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Background: A lot of outcome predictive tools are already in use in critical care setting with different degrees of reliability aiming for possible prevention or minimization of bad outcome and better resource management. Some critical illness sequelae significantly affect patient's outcome and currently not included in the in-use predictive scoring system. Muscle wasting/weakness is one of these sequelae, and it was found to be an independent risk factor of poor outcomes. Objective: This study was conducted to evaluate the degree of muscle wasting estimated by ultrasonography during ICU stay as a predictor of mortality, successful weaning of mechanical ventilation, ICU stay and hospital stay. Patients and Methods: A prospective observational study was conducted in critical care units in Ain Shams University Hospitals, Cairo, Egypt over a period of 12 months. Results: Decrease in muscle measurements was found to correlated to mortality in ICU with cutoff points from area under the curve for right QMT, left QMT, right RFCSA, left RFCSA, IEDT and EEDT were supposed to be:>9.77,>15, >16.67, >12.5, >12.63, >12.5, respectively, with best specificity and positive predictive value was found in right RFCSA (95.45, 87.5, respectively) while best sensitivity and negative predictive value was found in left RFCSA (65.38, 82, respectively). Significant negative correlation between vasoactive agent free period and maximum daily reduction in RFCSA, QMT, EIDT, and EEDT (P value = 0.001). Conclusion: Daily reduction of the RFCSA and to lesser extent the QMT has significant correlation to mortality, prolongation of mechanical ventilation days and reduction in the vasopressor free days but has a poor correlation to the ICU and hospital stay. Pneumonia and renal disease had significant correlation with the muscle mass reduction. The left RFCSA found to be comparable to SOFA score as mortality predictor. [ABSTRACT FROM AUTHOR]

Critical illness polyneuropathy (CIP) is a complex disease commonly occurring in septic patients which indicates a worse prognosis. Herein, we investigated the characteristics of cerebrospinal fluid (CSF) in septic patients with CIP.

OBJECTIVES: The COVID-19 pandemic significantly impacted global healthcare systems, particularly in managing critically ill mechanically ventilated patients. This study aims to assess the feasibility of robotic-assisted mobilization in COVID-19 patients. DESIGN: Randomized controlled pilot study. SETTING: Four COVID-19 specialized ICUs at Charité-Universitätsmedizin Berlin (March 2021 to February 2022). PATIENTS: Twenty critically ill COVID-19 patients expected to require greater than 24 hours of ventilation. INTERVENTIONS: A 5-day intervention phase with bid robotic-assisted mobilization greater than or equal to 20 minutes and follow-up at day 180, compared with standard care. MEASUREMENTS AND MAIN RESULTS: Intervention sessions were conducted in 98.9% according to protocol, with one session missing due to staff shortage. Primary outcome was the mobilization level measured with the ICU Mobility Scale (IMS) and Surgical ICU Optimal Mobilization Score (SOMS), assessed until day 5 or extubation. Safety events were recorded during mobilization. The median IMS and SOMS were 0 (0–0.16) and 1 (1–1.03) in the intervention group, and 0 (0–0.15) (p = 0.77) and 0.8 (0.65–1.20) (p = 0.08) in the standard care group, respectively. Significant secondary outcomes included average number of mobilization sessions (intervention: 8.5 [7.75–10] vs. standard care: 4.5 [3.5–5]; p = 0.001), total mobilization time (intervention: 232.5 min [187.25–266.5 min] vs. standard care: 147.5 min [107.5–167.5 min]; p = 0.011), and healthcare providers per session (intervention: 2 [2–2] vs. standard care: 1 [1–1.4]; p = 0.001) during intervention. Four safety events (hypertension and agitation, n = 2 each) in the intervention group and none in the standard care group were reported. CONCLUSIONS: Robotic-assisted mobilization in mechanically ventilated COVID-19 patients appears to be safe and feasible. [ABSTRACT FROM AUTHOR]

Background: Foot drop syndrome (FDS), characterized by severe weakness and atrophy of the dorsiflexion muscles of the feet, is commonly found in patients with severe acquired brain injury (ABI). If the syndrome is unilateral, the cause is often a peroneal neuropathy (PN), due to compression of the nervous trunk on the neck of the fibula at the knee level; less frequently, the cause is a previous or concomitant lumbar radiculopathy. Bilateral syndromes are caused by polyneuropathies and myopathies. Central causes, due to brain or spinal injury, mimic this syndrome but are usually accompanied by other symptoms, such as spasticity. Critical illness polyneuropathy (CIP) and myopathy (CIM), isolated or in combination (critical illness polyneuromyopathy, CIPNM), have been shown to constitute an important cause of FDS in patients with ABI. Assessing the causes of FDS in the intensive rehabilitation unit (IRU) has several limitations, which include the complexity of the electrophysiological tests, limited availability of neurophysiology consultants, and the severe disturbance in consciousness and lack of cooperation from patients. Objectives: We sought to propose a simplified electrophysiological screening that identifies FDS causes, particularly PN and CIPNM, to help clinicians to recognize the significant clinical predictors of poor outcomes in severe ABI at admission to IRU. Methods: This prospective, single-center study included 20 severe ABI patients with FDS (11 females/9 males, mean age 55.10 + 16.26; CRS-R= 11.90 + 6.32; LCF: 3.30 + 1.30; DRS: 21.45 + 3.33), with prolonged rehabilitation treatment (≥2 months). We applied direct tibialis anterior muscle stimulation (DMS) associated with peroneal nerve motor conduction evaluation, across the fibular head (NCS), to identify CIP and/or CIM and to exclude demyelinating or compressive unilateral PN. Results: At admission to IRU, simplified electrophysiological screening reported four unilateral PN, four CIP and six CIM with a CIPNM overall prevalence estimate of about 50%. After 2 months, the CIPNM group showed significantly poorer outcomes compared to other ABI patients without CIPNM, as demonstrated by the lower probability of achieving endotracheal-tube weaning (20% versus 90%) and lower CRS-R and DRS scores. Due to the subacute rehabilitation setting of our study, it was not possible to evaluate the motor results of recovery of the standing position, functional walking and balance, impaired by the presence of unilateral PN. Conclusions: The implementation of the proposed simplified electrophysiological screening may enable the early identification of unilateral PN or CIPNM in severe ABI patients, thereby contributing to better functional prognosis in rehabilitative settings. [ABSTRACT FROM AUTHOR]

