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In patients who are receiving mechanical ventilation, daily interruption of sedative-drug infusions decreases the duration of mechanical ventilation and the length of stay in the intensive care unit.

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eakness acquired in the intensive care unit (ICU) is caused by many different pathophysiological mechanisms that are not mutually exclusive. This is not surprising, given the diverse diseases that precipitate critical illness, the drugs used during its management, and the consequences of protracted immobility. Nonetheless, conceptualization of this entity is valuable, since weakness in survivors of critical illness is common and is associated with longstanding consequences that dramatically affect recovery. Moreover, as survival rates among patients in the ICU increase, ICU-acquired weakness will have increasing relevance for care providers outside the ICU. This article provides an overview of the condition and its effect on recovery after critical illness. Early descriptions of weakness in critical illness include reports by Osler 1 of neuromuscular dysfunction in patients with sepsis and reports by Olsen 2 of peripheral neuropathy complicating protracted coma. In 1977, myopathy was described in a patient with status asthmaticus 3 who received high doses of hydrocortisone and simultaneous neuromuscular blockade. These descriptions were followed by a landmark study by Bolton and colleagues 4 of polyneuropathy in patients in the ICU. This condition, termed critical illness polyneuropathy, is characterized by a primary axonal degeneration, without demyelination, that typically affects motor nerves more than sensory nerves. The predominant spinal cord finding is loss of anterior horn cells due to axonal degeneration. 5 Electrophysiological studies show that nerve conduction velocity is preserved, but there are reductions in the amplitudes of compound muscle action potentials (CMAPs) and sensory-nerve action potentials. Over the past two decades, improvements in survival after discharge from the ICU probably have led to increased awareness of ICU-acquired weakness. The magnitude of neuromuscular impairment in the increasing population of patients undergoing post-ICU rehabilitation has come to the attention of health care providers, patients, and families. Fe at ur es of ICU-Acquir ed W e a k ness Critical illness polyneuropathy affects the limbs (particularly the lower extremities) in a symmetric pattern. Weakness is most notable in proximal neuromuscular areas (e.g., the shoulders and hip girdle). In addition, involvement of the respiratory muscles can occur and can impede weaning from mechanical ventilation. 6 Facial and ocular muscles are rarely involved. Creatine kinase levels are not elevated in patients with critical illness polyneuropathy. The condition is distinct from the Guillain-Barré syndrome because demyelination is not seen. As distinct from a secondary myopathy resulting from muscle denervation, critical illness myopathy is a primary myopathy. 7 It is often difficult to distinguish this myopathy from critical illness polyneuropathy by means of a simple bedside

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Critically ill patients often receive sedatives, which may delay liberation from mechanical ventilation and intensive care unit discharge. Daily interruption of sedatives alleviates these problems, but the impact of this practice on long-term psychological outcomes is unknown. We compared psychological outcomes of intensive care unit patients undergoing daily sedative interruption (intervention) with those without this protocol (control). Assessments using (1) the Revised Impact of Event Scale (evaluates signs of posttraumatic stress disorder [PTSD]), (2) the Medical Outcomes Study 36 item short-form health survey, (3) the State-Trait Anxiety Inventory, (4) the Beck Depression Inventory-2, (5) and the Psychosocial Adjustment to Illness score (overall quality of adjustment to current or residual effects of illness) were done by blinded observers. The intervention group had a better total Impact of Events score (11.2 vs. 27.3, p=0.02), a trend toward a lower incidence of PTSD (0% vs. 32%, p=0.06), and a trend toward a better total Psychosocial Adjustment to Illness score (46.8 vs. 54.3, p=0.08). We conclude that daily sedative interruption does not result in adverse psychological outcomes, reduces symptoms of PTSD, and may be associated with reductions in posttraumatic stress disorder.

Early physical and occupational therapy is feasible from the onset of mechanical ventilation despite high illness acuity and presence of life support devices. Adverse events are uncommon, even in this high-risk group.

The multisociety statement on responding to requests for potentially inappropriate treatments in intensive care units provides guidance for clinicians to prevent and manage disputes in patients with advanced critical illness.