Log in | Register

Critical illness polyneuromyopathy: the electrophysiological components of a complex entity

Josef Bednarik| Zdenek Lukas| Petr Vondracek
Original
Volume 29, Issue 9 / September , 2003

Pages 1505 - 1514

Abstract

Objective

To evaluate the spectrum and time profile of electrophysiological parameters in the detection of neuromuscular involvement in critically ill patients and establish their correlation with biopsy findings.

Design

Prospective clinical and neurophysiological study.

Setting

One general and one neurological intensive care unit in a university hospital.

Patients

Forty-six critically ill patients with failure of at least two organ systems were enrolled and completed the 1-month follow up.

Interventions

Detailed clinical and electrophysiological evaluation including direct muscle stimulation was performed in all cases on entry and at the end of the follow-up. Muscle biopsy was performed in 11, and sural nerve biopsy in 5, cases.

Measurements and results

Electrophysiological signs of new or progressing neuromuscular involvement at the end of the first month were detected in 26 patients (56%) and could be classified into three groups: "pure motor syndrome" (12 cases), combined motor syndrome and sensory polyneuropathy (13 cases) and isolated sensory polyneuropathy (1 case). Direct muscle stimulation showed decreased muscle membrane excitability in 11 of these abnormal cases. Muscle biopsy disclosed various myopathic abnormalities in all 11 cases examined with motor syndrome, in 7 of them in association with denervation/re-innervation changes.

Conclusions

Electrophysiological and histological examinations showed significant overlapping of several pathogenic components of neuromuscular involvement in critically ill patients, namely decreased muscle excitability, myopathy, axonal motor neuropathy and sensory neuropathy. The characterisation of the electrophysiological components of a complex polyneuromyopathy is preferred to the strict categorisation of abnormalities into critical illness myopathy and polyneuropathy.