Intensive Care Unit (ICU)-Acquired Weakness (ICU-AW) is a generalized muscle weakness that is clinically detected in critical patients and has no plausible etiology other than critical illness. ICU-AW is uncommon in patients undergoing orthotopic liver transplantation (OLT). Our report sheds light on the highest number of ICU-AW cases observed in a single center on OLT patients with early allograft dysfunction. Out of 282 patients who underwent OLT from January 2015 to June 2023, 7 (2.5%) developed generalized muscle weakness in the ICU and underwent neurophysiological investigations. The neurologic examination showed preserved extraocular, flaccid quadriplegia with the absence of deep tendon reflexes in all patients. Neurophysiological studies, including electromyography and nerve conduction studies, showed abnormalities with fibrillation potentials and the rapid recruitment of small polyphasic motor units in the examined muscles, as well as a reduced amplitude of the compound muscle action potential and sensory nerve action potential, with an absence of demyelinating features. Pre-transplant clinical status was critical in all patients. During ICU stay, early allograft dysfunction, acute kidney injury, prolonged mechanical ventilation, sepsis, hyperglycemia, and high blood transfusions were observed in all patients. Two patients were retransplanted. Five patients were alive at 90 days; two patients died. In non-cooperative OLT patients, neurophysiological investigations are essential for the diagnosis of ICU-AW. In this setting, the high number of red blood cell transfusions is a potential risk factor for ICU-AW. [ABSTRACT FROM AUTHOR]

Background: Foot drop syndrome (FDS), characterized by severe weakness and atrophy of the dorsiflexion muscles of the feet, is commonly found in patients with severe acquired brain injury (ABI). If the syndrome is unilateral, the cause is often a peroneal neuropathy (PN), due to compression of the nervous trunk on the neck of the fibula at the knee level; less frequently, the cause is a previous or concomitant lumbar radiculopathy. Bilateral syndromes are caused by polyneuropathies and myopathies. Central causes, due to brain or spinal injury, mimic this syndrome but are usually accompanied by other symptoms, such as spasticity. Critical illness polyneuropathy (CIP) and myopathy (CIM), isolated or in combination (critical illness polyneuromyopathy, CIPNM), have been shown to constitute an important cause of FDS in patients with ABI. Assessing the causes of FDS in the intensive rehabilitation unit (IRU) has several limitations, which include the complexity of the electrophysiological tests, limited availability of neurophysiology consultants, and the severe disturbance in consciousness and lack of cooperation from patients. Objectives: We sought to propose a simplified electrophysiological screening that identifies FDS causes, particularly PN and CIPNM, to help clinicians to recognize the significant clinical predictors of poor outcomes in severe ABI at admission to IRU. Methods: This prospective, single-center study included 20 severe ABI patients with FDS (11 females/9 males, mean age 55.10 + 16.26; CRS-R= 11.90 + 6.32; LCF: 3.30 + 1.30; DRS: 21.45 + 3.33), with prolonged rehabilitation treatment (≥2 months). We applied direct tibialis anterior muscle stimulation (DMS) associated with peroneal nerve motor conduction evaluation, across the fibular head (NCS), to identify CIP and/or CIM and to exclude demyelinating or compressive unilateral PN. Results: At admission to IRU, simplified electrophysiological screening reported four unilateral PN, four CIP and six CIM with a CIPNM overall prevalence estimate of about 50%. After 2 months, the CIPNM group showed significantly poorer outcomes compared to other ABI patients without CIPNM, as demonstrated by the lower probability of achieving endotracheal-tube weaning (20% versus 90%) and lower CRS-R and DRS scores. Due to the subacute rehabilitation setting of our study, it was not possible to evaluate the motor results of recovery of the standing position, functional walking and balance, impaired by the presence of unilateral PN. Conclusions: The implementation of the proposed simplified electrophysiological screening may enable the early identification of unilateral PN or CIPNM in severe ABI patients, thereby contributing to better functional prognosis in rehabilitative settings.

