2019 ◽  
Vol 6 (12) ◽  
pp. 4664-4671
Author(s):  
Mohamed Hamdy Elghotmy ◽  
Hamdy Elewa ◽  
Mohamed Rabea
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Critical Illness ◽  
Muscle Strength ◽  
Burn Injury ◽  
De Novo ◽  
Axonal Neuropathy ◽  
Early Mobilization ◽  
Future Research ◽  
Number Of Patients

A substantial number of patients admitted to the ICU because of an acute illness, complicated surgery, severe trauma, or burn injury will develop a de novo form of muscle weakness during the ICU stay that is referred to as “intensive care unit acquired weakness” (ICUAW). This ICUAW evoked by critical illness can be due to axonal neuropathy, primary myopathy, or both. Underlying pathophysiological mechanisms comprise microvascular, electrical, metabolic, and bioenergetic alterations, interacting in a complex way and culminating in loss of muscle strength and/or muscle atrophy. ICUAW is typically symmetrical and affects predominantly proximal limb muscles and respiratory muscles, whereas facial and ocular muscles are often spared. ICUAW is diagnosed in awake and cooperative patients by bedside manual testing of muscle strength and the severity is scored by the Medical Research Council sum score. In cases of atypical clinical presentation or evolution, additional electrophysiological testing may be required for differential diagnosis. The cornerstones of prevention are aggressive treatment of sepsis, early mobilization, preventing hyperglycemia with insulin, and avoiding the use parenteral nutrition during the first week of critical illness. Future research should focus on new preventive and/or therapeutic strategies for this detrimental complication of critical illness and on clarifying how ICUAW contributes to poor longer-term prognosis.

scholarly journals Association between early mobilization or rehabilitation and intensive care unit acquired weakness: A systematic review and meta-analysis of randomized controlled trials.

2020 ◽  
Author(s):  
Minghang Li ◽  
Mingyue Ding ◽  
Huanzhang Shao ◽  
Bingyu Qin ◽  
Xingwei Wang ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Meta Analysis ◽  
Early Mobilization ◽  
Standard Of Care ◽  
Cochrane Library ◽  
Care Group ◽  
China National Knowledge Infrastructure ◽  
Number Of Patients ◽  
Icu Discharge

Abstract Background The prognosis of intensive care unit acquired weakness (ICUAW) is poor and the treatment effect is not ideal. At present, some effective and safe early prevention means are urgently needed to reduce its incidence.This study evaluated the effectiveness and safety of early activities or rehabilitation in the prevention of ICUAW. Methods We searched for articles in five electronic databases, including PubMed, EMBASE, the Cochrane Library, the China National Knowledge Infrastructure (CNKI) and Wanfang Med Online. All publications until June, 2020 were searched. We have selected trials investigating early mobilization or rehabilitation as compared to standard of care in critically ill adults.The extracted data included adverse events, the number of patients with ICUAW, the length of stay in the ICU (ICU-LOS) the length of mechanical ventilation (MV) etc. Results The final results showed that compared with the usual care group, early mobilization or rehabilitation reduced the prevalence of ICUAW (RR, 0.73; [0.61, 0.87]; I2 = 44%; P = 0.0006), ICU-LOS (MD, − 1.47;[2.83, 0.10]; I2 = 56%; P = 0.04), length of MV (MD, − 1.96; [2.41, 1.51]; I2 = 0%; P = 0.00001), but the mortality (RR, 0.90; [0.62, 1.32]; I2 = 3%; P = 0.60) at ICU discharge was not associated. The subgroup analysis of ICUAW prevalence and ICU-LOS based on the intervention methods showed that early combined rehabilitation could reduce the prevalence of ICUAW (RR, 0.56; [0.43, 0.74]; I2 = 34%; P = 0.0001) and shorten the ICU-LOS (MD, − 2.21; [3.28, 0.97]; I2 = 23%; P = 0.0003). EGDM was not associated with a decrease in ICUAW prevalence (RR, 0.85; [0.65, 1.09]; I2 = 26%; P = 0.20), but it reduced the ICU-LOS (MD, − 2.27; [3.86, 0.68]; I2 = 0%; P = 0.005).Early in-bed cycling was not associated with reduced ICUAW prevalence(RR, 1.25; [0.73, 2.13]; I2 = 0%; P = 0.41) and ICU-LOS(MD, 2.27; [0.27, 4.80]; I2 = 0%; P = 0.08) . Conclusions Early mobilization or rehabilitation was associated with a shorter length of MV and ICU-LOS, but not mortality. Of course, not all early activities or forms of rehabilitation are effective. The early combined rehabilitation model is effective for the prevention of ICUAW. However, EGDM and early in-bed cycling were not effective in preventing ICUAW.

