Neurophysiological study of critical illness polyneuropathy and myopathy in mechanically ventilated children; additional aspects in paediatric critical illness comorbidities

Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or “weaning” from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40–50% of the time spent on MV is required to liberate the patient from the ventilator, a process called “weaning”. In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, “prolonged weaning” is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of “prolonged weaning”, and to use this information as a foundation for formulating recommendations related to “prolonged weaning”, not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.

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“…Paediatric patients can also develop CIP or CIM, although the incidence here is potentially lower than that in adult patients [117].…”

Section: Pathophysiology Of Weaning Failurementioning

confidence: 99%

Prolonged Weaning: S2k Guideline Published by the German Respiratory Society

et al. 2020

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“…Prevalence of ICU-acquired weakness varies widely with the studied patient population and risk factors, the timing of assessment, the methods used for diagnosis, and inconsistent accounting for patients' pre-hospital muscle function or overall functional status (often overlooking agerelated frailty) [4,6,[9][10][11][12]. A systematic review reported a median prevalence of 43% (interquartile range 25-75%) over 31 studies [13].…”

Section: Introductionmentioning

confidence: 99%

ICU-acquired weakness

2020

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Critically ill patients often acquire neuropathy and/or myopathy labeled ICU-acquired weakness. The current insights into incidence, pathophysiology, diagnostic tools, risk factors, short-and long-term consequences and management of ICU-acquired weakness are narratively reviewed. PubMed was searched for combinations of "neuropathy", "myopathy", "neuromyopathy", or "weakness" with "critical illness", "critically ill", "ICU", "PICU", "sepsis" or "burn". ICU-acquired weakness affects limb and respiratory muscles with a widely varying prevalence depending on the study population. Pathophysiology remains incompletely understood but comprises complex structural/functional alterations within myofibers and neurons. Clinical and electrophysiological tools are used for diagnosis, each with advantages and limitations. Risk factors include age, weight, comorbidities, illness severity, organ failure, exposure to drugs negatively affecting myofibers and neurons, immobility and other intensive care-related factors. ICU-acquired weakness increases risk of in-ICU, in-hospital and long-term mortality, duration of mechanical ventilation and of hospitalization and augments healthcare-related costs, increases likelihood of prolonged care in rehabilitation centers and reduces physical function and quality of life in the long term. RCTs have shown preventive impact of avoiding hyperglycemia, of omitting early parenteral nutrition use and of minimizing sedation. Results of studies investigating the impact of early mobilization, neuromuscular electrical stimulation and of pharmacological interventions were inconsistent, with recent systematic reviews/meta-analyses revealing no or only low-quality evidence for benefit. ICU-acquired weakness predisposes to adverse short-and long-term outcomes. Only a few preventive, but no therapeutic, strategies exist. Further mechanistic research is needed to identify new targets for interventions to be tested in adequately powered RCTs.

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“…Our results support that ICU-AP frequency was more than one third of conscious patients and the most important factor for ICU paresis was mechanical ventilator. ICU-AP frequency has reported between 25% and 55% in literature (1,2,(10)(11)(12)(13)(14). Cramer mentioned that change in electrophysiological findings (sudden decrease in compound muscle action potential amplitude) indicating the development of CINM was monitored in higher than 65% of patients in one study (15).…”

Section: Discussionmentioning

confidence: 99%

Intensive Care Unit-acquired Paresis: Risk Factors in Conscious and Cooperative Patients in Intensive Care Units

Yurdakul¹,

Uçkun²,

Bodur³

et al. 2019

tybd

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Çalışmamızın amacı yoğun bakım ünitesindeki (YBÜ) hastalarımızda, kazanılmış parezi (KP) sıklığını ve kas güçsüzlüğü için predispozan faktörleri belirlemektir. Gereç ve Yöntem: Üçüncü basamak bir hastanenin 25 yataklı YBÜ'de prospektif gözlemsel bir çalışma yürütülmüştür. Kas gücü muayenesine koopere olan, YBÜ'de kalışı üç günden fazla olan ve daha öncesinde nöromüsküler bozukluğu olmayan hastalar dahil edildi. Yatış tanısı, mekanik ventilasyon ihtiyacı, komorbiditeleri, yatış süresi, mobilizasyon düzeyi, taburculuk durumu, Organ Yetmezliği Değerlendirmesi (SOFA) kaydedildi. Manuel kas gücü testi Medical Research Council ölçeğine göre değerlendirildi. Kaba kavrama ve üçlü kavrama ölçüleri yapıldı. Bulgular: Kırk iki hasta kas gücü muayenesini tamamladı. YBÜ-KP 16 hastada (%38,09) saptandı. YBÜ'de yatış süresi, mekanik ventilasyon oranı, SOFA skoru ve dekübit ülser sıklığı YBÜ-KP olan hastalarda daha fazla idi (p<0,05). Mekanik ventilasyon ve YBÜ-KP arasında anlamlı ilişki bulundu. Sonuç: YBÜ-KP yoğun bakım hastalarında sık görülen bir problemdir ve hastaların son durumlarını etkilemektedir. Mekanik ventilasyona bağlı olmayan hastalarda da YBÜ-KP görülebilmektedir ve mekanik ventilasyon kas güçsüzlüğü için risk faktörlerinden biri olarak tanımlanabilir.

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Neurophysiological study of critical illness polyneuropathy and myopathy in mechanically ventilated children; additional aspects in paediatric critical illness comorbidities

Abstract: Critically ill children frequently develop CIP/CIM, mostly of axonal polyneuropathy pattern, which compromises rehabilitation and recovery and is associated with a number of comorbidities.

Cited by 20 publications

References 47 publications

Prolonged Weaning: S2k Guideline Published by the German Respiratory Society

Prolonged Weaning: S2k Guideline Published by the German Respiratory Society

ICU-acquired weakness

Intensive Care Unit-acquired Paresis: Risk Factors in Conscious and Cooperative Patients in Intensive Care Units

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