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Intensive care unit-acquired weakness (ICUAW) is one of the most common neuromuscular complications in intensive care medicine. The clinical diagnosis and assessment of the severity using established diagnostic methods (e.g., clinical examination using the Medical Research Council Sum Score or electrophysiological examination) can be difficult or even impossible, especially in sedated, ventilated and delirious patients. Neuromuscular ultrasound (NMUS) has increasingly been investigated in ICUAW as an easy to use noninvasive and mostly patient compliance-independent diagnostic alternative. It has been shown that NMUS appears to be a promising tool to detect ICUAW, to assess the severity of muscular weakness and to monitor the clinical progression. Further studies are needed to standardize the methodology, to evaluate the training effort and to optimize outcome predication. The formulation of an interdisciplinary neurological and anesthesiological training curriculum is warranted to establish NMUS as a complementary diagnostic method of ICUAW in daily clinical practice. [ABSTRACT FROM AUTHOR]

Intensive care unit-acquired weakness (ICUAW) is one of the most common causes of muscle atrophy and functional disability in critically ill intensive care patients. Clinical examination, manual muscle strength testing and monitoring are frequently hampered by sedation, delirium and cognitive impairment. Many different attempts have been made to evaluate alternative compliance-independent methods, such as muscle biopsies, nerve conduction studies, electromyography and serum biomarkers. However, they are invasive, time-consuming and often require special expertise to perform, making them vastly impractical for daily intensive care medicine. Ultrasound is a broadly accepted, non-invasive, bedside-accessible diagnostic tool and well established in various clinical applications. Hereby, neuromuscular ultrasound (NMUS), in particular, has been proven to be of significant diagnostic value in many different neuromuscular diseases. In ICUAW, NMUS has been shown to detect and monitor alterations of muscles and nerves, and might help to predict patient outcome. This narrative review is focused on the recent scientific literature investigating NMUS in ICUAW and highlights the current state and future opportunities of this promising diagnostic tool. [ABSTRACT FROM AUTHOR]

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has made a considerable global effect, posing notable challenges for clinicians, the pandemic becoming one of the most imperative international health emergencies lately. Among other more frequent manifestations, SARS-CoV-2 disease may also give rise to skeletal muscle involvement. Viral-induced skeletal muscle involvement is a potentially severe manifestation of COVID-19 (Coronavirus Disease 2019) and may be either acute, or in the context of “long-COVID”. The present review aimed to illustrate few aspects about pathomechanisms, clinical and paraclinical frames, and treatment options for SARS-CoV-2-induced muscle involvement. Notably, it has been stated that SARS-CoV-2 may have the ability to invade muscle myocytes directly, the disease having a variety of clinical manifestations, from myalgia and muscle weakness to rhabdomyolysis. Nevertheless, it is also important to take into account that most of patients with severe forms receiving mechanical ventilation for more than one week may have complications such as CIM (critical illness myopathy) and/or CIP (critical illness polyneuropathy) that may be clinically similar to SARS-CoV-2-induced myositis, yet may be differentiated paraclinical from it. Additionally, it was hypothesized that SARS-CoV-2 infection may constitute a trigger for autoimmune diseases such as polymyositis/dermatomyositis. Presently, there are no diagnosis criteria and no specific therapeutic strategy for SARS-CoV-2-induced myositis.

Abstract Purpose ICU-acquired weakness, comprising Critical Illness Polyneuropathy (CIP) and Myopathy (CIM) is associated with immobilization and prolonged mechanical ventilation. This study aims to assess feasibility of early detection of CIP and CIM by peroneal nerve test (PENT) and sensory sural nerve action potential (SNAP) screening in patients with septic shock and invasively ventilated for more than 72 h. Methods We performed repetitive PENT screening from 72 h after intubation until detecting a pathological response. We tested SNAPs in pathological PENT to differentiate CIP from CIM. We performed muscle strength examination in awake patients and recorded time from intubation to first in-bed and out-of-bed mobilization. Results Eighteen patients were screened with PENT and 88.9% had abnormal responses. Mean time between intubation and first screening was 94.38 (± 22.41) hours. Seven patients (38.9%) had CIP, two (11.1%) had CIM, one (5.6%) had CIP and CIM, six (33.3%) had a pathological response on PENT associated with ICU-acquired weakness (but no SNAP could be performed to differentiate between CIP and CIM) and two patients had (11.1%) had no peripheral deficit. In patients where it could be performed, muscle strength testing concorded with electrophysiological findings. Twelve patients (66.7%) had out-of-bed mobilization 10.8 (± 7.4) days after admission. Conclusion CIP and CIM are frequent in septic shock patients and can be detected before becoming symptomatic with simple bedside tools. Early detection of CIP and CIM opens new possibilities for their timely management through preventive measures such as passive and active mobilization.

Intensive Care Unit (ICU)-Acquired Weakness (ICU-AW) is a generalized muscle weakness that is clinically detected in critical patients and has no plausible etiology other than critical illness. ICU-AW is uncommon in patients undergoing orthotopic liver transplantation (OLT). Our report sheds light on the highest number of ICU-AW cases observed in a single center on OLT patients with early allograft dysfunction. Out of 282 patients who underwent OLT from January 2015 to June 2023, 7 (2.5%) developed generalized muscle weakness in the ICU and underwent neurophysiological investigations. The neurologic examination showed preserved extraocular, flaccid quadriplegia with the absence of deep tendon reflexes in all patients. Neurophysiological studies, including electromyography and nerve conduction studies, showed abnormalities with fibrillation potentials and the rapid recruitment of small polyphasic motor units in the examined muscles, as well as a reduced amplitude of the compound muscle action potential and sensory nerve action potential, with an absence of demyelinating features. Pre-transplant clinical status was critical in all patients. During ICU stay, early allograft dysfunction, acute kidney injury, prolonged mechanical ventilation, sepsis, hyperglycemia, and high blood transfusions were observed in all patients. Two patients were retransplanted. Five patients were alive at 90 days; two patients died. In non-cooperative OLT patients, neurophysiological investigations are essential for the diagnosis of ICU-AW. In this setting, the high number of red blood cell transfusions is a potential risk factor for ICU-AW.