scholarly journals Neuromuscular Electrical Stimulation for Intensive Care Unit–Acquired Weakness: Protocol and Methodological Implications for a Randomized, Sham-Controlled, Phase II Trial

2012 ◽  
Vol 92 (12) ◽  
pp. 1564-1579 ◽  
Author(s):  
Michelle E. Kho ◽  
Alexander D. Truong ◽  
Roy G. Brower ◽  
Jeffrey B. Palmer ◽  
Eddy Fan ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Electrical Stimulation ◽  
Critical Illness ◽  
Pilot Study ◽  
Muscle Strength ◽  
Phase Ii ◽  
Neuromuscular Electrical Stimulation ◽  
Bed Rest

BackgroundAs the population ages and critical care advances, a growing number of survivors of critical illness will be at risk for intensive care unit (ICU)–acquired weakness. Bed rest, which is common in the ICU, causes adverse effects, including muscle weakness. Consequently, patients need ICU-based interventions focused on the muscular system. Although emerging evidence supports the benefits of early rehabilitation during mechanical ventilation, additional therapies may be beneficial. Neuromuscular electrical stimulation (NMES), which can provide some muscular activity even very early during critical illness, is a promising modality for patients in the ICU.ObjectiveThe objectives of this article are to discuss the implications of bed rest for patients with critical illness, summarize recent studies of early rehabilitation and NMES in the ICU, and describe a protocol for a randomized, phase II pilot study of NMES in patients receiving mechanical ventilation.DesignThe study was a randomized, sham-controlled, concealed, phase II pilot study with caregivers and outcome assessors blinded to the treatment allocation.SettingThe study setting will be a medical ICU.ParticipantsThe study participants will be patients who are receiving mechanical ventilation for 1 day or more, who are expected to stay in the ICU for an additional 2 days or more, and who meet no exclusion criteria.InterventionThe intervention will be NMES (versus a sham [control] intervention) applied to the quadriceps, tibialis anterior, and gastrocnemius muscles for 60 minutes per day.MeasurementsLower-extremity muscle strength at hospital discharge will be the primary outcome measure.LimitationsMuscle strength is a surrogate measure, not a patient-centered outcome. The assessments will not include laboratory, genetic, or histological measures aimed at a mechanistic understanding of NMES. The optimal duration or dose of NMES is unclear.ConclusionsIf NMES is beneficial, the results of the study will help advance research aimed at reducing the burden of muscular weakness and physical disability in survivors of critical illness.

scholarly journals Intensive care unit–acquired weakness: unanswered questions and targets for future research

F1000Research ◽  
2019 ◽  
Vol 8 ◽  
pp. 508 ◽  
Author(s):  
Simone Piva ◽  
Nazzareno Fagoni ◽  
Nicola Latronico
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Critical Illness ◽  
Early Mobilization ◽  
Critical Illness Polyneuropathy ◽  
Artificial Nutrition ◽  
Limb Weakness ◽  
Muscle Involvement ◽  
Difficult Weaning ◽  
The Impact

Intensive care unit–acquired weakness (ICU-AW) is the most common neuromuscular impairment in critically ill patients. We discuss critical aspects of ICU-AW that have not been completely defined or that are still under discussion. Critical illness polyneuropathy, myopathy, and muscle atrophy contribute in various proportions to ICU-AW. Diagnosis of ICU-AW is clinical and is based on Medical Research Council sum score and handgrip dynamometry for limb weakness and recognition of a patient’s ventilator dependency or difficult weaning from artificial ventilation for diaphragmatic weakness (DW). ICU-AW can be caused by a critical illness polyneuropathy, a critical illness myopathy, or muscle disuse atrophy, alone or in combination. Its diagnosis requires both clinical assessment of muscle strength and complete electrophysiological evaluation of peripheral nerves and muscles. The peroneal nerve test (PENT) is a quick simplified electrophysiological test with high sensitivity and good specificity that can be used instead of complete electrophysiological evaluation as a screening test in non-cooperative patients. DW, assessed by bilateral phrenic nerve magnetic stimulation or diaphragm ultrasound, can be an isolated event without concurrent limb muscle involvement. Therefore, it remains uncertain whether DW and limb weakness are different manifestations of the same syndrome or are two distinct entities. Delirium is often associated with ICU-AW but a clear correlation between these two entities requires further studies. Artificial nutrition may have an impact on ICU-AW, but no study has assessed the impact of nutrition on ICU-AW as the primary outcome. Early mobilization improves activity limitation at hospital discharge if it is started early in the ICU, but beneficial long-term effects are not established. Determinants of ICU-AW can be many and can interact with each other. Therefore, future studies assessing early mobilization should consider a holistic patient approach with consideration of all components that may lead to muscle weakness.

