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Critical Illness Polyneuropathy CIP

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An acute, predominantly motor axonal polyneuropathy occurring in critically ill patients. Flaccid tetraparesis, failure to wean. Cranial nerves are spared ... – PowerPoint PPT presentation

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Title: Critical Illness Polyneuropathy CIP


1
Critical Illness Polyneuropathy (CIP)
  • Current Opionion in Critical Care
  • vol 8(4) August 2002, pp. 302-310
  • Presented by Ri ???

2
Critical Illness Polyneuropathy (CIP)
  • Definition
  • Epidemiology
  • Onset
  • Diagnosis
  • Risk factor
  • Therapy
  • Prognosis and Outcome

3
Definition
  • An acute, predominantly motor axonal
    polyneuropathy occurring in critically ill
    patients.
  • Flaccid tetraparesis, failure to wean
  • Cranial nerves are spared
  • - Movement discrepancy about pain
  • Distal gt proximal with muscle atrophy
  • DTR ? or absent (13100)
  • - CIP cant be r/o with DTR presence

4
Epidemiology
5
Onset
  • Few study have addressed
  • Evidence of very early onset of CIP
  • - 80 within 72hr (Dutch study)
  • - 100 in 25 days (Finland study)

6
Diagnosis
  • Clinical presentation
  • Laboratory parameters
  • Electrophysiologic studies
  • Nerve and muscle biopsy
  • Additional technique
  • Differential diagnosis

7
Clinical Presentation
  • Difficulty weaning from ventilator
  • Distal weakness with DTR ?
  • - encephalopathy
  • - sedation
  • - specificity of DTR test

8
Laboratory Parameters
  • Not diagnostic
  • Creakine kinase levels
  • - Normality do not rule out N-M disease
  • - marginally raised or normal in CIP
  • - other contributing factor
  • (convulsions, ischemia..)

9
Electrophysiologic Studies
  • Nerve conduction studies and EMG
  • - valuable and sensitive
  • - pure axonal polyneuropathy
  • - severity quantification

10
Electrophysiologic Studies
  • Nerve conduction studies
  • - ? amplitude of compound motor AP
  • - severe muscle atrophy?
  • - ? amplitude of sensory nerve AP
  • - tissue edema?
  • - latency and velocity are unchanged
  • - repetitive stimulation r/o N-M synapse dz
  • - muscle biopsy r/o myopathy

11
Electrophysiologic Studies
  • Electromyographic studies
  • - signs of denervation
  • - spontaneous activity with fibrillations
  • - positive sharp waves
  • - diaphramatic denervation
  • - diaphramatic needle EMG
  • - phrenic nerve conduction study EMG

12
Nerve and muscle biopsy
  • Have not been performed as routine.
  • No inflammatory changes were found
  • Nerve biopsy
  • - No demyelination was found
  • - Discrepancy between histologic and
    electrophysiologic studies
  • - Early impairment of axonal transport and
    transmembrane potential
  • ? Normal histological study cannot r/o CIP

13
Nerve and muscle biopsy
  • Muscle biopsy
  • - Atrophy of type II fibers denervation
  • - Fiber necrosis in 30
  • - Primary or secondary?
  • - No clear relationship with neurophysiology
  • - Low motor amplitudes with normal sensory
    neurography, and little spontaneous activity
  • Critical Illness Myo- and (poly)Neuropathy
  • - CRIMYNE

14
Additional Technique
  • Quantitative EMG
  • Muscle fiber excitability by direct muscle
    stimulation
  • - differentiate myopathy and neuropathy

15
Differential diagnosis
16
Differential diagnosis
17
Risk factors
  • Systemic inflammatory response syndrome /or
    sepsis
  • Steroids
  • Neuromuscular blocking agents
  • Aminoglycoside antibiotics
  • Total parenteral nutrition
  • Vasopressor support (gt3d)
  • Immune mechanisms (neurotoxic factor)
  • Neurologic failure (GCSlt10)
  • Renal replacement therapy
  • Low albumin and elevated glucose levels

18
Therapy
  • Neither therapy nor prevention is available
  • Possible prevention
  • - treatment of underlying sepsis /SIRS
  • - glycemic control with insulin (?4048)
  • - minimize steroid and depolarizing NMBA
  • Possible treatment
  • - intensive psychological care and reassurance
  • - intensive physiotherapy and supportive care
  • - intensive rehabilitation program

19
Prognosis and Outcome
  • Short-term prognosis
  • - high mortality rate with sepsis/ SIRS
  • - take weeks to months to recover
  • - prolonged ventilator support?
  • - scoring system? APACHE III
  • Long-term prognosis
  • - 50 chance of complete recovery
  • - depending on the initial severity

20
Take Home Message
  • CIP is an acute, predominantly motor axonal
    polyneuropathy occurring in critically ill
    patients.
  • Onset in 3d as 3 Ds (Difficulty weaning and
    Distal weakness with DTR ?)
  • Electrophysiologic studies are valuable and
    sensitive
  • Neither therapy nor prevention is available
  • Weeks to months are needed to recover (50)

21
In our patient
  • 66y/o male with CHF for 2 yrs r/o DCM
  • Underlying DM
  • Cardiogenic shock s/p IABP at 6/17
  • VT/VF s/p CPR at 6/18
  • Heart transplantation at 6/22
  • EMB at 7/7, 7/14 revealed no rejection

22
Post OP
  • 6/22 heart transplantation
  • 6/25 general weakness
  • 6/28 neurologist consultation
  • - intact cranial nerve function
  • - generally low muscle power (12 score)
  • - DTR?at upper extremities, absent at lower
  • - muscle atrophy without fasciculation

23
Post OP
  • 7/12 Electrophysiological study
  • - NCV
  • Markedly ?amplitude of CMAP and sensory AP
    with relative preserved conduction velocity in
    all tested nerves
  • - EMG
  • No active denervation change
  • 7/16 Extubation

24
Risk factors
  • Systemic inflammatory response syndrome /or
    sepsis
  • Steroids (Solumedrol 120mg iv q8h at 6/22)
  • Neuromuscular blocking agents
  • Aminoglycoside antibiotics
  • Total parenteral nutrition
  • Vasopressor support (gt3d)
  • Immune mechanisms (neurotoxic factor)
  • Neurologic failure (GCSlt10)
  • Renal replacement therapy
  • ?alb (3.3, 3.2, 3.1) and ? glu (283, 391, 469)

25
  • Thanks for your attention
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