Purpose: ICU-acquired weakness, comprising Critical Illness Polyneuropathy (CIP) and Myopathy (CIM) is associated with immobilization and prolonged mechanical ventilation. This study aims to assess feasibility of early detection of CIP and CIM by peroneal nerve test (PENT) and sensory sural nerve action potential (SNAP) screening in patients with septic shock and invasively ventilated for more than 72 h. Methods: We performed repetitive PENT screening from 72 h after intubation until detecting a pathological response. We tested SNAPs in pathological PENT to differentiate CIP from CIM. We performed muscle strength examination in awake patients and recorded time from intubation to first in-bed and out-of-bed mobilization. Results: Eighteen patients were screened with PENT and 88.9% had abnormal responses. Mean time between intubation and first screening was 94.38 (± 22.41) hours. Seven patients (38.9%) had CIP, two (11.1%) had CIM, one (5.6%) had CIP and CIM, six (33.3%) had a pathological response on PENT associated with ICU-acquired weakness (but no SNAP could be performed to differentiate between CIP and CIM) and two patients had (11.1%) had no peripheral deficit. In patients where it could be performed, muscle strength testing concorded with electrophysiological findings. Twelve patients (66.7%) had out-of-bed mobilization 10.8 (± 7.4) days after admission. Conclusion: CIP and CIM are frequent in septic shock patients and can be detected before becoming symptomatic with simple bedside tools. Early detection of CIP and CIM opens new possibilities for their timely management through preventive measures such as passive and active mobilization. [ABSTRACT FROM AUTHOR]

This review article summarizes the major clinical studies in neurological emergency and intensive care medicine from the end of 2020 to 2021 on the topics: recanalizing treatment in ischemic stroke, usefulness and effect of brain tissue oxygen monitoring in subarachnoid hemorrhage, efficacy of induced hypothermia in patients with cardiac arrest (CA), value of early cranial imaging after CA, relevance of rapid management and effects of different anticonvulsants in status epilepticus and incidence of critical illness polyneuropathy myopathy in intensive care unit patients with COVID-19 infections. [ABSTRACT FROM AUTHOR]

COVID‐19 patients often develop neuromuscular complications, and critically ill patients often develop ICU‐acquired weakness. We report a COVID‐19 patient who developed flaccid quadriplegia after ECMO therapy and achieved a slow but consistent recovery during a 14‐month period of sustained holistic rehabilitation including early mobilization to an outdoor environment. [ABSTRACT FROM AUTHOR]

Background: Intensive care unit (ICU) acquired weakness is associated with reduced physical function, increased mortality and reduced quality of life, and affects about 43% of survivors of critical illness. Lacking therapeutic options, the prevention of known risk factors and implementation of early mobilization is essential. Robotic assistance devices are increasingly being studied in mobilization. Objective: This qualitative review synthesizes the evidence of early mobilization in the ICU and focuses on the advantages of robotic assistance devices. Results: Active mobilization should begin early during critical care. Interventions commencing 72 h after admission to the ICU are considered early. Mobilization interventions during critical care have been shown to be safe and reduce the time on mechanical ventilation in the ICU and the length of delirious episodes. Protocolized early mobilization interventions led to more active mobilization and increased functional independence and mobility at hospital discharge. In rehabilitation after stroke, robot-assisted training increases the chance of regaining independent walking ability, especially in more severely impaired patients, seems to be safe and increases muscle strength and quality of life in small trials. Conclusion: Early mobilization improves the outcome of the critically ill. Robotic devices support the gait training after stroke and are the subject of ongoing studies on early mobilization and verticalization in the intensive care setting. [ABSTRACT FROM AUTHOR]

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has made a considerable global effect, posing notable challenges for clinicians, the pandemic becoming one of the most imperative international health emergencies lately. Among other more frequent manifestations, SARS-CoV-2 disease may also give rise to skeletal muscle involvement. Viral-induced skeletal muscle involvement is a potentially severe manifestation of COVID-19 (Coronavirus Disease 2019) and may be either acute, or in the context of “long-COVID”. The present review aimed to illustrate few aspects about pathomechanisms, clinical and paraclinical frames, and treatment options for SARS-CoV-2-induced muscle involvement. Notably, it has been stated that SARS-CoV-2 may have the ability to invade muscle myocytes directly, the disease having a variety of clinical manifestations, from myalgia and muscle weakness to rhabdomyolysis. Nevertheless, it is also important to take into account that most of patients with severe forms receiving mechanical ventilation for more than one week may have complications such as CIM (critical illness myopathy) and/or CIP (critical illness polyneuropathy) that may be clinically similar to SARS-CoV-2-induced myositis, yet may be differentiated paraclinically from it. Additionally, it was hypothesized that SARS-CoV-2 infection may constitute a trigger for autoimmune diseases such as polymyositis/ dermatomyositis. Presently, there are no diagnosis criteria and no specific therapeutic strategy for SARS-CoV-2-induced myositis. [ABSTRACT FROM AUTHOR]