scholarly journals Plasma glutamine status at intensive care unit admission: an independent risk factor for mortality in critical illness

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Marie Smedberg ◽  
Johan Helleberg ◽  
Åke Norberg ◽  
Inga Tjäder ◽  
Olav Rooyackers ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Critical Illness ◽  
Mortality Rate ◽  
Do Not Resuscitate ◽  
Glutamine Concentration ◽  
Normal Range ◽  
Icu Admission ◽  
Number Of Patients ◽  
Risk Scoring

Abstract Background A plasma glutamine concentration outside the normal range at Intensive Care Unit (ICU) admission has been reported to be associated with an increased mortality rate. Whereas hypoglutaminemia has been frequently reported, the number of patients with hyperglutaminemia has so far been quite few. Therefore, the association between hyperglutaminemia and mortality outcomes was studied in a prospective, observational study. Patients and methods Consecutive admissions to a mixed general ICU were eligible. Exclusion criteria were < 18 years of age, readmissions, no informed consent, or a ‘do not resuscitate’ order at admission. A blood sample was saved within one hour from admission to be analysed by high-pressure liquid chromatography for glutamine concentration. Conventional risk scoring (Simplified Acute Physiology Score and Sequential Organ Failure Assessment) at admission, and mortality outcomes were recorded for all included patients. Results Out of 269 included patients, 26 were hyperglutaminemic (≥ 930 µmol/L) at admission. The six-month mortality rate for this subgroup was 46%, compared to 18% for patients with a plasma glutamine concentration < 930 µmol/L (P = 0.002). A regression analysis showed that hyperglutaminemia was an independent mortality predictor that added prediction value to conventional admission risk scoring and age. Conclusion Hyperglutaminemia in critical illness at ICU admission was an independent mortality predictor, often but not always, associated with an acute liver condition. The mechanism behind a plasma glutamine concentration outside normal range, as well as the prognostic value of repeated measurements of plasma glutamine during ICU stay, remains to be investigated.

scholarly journals Effectiveness, Safety, and Barriers to Early Mobilization in the Intensive Care Unit

2020 ◽  
Vol 2020 ◽  
pp. 1-14
Author(s):  
Gopala Krishna Alaparthi ◽  
Aishwarya Gatty ◽  
Stephen Rajan Samuel ◽  
Sampath Kumar Amaravadi
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Critical Illness ◽  
Full Text ◽  
Early Mobilization ◽  
Scoring Systems ◽  
Inclusion Criteria ◽  
Limited Mobility ◽  
Positive Effects

Purpose. Patients admitted to the intensive care unit (ICU) are generally confined to bed leading to limited mobility that may have detrimental effects on different body systems. Early mobilization prevents or reduces these effects and improves outcomes in patients following critical illness. The purpose of this review is to summarize different aspects of early mobilization in intensive care. Methods. Electronic databases of PubMed, Google Scholar, ScienceDirect, and Scopus were searched using a combination of keywords. Full-text articles meeting the inclusion criteria were selected. Results. Fifty-six studies on various aspects such as the effectiveness of early mobilization in various intensive care units, newer techniques in early mobilization, outcome measures for physical function in the intensive care unit, safety, and practice and barriers to early mobilization were included. Conclusion: Early mobilization is found to have positive effects on various outcomes in patients with or without mechanical ventilation. The newer techniques can be used to facilitate early mobilization. Scoring systems—specific to the ICU—are available and should be used to quantify patients’ status at different intervals of time. Early mobilization is not commonly practiced in many countries. Various barriers to early mobilization have been identified, and different strategies can be used to overcome them.

