Professional Documents
Culture Documents
long\x=req-\
early
identified by EMG studies in the intensive care unit (ICU). During a 1-year follow\x=req-\
up, amount of time was recorded to reach a rehabilitation end point.
Setting.\p=m-\Thegeneral ICU of a community hospital.
Patients.\p=m-\Fiftypatients younger than 75 years who were receiving mechanical
ventilation for more than 7 days.
Main Outcome Measures.\p=m-\Arehabilitation end point was defined as return of
normal muscle strength and ability to walk 50 m independently.
Results.\p=m-\In29 of 50 patients, an EMG diagnosis of polyneuropathy was made
in the ICU. Patients with polyneuropathy had a higher mortality in the ICU (14 vs 4;
P=.03), probably related to multiple organ failure (22 vs 11; P=.08) or aminoglycoside
treatment of suspected gram-negative sepsis (17 vs 4; P=.05). Rehabilitation was
more prolonged in 12 patients with polyneuropathy than in 12 without polyneuropathy (P=.001). Of nine patients with delays beyond 4 weeks, eight had polyneuropathy, five of whom had persistent motor handicap after 1 year. In particular, axonal
polyneuropathy with conduction slowing on EMG indicated a poor prognosis.
Conclusions.\p=m-\Polyneuropathyin the critically ill is related to multiple organ
failure and gram-negative sepsis, is associated with higher mortality, and causes
important rehabilitation problems. EMG recordings in the ICU can identify patients
at risk.
(JAMA. 1995;274:1221-1225)
\s=d\Deceased.
Corresponding author: Frans S. S. Leijten, MD, Department of Clinical Neurophysiology, Meer en Bosch,
PO Box 21, 2100 AA Heemstede, the Netherlands.
METHODS
Study Design
From July 1991 to January 1993, all
patients younger than 75 years who were
receiving mechanical ventilation for more
than 7 days were enrolled in the study.
Two patients with Guillain-Barr syn
drome and four with thiopental-induced
coma were excluded. The patient or, most
often, a close relative was questioned
about signs of polyneuropathy before the
Patients
mance was
ness
involved, often
tained from
consent
was
ob
close relative.
Statistical Analysis
Patients were divided into a nonpolyneuropathy group and a polyneuropathy
group according to the EMG criteria just
described. Differences between groups in
mean age, number of days on medication
and ventilation, and Acute Physiology and
Chronic Health Evaluation II (APACHE
II) scores were tested using a two-sided
Student's t test (corrected for unequal vari
ances). We used 2 analysis to study pro
portional differences in sex, comorbidi-
RESULTS
EMG Studies
The EMG results during mechanical
ventilation were considered criteria for
Table 1.Results of
Velocity, m/s
I
Studies
Latency,
I
During
Mechanical Ventilation*
ms
60.37.7
56.910.8
2.60.4
3.00.9
24.9i10.5
Tibial_45.46.0
Peroneal_47.34.6
40.86.6
41.06.1
45.95.8H
5.30.7
6.11.0
7.42.1
10.1
Sural
48.58.2||
5.01.5
22.813.5
5.4_3.32.8
7.14.8_1.91.4
17.010.9||
...
14.610.5H
...
General Characteristics
General characteristics were com
pared between patients with and with
out polyneuropathy detected by EMG.
There were no major differences in rea
son for ICU admission. For both groups,
38% were admitted to the ICU because
of acute surgery or complicated elective
surgery (eight patients without poly
neuropathy and 11 patients with poly
neuropathy), 24% because of infection
(five vs seven), 18% because of trauma
(four vs five) and 20% for other reasons
(four vs six; all values, .87 to .99). In
addition, comorbidities were evenly dis
tributed: chronic obstructive pulmonary
disease in 18% (four vs five) and history
of cardiovascular disease in 28% (six vs
eight;
values,
.87 to
.94).
Undergoing
rehabilitation
Days*
PNP
_(n=21)_(n=29)_P__
Men, No. (%)_14 (67)_21 (72)_.66
Age, y (meanSD)_54.316.9_59.713.9_.22
Risk factors for preexisting PNP, No. (%)_2(10)_5(17)_.44
No. of days on ventilator, median (range)
No. of days receiving medication, median
Vecuronium
20(8-49)
(range)
Midazolam
1
7
(0-16)
(0-29)
25(8-109)
1
8
(0-21)
(0-36)
.03
.47
9
Aminoglycosides_0(0-11)_4 (0-9)_.05
APACHE II
score
in first 24 hours of
ICU,
meanSD_23.1 6.6_22.39.0_.74
Total
(<1y)
9(43)
11(52)
14(48)
22(76)
.70
4(19)
9(43)
14(48)
18(62)
.03
.08
.18
*PNP indicates polyneuropathy; APACHE II, Acute Physiology and Chronic Heath Evaluation II; and ICU, Intensive
care
unit.