Abstract Background Intensive care unit acquired weakness (ICUAW), embraces an array of disorders labeled “critical illness polyneuropathy” (CIP), “critical illness myopathy” (CIM) or “critical illness polyneuromyopathy” (CIPNM). Several studies have addressed the various characteristics of ICUAW, but the recovery is still unclear. Objective The present review investigated the recovery and the long-term functional outcome of subjects with ICUAW, whether the types of ICUAW have different outcomes and whether there is any supporting evidence. Methods Literature search was performed from MEDLINE/PubMed, CINAHL, EMBASE, PeDro, Web of Science and Scopus. Inclusion criteria were: i) sample size including five or more subjects; ii) subjects who suffered from ICUAW and/or CIP, CIM and CIP/CIM; iii) ICUAW ascertained by EMG. Follow-ups longer than one year were defined as long-term. Results Twenty-nine studies met the inclusion criteria. In total, 788 subjects with ICUAW were enrolled: 159 (20.1%) died and 588 (74.6%) were followed. Of all the included patients, 613 (77.7%) had CIP, 82 (10.4%) CIM and 56 (7.1%) CIP/CIM. Overall, 70.3% of the subjects with ICUAW fully recovered. Seven (24.1%) studies had a follow-up longer than 1 year (range 2–8) with 173 (21.9%) subjects enrolled globally and 108 followed. Of these subjects, 88.8% gained full recovery. Most of the studies did not use proper functional scales and only 4 and 3 studies employed the Barthel scale and the Functional Independence Measure (FIM) scale. Differentiation between the types of ICUAW was performed in 7 studies, but only 3 studies reported that subjects with CIM had a better prognosis and earlier recovery than subjects with CIP/CIM. Conclusions Subjects with ICUAW could achieve good recovery and could improve at follow-up. However, the quality of the published studies due to short follow-ups and the paucity of defined outcome measures require confirms.

Aim Our aim was to investigate the possible neuroprotective properties of papaverine in sepsis-induced critical illness neuropathy (SCIN) through the evaluation of various inflammatory biochemical markers, including interleukin 6 (IL-6), C-reactive protein (CRP), and tumor necrosis factor-alpha (TNF-α), and oxidative stress biomarkers, such as malondialdehyde (MDA) and lactic acid. Additionally, evaluation of the HMGB1/RAGE interactions in SCIN was another target of this research. Method To create a sepsis model, a procedure involving intraperitoneal injection of feces was performed on 48 rats. The rats were divided into four equal groups: sham operated, controls and those receiving 20 and 40 mg/kg/day papaverine. After five-day treatments, compound muscle action potential (CMAPs) with electroneuromyography (ENMG) was recorded in all rats. Following ENMG evaluations, the plasma levels of sRAGE, HMGB1, TNF-α, IL-6, CRP, MDA and lactic acid were measured. Results TNF-α, CRP, IL-6, HMGB1, MDA, and lactic acid levels were significantly elevated in the SCIN group, and sRAGE levels were significantly decreased. In recipients of papaverine (20 and 40 mg/kg) treatment, these biochemical findings were improved. Furthermore, electrophysiological findings also showed significant improvement in both 20 and 40 mg/kg papaverine treated groups. Conclusion Papaverine demonstrates neuroprotective effects in a rat model of SCIN. Considering its anti-inflammatory and antioxidant properties, papaverine’s neuroprotective effects possibly stem from the suppression of the RAGE-HMGB1 axis.

Abstract COVID‐19 patients often develop neuromuscular complications, and critically ill patients often develop ICU‐acquired weakness. We report a COVID‐19 patient who developed flaccid quadriplegia after ECMO therapy and achieved a slow but consistent recovery during a 14‐month period of sustained holistic rehabilitation including early mobilization to an outdoor environment.

Background: Intensive care unit-acquired weakness (ICU-AW) is one of the most frequent causes of neuromuscular dysfunction in intensive care medicine. To date no evidence-based recommendations exist for the diagnostics, monitoring or further intensive care treatment. Objective: To evaluate the current clinical practice of diagnostics, monitoring and treatment strategies of ICU-AW on intensive care units in Germany. Material and methods: We conducted an online survey with a self-designed questionnaire and invited 448 members of the Scientific Working Group for Intensive Care Medicine (WAKI) and the Scientific Working Group for Neuroanesthesia (WAKNA) to participate. Results: A total of 68/448 (15.2%) questionnaires were analyzed. Of the participants 13.4% (9/67) stated that a structured diagnostic approach for the detection of ICU-AW is applied in their units. The clinical examination was the preferred method for screening (60/68; 88.2%) and follow-up (57/65; 87.7%). Scores, such as the Medical Research Council sum score (MRC-SS) seem to be less important for the screening (7/68; 10.3%) and follow-up assessment (7/65; 10.8%). Mobilization with physiotherapy (45/68; 66.2%) is the most common strategy applied to treat ICU-AW. A lack of physiotherapists (64/68; 94.1%) and intensive care nurses (57/68; 83.8%) are the main deficits identified in the care of patients with ICU-AW. The majority of the study participants (62/68; 91.2%) would welcome evidence-based guidelines for diagnostics, monitoring and treatment approaches in ICU-AW. Discussion: To date comprehensive recommendations for diagnostics, monitoring, prevention and treatment of ICU-AW are still lacking in German intensive care units. The introduction of new diagnostic approaches could help to detect ICU-AW and therefore to initiate earlier preventive and treatment approaches. [ABSTRACT FROM AUTHOR]