scholarly journals A multidisciplinary early mobility model for cardiac patients in coronary intensive care unit

2021 ◽  
Vol 20 (Supplement_1) ◽  
Author(s):  
S Matharsa ◽  
D Selvamani ◽  
R Thakur ◽  
P Mathew ◽  
M Thomas ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Quality Improvement ◽  
Early Mobilization ◽  
Quality Improvement Project ◽  
Second Phase ◽  
Improvement Project ◽  
Early Mobility ◽  
Number Of Patients ◽  
Ventilated Patients

Abstract Funding Acknowledgements This is an unfunded project Background Early mobilization is considered as a complex task in an intensive care unit (ICU) and patients are often on prolonged bed rest leading to physical deconditioning. Intensive care early mobility programs have been recognized to be safe and have shown positive outcomes. However, implementing early mobility program as a standard of care remains a challenge. Coronary Intensive Care Unit (CICU) provides complex care for cardiac critically ill patients. In February 2018, the CICU multidisciplinary team (MDT) started a quality improvement project to implement early mobility program in the unit. Purpose This project aimed to investigate the feasibility of implementing an Early Mobility Protocol in CICU to increase the number of patients mobilized to more than 95%. Secondary objective was to explore the impact of the protocol on the mobility level of the patients at the time of discharge or transfer from the CICU. Methods A multidisciplinary mobility task force including Physicians, nurses, physiotherapists and respiratory therapists was formed to analyze the barriers in implementing an early mobility program. A staff survey was conducted to identify the need for a standard early mobility protocol. Root cause analysis and Pareto analysis was done. An evidence based early mobility protocol was developed and implemented. All non-mechanical ventilated patients were included in the first phase and all mechanical ventilated patients were included in the second phase of the project. A standard ICU Mobility scale (IMS) was used for scoring the mobility level of the patients. This quality improvement project is based on "Institute for Healthcare Improvement" model. Periodical staff education and training programs about early mobilization were conducted to improve staff confidence. Change ideas were implemented using multiple Plan Do Study Act cycles. Results The total number of patients included from 1st March 2018 till 31st December 2019 was 2356. This included both the genders. In March 2018, only 68% of non-mechanical ventilated patients were mobilized, that reached to 88% by November 2018. This gradually increased to 100% in May 2019 and is currently sustained at 100%. In November 2019, only 50% of mechanical ventilated patients were mobilized which gradually increased to 66.66% and 75% in middle and end of December 2019. The mean IMS score at discharge or transfer from CICU was "8". From patient-family experience survey, 93.75% of patients perceived that the program was helpful in regaining mobility and 96.25% of patients felt that the program helped in regaining their autonomy. Conclusion The result shows that it is safe and feasible to implement an early mobility program in a Coronary Intensive Care Unit. A standardized mobility protocol can lead to efficient mobilization practice facilitating early transfers from ICUs without any complications. This could further enhance the collaboration of the MDT members leading to culture change in ICUs.

Neurological disorders

2019 ◽  
pp. 393-430
Author(s):  
Carl Waldmann ◽  
Andrew Rhodes ◽  
Neil Soni ◽  
Jonathan Handy
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Status Epilepticus ◽  
Critical Illness ◽  
Subarachnoid Haemorrhage ◽  
Myasthenia Gravis ◽  
Ischaemic Stroke ◽  
Intracerebral Haemorrhage ◽  
Neurological Disorders ◽  
De Novo

This chapter discusses neurological disorders and includes discussion on delirium, status epilepticus, meningitis and encephalitis, intracerebral haemorrhage, subarachnoid haemorrhage, ischaemic stroke, Guillain–Barré syndrome, myasthenia gravis, intensive care unit-acquired weakness, tetanus, botulism, rehabilitation and critical illness, and hyperthermias. The aim is to provide a summary of the extensive complex neuological pathologies that can present to an intensive care clinician. Where appropriate, descriptions are provided on clinical presentation, epidemiology, diagnosis (including investigations), and management. Of note, some of the conditions covered can arise on the ward or prehospital environments with subsequent requirement for intensive care, but they can also arise de novo on the intensive care unit itself, highlighting the need for intensive care clinicians to maintain a broad knowledge and understanding of their presentation and management.