3.Delays in Reaching the Rehabilitation End Point in 24 Patients Who Had No Other Impairments
Interfering With Motor Function*
Table
*PNP indicates
1
3
0
5
12
12
polyneuropathy.
polyneuropathy.
2 test).
Rehabilitation
COMMENT
In this study, polyneuropathy had an
incidence of 58% among patients younger
than 75 years who were mechanically
ventilated for more than 7 days. Preex
isting peripheral nerve disease probably
does not account for this high rate, al
though it may have been more frequent
than judged by our estimates.
In more than 75% of patients with
polyneuropathy, widespread abnormal
spontaneous muscle activity was found
during needle EMG examination, sug
gestive of acute and active muscle denervation. These cases were classified
as classical (axonal) critical illness poly
neuropathy. The overall incidence in this
study was 44% (22/50), in accordance
with others.19 The exact incidence may
be somewhat lower or higher because
22 patients could not be evaluated ac
cording to protocol.
polarizing
polyneuropathy.
The presence of polyneuropathy is
intuitively and statistically related to im
paired convalescence. Electromyography
is probably the most sensitive means of
detecting polyneuropathy in the inten
sive care situation where the neurologi
cal examination can only be cursory.
By performing EMG studies in the criti
cally ill, motor recovery delays can be
anticipated. This may direct more intense
physiotherapy programs for certain pa
tients at an earlier stage. In our study,
the mixed-polyneuropathy subgroup
showed the highest risk of motor deficit
References
1. Repine JE. Scientific perspectives on adult respiratory distress syndrome. Lancet. 1992;339:466-469.
2. Kelly BJ, Matthay MA. Prevalence and severity
of neurologic dysfunction in critically ill patients.
Chest. 1993;104:1818-1824.
3. Roelofs RJ, Cerra F, Bielka N, Rosenberg L,
Delaney J. Prolonged respiratory insufficiency due
to acute motor neuropathy: a new syndrome? Neurology. 1983;33(suppl 2):240.
4. Rivner MH, Kim S, Greenberg M, Swift TR.
Reversible generalized paresis following hypotension. Neurology. 1983;33(suppl 2):164.
5. Op de Coul AAW, Lambregts PCLA, Koeman J,
Van Puyenbroek MJE, Palmen FMLHG. Neuromuscular complications after artificial respiration
with Pavulon (pancuronium bromide). Clin Neurol
Neurosurg. 1983;85:197.
6. Bolton CF, Brown JD, Sibbald WJ. The electrophysiologic investigation of respiratory paralysis in
critically ill patients. Neurology. 1983;33(suppl 2):186.
7. Bolton CF, Laverty DA, Brown JD, Witt NJ,
Hahn AF, Sibbald WJ. Critically ill polyneuropathy: electrophysiological studies and differentiation from Guillain\p=m-\Barr\l=e'\syndrome. J Neurol Neurosurg Psychiatry. 1986;49:563-573.
8. Zochodne DW, Bolton CF, Wells GA, et al. Critical illness polyneuropathy: a complication of sepsis
and multiple organ failure. Brain. 1987;110:819-842.
9. Bolton CF, Gilbert JJ, Hahn AF, Sibbald WJ.
Polyneuropathy in critically ill patients. J Neurol
Neurosurg Psychiatry. 1984;47:1223-1231.
10. Op de Coul AAW, Lambregts PCLA, Koeman
J, Van Puyenbroek MJE, Ter Laak HJ, Gabre\l=e"\s\x=req-\
Festen AAWM. Neuromuscular complications in
patients given Pavulon (pancuronium bromide) dur-
7:575-585.
13. Barat M, Brochet B, Vital C, Mazaux JM, Arn\l=e'\
L. Polyneuropathies au cours de s\l=e'\joursprolong\l=e'\s
en r\l=e'\animation.Rev Neurol. 1987;143:823-831.
14. Coronel B, Mercatello A, Couturier JC, et al.
Polyneuropathy: potential cause of difficult weaning. Crit Care Med. 1990;18:486-489.
15. Lopez Messa JB, Garc\l=i'\aA. Acute polyneuropathy in critically ill patients. Intensive Care Med.
1990;16:159-162.
16. Gorson KC, Ropper AH. Acute respiratory failure neuropathy: a variant of critical illness polyneuropathy. Crit Care Med. 1993;21:267-271.
17. Leijten FSS, De Weerd AW. Critical illness
polyneuropathy: a review of the literature, definition, and pathophysiology. Clin Neurol Neurosurg.
1994;96:10-19.
18. Witt NJ, Zochodne DW, Bolton CF, et al. Peripheral nerve function in sepsis and multiple organ
failure. Chest. 1991;99:176-184.
19. Spitzer AR, Giancarlo T, Maher L, Awerbuch G,
Bowles A. Neuromuscular causes of prolonged ventilator dependency. Muscle Nerve. 1992;15:682-686.
20. Coakley JH, Nagendran K, Honavar M, Hinds
CJ. Preliminary observations on the neuromuscular abnormalities in patients with organ failure and
sepsis.