Background and Objectives: Intensive care unit-acquired weakness (ICU-AW) is one of the most frequent neuromuscular complications in critically ill patients. We conducted a global survey to evaluate the current practices of diagnostics, treatment and prevention in patients with ICU-AW. Materials and Methods: A pre-survey was created with international experts. After revision, the final survey was endorsed by the European Society of Intensive Care Medicine (ESICM) using the online platform SurveyMonkey®. In 27 items, we addressed strategies of diagnostics, therapy and prevention. An invitation link was sent by email to all ESICM members. Furthermore, the survey was available on the ESICM homepage. Results: A total of 154 healthcare professionals from 39 countries participated in the survey. An ICU-AW screening protocol was used by 20% (28/140) of participants. Forty-four percent (62/141) of all participants reported performing routine screening for ICU-AW, using clinical examination as the method of choice (124/141, 87.9%). Almost 63% (84/134) of the participants reported using current treatment strategies for patients with ICU-AW. The use of treatment and prevention strategies differed between intensivists and non-intensivists regarding the reduction in sedatives (80.0% vs. 52.6%, p = 0.002), neuromuscular blocking agents (76.4% vs. 50%, p = 0.004), corticosteroids (69.1% vs. 37.2%, p < 0.001) and glycemic control regimes (50.9% vs. 23.1%, p = 0.002). Mobilization and physical activity are the most frequently reported treatment strategies for ICU-AW (111/134, 82.9%). The availability of physiotherapists (92/134, 68.7%) and the lack of knowledge about ICU-AW within the medical team (83/134, 61.9%) were the main obstacles to the implementation of the strategies. The necessity to develop guidelines for the screening, diagnosing, treatment and prevention of ICU-AW was recognized by 95% (127/133) of participants. Conclusions: A great heterogeneity regarding diagnostics, treatment and prevention of ICU-AW was reported internationally. Comprehensive guidelines with evidence-based recommendations for ICU-AW management are needed. [ABSTRACT FROM AUTHOR]

Intensive care unit-acquired weakness (ICUAW) is one of the most common causes of muscle atrophy and functional disability in critically ill intensive care patients. Clinical examination, manual muscle strength testing and monitoring are frequently hampered by sedation, delirium and cognitive impairment. Many different attempts have been made to evaluate alternative compliance-independent methods, such as muscle biopsies, nerve conduction studies, electromyography and serum biomarkers. However, they are invasive, time-consuming and often require special expertise to perform, making them vastly impractical for daily intensive care medicine. Ultrasound is a broadly accepted, non-invasive, bedside-accessible diagnostic tool and well established in various clinical applications. Hereby, neuromuscular ultrasound (NMUS), in particular, has been proven to be of significant diagnostic value in many different neuromuscular diseases. In ICUAW, NMUS has been shown to detect and monitor alterations of muscles and nerves, and might help to predict patient outcome. This narrative review is focused on the recent scientific literature investigating NMUS in ICUAW and highlights the current state and future opportunities of this promising diagnostic tool.

Echogenicity of peripheral nerves in high-resolution ultrasound (HRUS) provides insight into the structural damage of peripheral nerves in various polyneuropathies. The aim of this study was to compare nerve echogenicity in different primarily axonal or demyelinating polyneuropathies to examine the significance of this parameter. Performing semi-automated echogenicity analysis and applying Image J, we retrospectively used HRUS images of 19 patients with critical illness polyneuropathy (CIP), and 27 patients with chemotherapy-induced polyneuropathy (CIN) and compared them to 20 patients with chronic inflammatory demyelinating polyneuropathy (CIDP). The fraction of black representing echogenicity was measured after converting the images into black and white. The nerves of patients with progressive CIDP significantly differed from the hyperechogenic nerves of patients with other polyneuropathies at the following sites: the median nerve at the forearm (p < 0.001), the median nerve at the upper arm (p < 0.004), and the ulnar nerve at the upper arm (p < 0.001). The other polyneuropathies showed no notable differences. Altogether, the comparison of echogenicity between different polyneuropathies supports the assumption that there are differences depending on the genesis of the structural nerve damage. However, these differences are slight, and cannot be used to show clear differences between each polyneuropathy form. [ABSTRACT FROM AUTHOR]

Ample evidence exists that intensive care unit (ICU) treatment and invasive ventilation induce a transient or permanent decline in muscle mass and function. The functional deficit is often called ICU-acquired weakness with critical illness polyneuropathy (CIP) and/or myopathy (CIM) being the major underlying causes. Histopathological studies in ICU patients indicate loss of myosin filaments, muscle fiber necrosis, atrophy of both muscle fiber types as well as axonal degeneration. Besides medical prevention of risk factors such as sepsis, hyperglycemia and pneumonia, treatment is limited to early passive and active mobilization and one third of CIP/CIM patients discharged from ICU never regain their pre-hospitalization constitution. Electromyostimulation [EMS, also termed neuromuscular electrical stimulation (NMES)] is known to improve strength and function of healthy and already atrophied muscle, and may increase muscle blood flow and induce angiogenesis as well as beneficial systemic vascular adaptations. This systematic review aimed to investigate evidence from randomized controlled trails (RCTs) on the efficacy of EMS to improve the condition of critically ill patients treated on ICU. A systematic search of the literature was conducted using PubMed (Medline), CENTRAL (including Embase and CINAHL), and Google Scholar. Out of 1,917 identified records, 26 articles (1,312 patients) fulfilled the eligibility criteria of investigating at least one functional measure including muscle function, functional independence, or weaning outcomes using a RCT design in critically ill ICU patients. A qualitative approach was used, and results were structured by 1) stimulated muscles/muscle area (quadriceps muscle only; two to four leg muscle groups; legs and arms; chest and abdomen) and 2) treatment duration (≤10 days, >10 days). Stimulation parameters (impulse frequency, pulse width, intensity, duty cycle) were also collected and the net EMS treatment time was calculated. A high grade of heterogeneity between studies was detected with major cofactors being the analyzed patient group and selected outcome variable. The overall efficacy of EMS was inconclusive and neither treatment duration, stimulation site or net EMS treatment time had clear effects on study outcomes. Based on our findings, we provide practical recommendations and suggestions for future studies investigating the therapeutic efficacy of EMS in critically ill patients. Systematic Review Registration : [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021262287]. [ABSTRACT FROM AUTHOR]