Characteristics of a child's critical illness and parents' reactions: preliminary report of a pilot study

1992 ◽  
Vol 1 (3) ◽  
pp. 80-84 ◽  
Author(s):  
JM Youngblut ◽  
SY Shiao
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Critical Illness ◽  
Pediatric Intensive Care Unit ◽  
Severity Of Illness ◽  
Pediatric Intensive Care ◽  
Small Sample ◽  
Future Research ◽  
Convenience Sample ◽  
Risk Of Mortality

OBJECTIVE: To explore the relationships between parents' reactions to the pediatric intensive care unit admission of a child and characteristics of the child's illness. METHOD: A convenience sample, consisting of 16 mothers and 13 fathers of 16 children aged 5 years and younger, was used. The Pediatric Risk of Mortality scale was used to measure severity of illness. Parental reactions were measured at about 24 hours after the child's admission with the Parental Stressor Scale: PICU and the Parental Concerns Scale. RESULTS: Mothers' concerns and stressors were not related to the child's Pediatric Risk of Mortality score. However, fathers reported greater concern about the child's experience and about parenting as the child's Pediatric Risk of Mortality score increased. CONCLUSIONS: Parents' reactions to their child's critical illness and admission to the pediatric intensive care unit were not related to characteristics of the child's condition in this small sample. Future research needs are suggested.

scholarly journals Assessment of atrial fibrillation in emergency department

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
S Manzo-Silberman ◽  
T Chouihed ◽  
L Fraticelli ◽  
A Peiretti ◽  
C Claustre ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Intensive Care Unit ◽  
Emergency Department ◽  
Intensive Care ◽  
Vitamin K ◽  
De Novo ◽  
Bleeding Event ◽  
Vitamin K Antagonist ◽  
Funding Source ◽  
Private Company

Abstract Introduction Atrial Fibrillation (AF) is the most common arrythmia, especially in older adults. AF represents 1% of emergency department (ED) visits a third of which are de novo or recurrent. While the diagnosis is given quickly by reading the electrocardiogram (ECG), its management both remains complex. European guidelines have been published in 2016. Purpose Our study aimed to investigate guidelines implementation in French ED. Methods Prospective national multicenter study (clinical trials NCT 03836339) and core interpretation of ECG. Consecutive patients admitted in 32 French ED for AF confirmed by ECG were prospectively included. Clinical characteristics at admission were recorded by the physician. The 3-months telephone follow-up was ensured by one operator. Results From 1/10/2018 to 30/11/2018, 1369 patients with AF were included, of whom 295 (21.55%) had a de novo AF. Patients were 80 [65; 87] years old, 51.17% of men, 71.53% self-ruling, 91.53% living at home, 65.42% transported by firemen or by ambulances and 4,07% by a mobile intensive care unit. Twenty-six (8.84%) patients had a history of stroke or transient ischemic stroke and none of them on anticoagulants. CHA2DS2-VASC score was performed in 66.78% of patients and was 0 in 14 (7.11%) patients. HAS-BLED score = 2 [1; 3]. At admission 50.17% of patients received anticoagulants, of whom 49.32% a non-vitamin K antagonist oral anticoagulant, 0.68% Vitamin K antagonists, 50.68% UFH or LMWH. Beta-blockers were administered in 102 (24.01%) patients and amiodarone in 38 (12.89%). Cardiac echography has been performed in 20.34% of patients. Atrial fibrillation was the primary diagnosis in 42.71% of patients. It has been associated to a pneumopathy in 25.17% of patients, a pulmonary embolism in 4.76% and acute alcoholism in 1.36% of them. Precipitating factor was often undetermined. The discharge to the home concerned 18.64% of patients, 26.78% of patients were hospitalized in ED hospitalization unit, 23.05% in cardiology or intensive care unit. At 3 months, 49% of patients were on anticoagulants, of whom 90% on non-vitamin K antagonist oral anticoagulants, 95% of them didn't report any bleeding event and 41.77% of them were able to have a cardiology consultation within three months. Three-months mortality was about 22.09%, and rehospitalization rate about 22.89%. Conclusion It seems to be a reticence to initiate anticoagulation of patients admitted to ED with a de novo AF. It could be explained by both the advanced age of the patients and the lack of an organized access to a systematic cardiology consultation at discharge. Patients with chronic AF are subject to high mortality at 3 months and a significant risk of readmission. The application of the guidelines could be optimized by a better training program and the implementation of a dedicated pathway of care. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Bayer

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