Keywords

References

  1. Bolton CF, Brown JD, Sibbald WJ (1983) The electrophysiological investigation of respiratory paralysis in critically ill patients. Neurology 33:186
  2. Bolton CF, Gilbert JJ, Hahn AF, Sibbald WA (1984) Polyneuropathy in critically ill patients. J Neurol Neurosurg Psychiatry 47:1223–1231
    • View reference on PubMed
  3. Lopez Messa JB, García A (1990) Acute polyneuropathy in critically ill patients. Intensive Care Med 16:159–162
    • View reference on PubMed
  4. Zochodne DW, Bolton CF, Wells GA, Gilbert JJ, Hahn AF, Brown JD, Sibbald WA (1987) Critical illness polyneuropathy. A complication of sepsis and multiple organ failure. Brain 110:819–842
    • View reference on PubMed
  5. Witt NJ, Zochodne DW, Bolton CF, Grand'Maison F, Wells G, Young GB, Sibbald WJ (1991) Peripheral nerve function in sepsis and multiple organ failure. Chest 99:176–184
    • View reference on PubMed
  6. MacFarlane IA, Rosenthal FD (1977) Severe myopathy after status asthmaticus. Lancet 2:615–620
  7. Barohn RJ, Jackson CE, Rogers SJ, Ridings LW, McVey AL (1994) Prolonged paralysis due to non-depolarizing neuromuscular blocking agents and corticosteroids. Muscle Nerve 17:647–654
    • View reference on PubMed
  8. Helliwel TR, Coakley JH, Wagenmakers AJ, Griffiths RD, Campbell IT, Green CJ, McClelland P, Bone JM (1991) Necrotizing myopathy in critically ill patients. J Pathol 164:307–314
    • View reference on PubMed
  9. Latronico N, Fenzi F, Recupero D, Guarneri B, Tomelleri G, Tonin P, De Maria G, Antonini L, Rizzuto N, Candiani A. (1996) Critical illness myopathy and neuropathy. Lancet 347:1579–1582
    • View reference on PubMed
  10. Bolton CF, Breuer AC (1999) Critical illness polyneuropathy. Muscle Nerve 22:419–424
    • View reference on publisher's website
    • View reference on PubMed
  11. Lacomis D, Zochodne DW, Bird SJ (2000) Critical illness myopathy. Muscle Nerve 23:1785–1788
    • View reference on publisher's website
    • View reference on PubMed
  12. Op de Coul AAW, Lambregts PCLA, Koeman J, van Puyenbroek PJ, Ter Laak HJ, Gabreels-Festen AA (1985) Neuromuscular complications in patients given Pavulon (pancuronium bromide) during artificial ventilation. Clin Neurol Neurosurg 87:17–22
    • View reference on PubMed
  13. Lycklama A, Nijeholt J, Troost J (1987) Critical illness polyneuropathy. In: Vinken PJ, Bruyn GW, Klawans HL (eds) Handbook of Clinical Neurology Vol.51, revised series 7. Elsevier/North Holland, Amsterdam, pp 575–585
  14. Wijdicks EF, Litchy WJ, Harrison BA, Gracey DR (1994) The clinical spectrum of critical illness polyneuropathy. Mayo Clin Proc 69:955–959
    • View reference on PubMed
  15. Gorson KC, Ropper AH (1993) Acute respiratory failure neuropathy: a variant of critical illness polyneuropathy. Crit Care Med 21:267–271
    • View reference on PubMed
  16. Trojaborg W, Weimer LH, Hays AP (2001) Electrophysiologic studies in critical illness associated weakness: myopathy or neuropathy—a reappraisal. Clin Neurophysiol 112:1586–1593
  17. Coakley JH, Nagendran K, Yarwood GD, Honavar M, Hinds CJ (1998) Patterns of neurophysiological abnormality in prolonged critical illness. Intensive Care Med 24:801–807
  18. Gutmann L, Gutmann L (1999) Critical illness neuropathy and myopathy. Arch Neurol 56:527–528
    • View reference on publisher's website
    • View reference on PubMed
  19. Schwarz J, Planck J, Briegel J, Straube A (1997) Single-fibre electromyography, nerve conduction studies and conventional electromyography in patients with critical-illness polyneuropathy: evidence for a lesion of terminal motor axons. Muscle Nerve 20:696–701
  20. Tepper M, Rakic S, Haas JA, Woittiez AJJ (2000) Incidence and onset of critical illness polyneuropathy in patients with septic shock. Neth J Med 56:211–214
  21. Tennila A, Salmi T, Pettila V, Roine RO, Varpula T, Takkunen O (2000) Early signs of critical illness polyneuropathy in ICU patients with systemic inflammatory response syndrome or sepsis. Intensive Care Med 26:1360–1363
    • View reference on PubMed
  22. Rich MM, Teener JW, Raps EC, Schotland DL, Bird SJ (1996) Muscle is electrically inexcitable in acute quadriplegic myopathy. Neurology 46:731–736
    • View reference on PubMed
  23. Rich MM, Bird SJ, Raps EC, Mc Cluskey LF, Teener JW (1997) Direct muscle stimulation in acute quadriplegic myopathy. Muscle Nerve 20:665–673
    • View reference on publisher's website
    • View reference on PubMed
  24. Rich MM, Pinter MJ (2003) Crucial role of sodium channel fast inactivation in muscle fibre inexcitability in a rat model of critical illness myopathy. J Physiol 547:555–566
    • View reference on publisher's website
    • View reference on PubMed
  25. Rich MM, Pinter MJ (2001) Sodium channel inactivation in an animal model of acute quadriplegic myopathy. Ann Neurol 50:26–33
    • View reference on publisher's website
    • View reference on PubMed
  26. Op de Coul AAV, Verheul AAW, Leyten ACM, Schellens RLLA, Teepen JLJM (1991) Critical illness polyneuromyopathy after artificial respiration. Clin Neurol Neurosurg 93:27–33
    • View reference on PubMed
  27. De Letter MA, van Doorn PA, Savelkoul HF, Laman JD, Schmitz PI, Op de Coul AA, Visser LH, Kros JM, Teepen JL, van der Meche FG (2000) Critical illness polyneuropathy and myopathy (CIPNM): evidence for local immune activation by cytokine-expression in the muscle tissue. J Neuroimmunol 106:206–213
    • View reference on publisher's website
    • View reference on PubMed
  28. Breuer AC (1999) An outdated concept. Muscle Nerve 22:422–424
    • View reference on publisher's website
  29. Vincent JL, de Mendonca A, Cantraine F, Moreno R, Takala J, Suter PM, Sprung CL, Colardyn F, Blecher S (1998) Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on "sepsis-related problems" of the European Society of Intensive Care Medicine. Crit Care Med 26:1793–1800
    • View reference on PubMed
  30. Moreno R, Vincent JL, Matos R, Mendonca A, Cantraine F, Thijs L, Takala J, Sprung C, Antonelli M, Bruining H, Willatts S (1999) The use of maximum SOFA score to quantify organ dysfunction/failure in intensive care. Results of a prospective, multicentre study. Working Group on Sepsis-related Problems of the ESICM. Intensive Care Med 25:686–696
  31. Aid to the examination of peripheral nervous system (1976) Memorandum No.45. HMSO, London
  32. Bone RC, Sprung CL, Sibald WBJ (1992) Definitions for sepsis and organ failure. Crit Care Med 20:724–726
    • View reference on PubMed
  33. Stalberg E, Nandedkar SD, Sanders DB, Falck B (1996) Quantitative motor unit potential analysis. J Clin Neurophysiol 13:401–422
  34. Dubowitz V (1985) Definition of pathological changes seen in muscle biopsies. In: Dubowitz (ed) Muscle biopsy: a practical approach. Balliére Tindal, East Sussex, pp 82–129
  35. Geller TJ, Kaiboriboon K, Fenton GA, Hayat GR (2001) Vecuronium-associated axonal motor neuropathy: a variant of critical illness polyneuropathy? Neuromuscul Disord 11:579–582
  36. Gooch JL, Suchyta MR, Balbierz MJ, Petajan JH, Clemmer TP (1991) Prolonged paralysis after treatment with neuromuscular junction agents. Crit Care Med 19:1125–1131
    • View reference on PubMed
  37. Bazzi P, Moggio M, Prelle A, Sciacco M, Messina S, Barbieri S, Tonin P, Tomelleri G, Battistel A, Adobbati L, Checcarelli N, Veschi G, Scarlato G (1999) Critically ill patients: immunological evidence of inflammation in muscle biopsy. Clin Neuropathol 18:23–30
    • View reference on PubMed
  38. Hund E (1999) Myopathy in critically ill patients. Crit Care Med 27:2544–2547
    • View reference on PubMed

Sign In

Connect with ICM

Top 5 Articles Editors Picks Supplement