Ample evidence exists that intensive care unit (ICU) treatment and invasive ventilation induce a transient or permanent decline in muscle mass and function. The functional deficit is often called ICU-acquired weakness with critical illness polyneuropathy (CIP) and/or myopathy (CIM) being the major underlying causes. Histopathological studies in ICU patients indicate loss of myosin filaments, muscle fiber necrosis, atrophy of both muscle fiber types as well as axonal degeneration. Besides medical prevention of risk factors such as sepsis, hyperglycemia and pneumonia, treatment is limited to early passive and active mobilization and one third of CIP/CIM patients discharged from ICU never regain their pre-hospitalization constitution. Electromyostimulation [EMS, also termed neuromuscular electrical stimulation (NMES)] is known to improve strength and function of healthy and already atrophied muscle, and may increase muscle blood flow and induce angiogenesis as well as beneficial systemic vascular adaptations. This systematic review aimed to investigate evidence from randomized controlled trails (RCTs) on the efficacy of EMS to improve the condition of critically ill patients treated on ICU. A systematic search of the literature was conducted using PubMed (Medline), CENTRAL (including Embase and CINAHL), and Google Scholar. Out of 1,917 identified records, 26 articles (1,312 patients) fulfilled the eligibility criteria of investigating at least one functional measure including muscle function, functional independence, or weaning outcomes using a RCT design in critically ill ICU patients. A qualitative approach was used, and results were structured by 1) stimulated muscles/muscle area (quadriceps muscle only; two to four leg muscle groups; legs and arms; chest and abdomen) and 2) treatment duration (≤10 days, >10 days). Stimulation parameters (impulse frequency, pulse width, intensity, duty cycle) were also collected and the net EMS treatment time was calculated. A high grade of heterogeneity between studies was detected with major cofactors being the analyzed patient group and selected outcome variable. The overall efficacy of EMS was inconclusive and neither treatment duration, stimulation site or net EMS treatment time had clear effects on study outcomes. Based on our findings, we provide practical recommendations and suggestions for future studies investigating the therapeutic efficacy of EMS in critically ill patients.Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021262287].

Patients with COVID-19 may develop a range of neurological disorders. We report here 4 COVID-19 subjects with intensive care unit-acquired weakness and their functional outcome. In addition, a scoping review of COVID-19 literature was performed to investigate this issue. Of the post-COVID-19 patients admitted to our Neuro-Rehabilitation Unit, 4 (3 males, 1 female; mean age 59.2 ± 8.62 years) had intensive care unit-acquired weakness, diagnosed with electromyography. Muscle strength and functional evaluation were performed on all patients with Medical Research Council, Disability Rating Scale and Functional Independence Measure, respectively, at admission, discharge and 6-month follow-up after discharge. Electromyography revealed that 3 subjects had critical illness polyneuropathy and 1 had critical illness polyneuropathy/critical illness myopathy. At follow-up, the 3 subjects with critical illness polyneuropathy reached full recovery. The patient with critical illness polyneuropathy/critical illness myopathy showed moderate disability requiring bilateral ankle foot-orthosis and support for ambulation. The scoping review retrieved 11 studies of COVID-19 patients with intensive care unit-acquired weakness, concerning a total of 80 patients: 23 with critical illness myopathy (7 probable), 21 with critical illness polyneuropathy (8 possible), 15 with critical illness polyneuropathy and myopathy (CIPNM) and 21 with intensive care unit-acquired weakness. Of 35 patients who survived, only 3 (8.5%) reached full recovery. All 3 had critical illness myopathy, but 2 of these had a diagnosis of probable critical illness myopathy. Intensive care unit-acquired weakness commonly occurred in subjects with COVID-19. Recovery was variable and a low percentage reached full recovery. However, the heterogeneity of studies did not allow definitive conclusions to be drawn. LAY ABSTRACT Patients with COVID-19 may develop a range of neurological disorders. We report here 4 cases of COVID-19 patients with intensive care unit-acquired weakness and their functional outcome. In addition, a scoping review of the COVID-19 literature was performed to investigate the occurrence of, and recovery from, intensive care unit-acquired weakness and sub-types (critical illness polyneuropathy, critical illness myopathy and critical illness polyneuropathy/critical illness myopathy) in subjects with COVID-19. Of these 4 patients, the 3 patients with critical illness polyneuropathy reached full recovery. The patient with critical illness polyneuropathy/critical illness myopathy showed moderate disability, requiring use of a bilateral device (ankle foot-orthosis). The scoping review of studies of COVID-19 patients with intensive care unit-acquired weakness retrieved a total of 80 patients: 21 with intensive care unit-acquired weakness, 23 with critical illness myopathy, 21 with critical illness polyneuropathy, and 15 with critical illness polyneuropathy/critical illness myopathy. Intensive care unit-acquired weakness commonly occurred in COVID-19 subjects, but the outcome was variable and a low percentage reached full recovery. COVID-19 subjects can develop long-term consequences and limitations, particularly those with intensive care unit-acquired weakness, who need more rehabilitation. New rehabilitative strategies and well-designed studies investigating the benefit of rehabilitation are necessary.

Background: Intensive care unit acquired weakness (ICUAW), embraces an array of disorders labeled "critical illness polyneuropathy" (CIP), "critical illness myopathy" (CIM) or "critical illness polyneuromyopathy" (CIPNM). Several studies have addressed the various characteristics of ICUAW, but the recovery is still unclear.Objective: The present review investigated the recovery and the long-term functional outcome of subjects with ICUAW, whether the types of ICUAW have different outcomes and whether there is any supporting evidence.Methods: Literature search was performed from MEDLINE/PubMed, CINAHL, EMBASE, PeDro, Web of Science and Scopus. Inclusion criteria were: i) sample size including five or more subjects; ii) subjects who suffered from ICUAW and/or CIP, CIM and CIP/CIM; iii) ICUAW ascertained by EMG. Follow-ups longer than one year were defined as long-term.Results: Twenty-nine studies met the inclusion criteria. In total, 788 subjects with ICUAW were enrolled: 159 (20.1%) died and 588 (74.6%) were followed. Of all the included patients, 613 (77.7%) had CIP, 82 (10.4%) CIM and 56 (7.1%) CIP/CIM. Overall, 70.3% of the subjects with ICUAW fully recovered. Seven (24.1%) studies had a follow-up longer than 1 year (range 2-8) with 173 (21.9%) subjects enrolled globally and 108 followed. Of these subjects, 88.8% gained full recovery. Most of the studies did not use proper functional scales and only 4 and 3 studies employed the Barthel scale and the Functional Independence Measure (FIM) scale. Differentiation between the types of ICUAW was performed in 7 studies, but only 3 studies reported that subjects with CIM had a better prognosis and earlier recovery than subjects with CIP/CIM.Conclusions: Subjects with ICUAW could achieve good recovery and could improve at follow-up. However, the quality of the published studies due to short follow-ups and the paucity of defined outcome measures require confirms. [ABSTRACT FROM AUTHOR]

Our aim was to investigate the possible neuroprotective properties of papaverine in sepsis-induced critical illness neuropathy (SCIN) through the evaluation of various inflammatory biochemical markers, including interleukin 6 (IL-6), C-reactive protein (CRP), and tumor necrosis factor-alpha (TNF-α), and oxidative stress biomarkers, such as malondialdehyde (MDA) and lactic acid. Additionally, evaluation of the HMGB1/RAGE interactions in SCIN was another target of this research. To create a sepsis model, a procedure involving intraperitoneal injection of feces was performed on 48 rats. The rats were divided into four equal groups: sham operated, controls and those receiving 20 and 40 mg/kg/day papaverine. After five-day treatments, compound muscle action potential (CMAPs) with electroneuromyography (ENMG) was recorded in all rats. Following ENMG evaluations, the plasma levels of sRAGE, HMGB1, TNF-α, IL-6, CRP, MDA and lactic acid were measured. TNF-α, CRP, IL-6, HMGB1, MDA, and lactic acid levels were significantly elevated in the SCIN group, and sRAGE levels were significantly decreased. In recipients of papaverine (20 and 40 mg/kg) treatment, these biochemical findings were improved. Furthermore, electrophysiological findings also showed significant improvement in both 20 and 40 mg/kg papaverine treated groups. Papaverine demonstrates neuroprotective effects in a rat model of SCIN. Considering its anti-inflammatory and antioxidant properties, papaverine's neuroprotective effects possibly stem from the suppression of the RAGE-HMGB1 axis. [ABSTRACT FROM AUTHOR]

Introduction:The aim of this study was to determine the frequency of patients with critical illness polyneuropathy/myopathy followed by mechanical ventilator in the intensive care unit, and to determine the risk factors associated with this condition and discuss them with the literature.Methods:This study was performed retrospectively (August 2012 to August 2017), at a tertiary university hospital in Turkey. A total of 31 patients who were on mechanical ventilation and diagnosed with polyneuropathy/myopathy by electroneuromyography (ENMG) during pediatric intensive care unit follow-up were included in the study. Data were collected from patient files and computer system. Demographic characteristics of the patients, causes of hospitalization, underlying disease, length of the pediatric intensive care unit and hospital stay, length of mechanical ventilation, and treatment modalities were recorded. Patients without respiratory support and patients on mechanical ventilation without ENMG procedures were excluded.Results:A total of 31 patients were included in the study. Myopathy was present in 5/31 (16.1%) and polyneuropathy in 26/31 (83.9%) patients. Respiratory distress/failure was the most common cause of respiratory support (n=10, 32.3%) and the second most common cause was post cardiac surgery (n=9, 29%). The diagnosis of 18 (58%) patients were sepsis and 2 (6.4%) patients had multiple organ failure. The mean duration of mechanical ventilation was 27.4±14.1 days, length of pediatric intensive care unit stay was 41.5±24 days, length of hospital stay was 57.5±27.5 days. Mortality was observed in 5 (16.1%) of 31 patients.Conclusion:Critical illness polyneuropathy and myopathy in intensive care practice is a condition with increasing frequency and importance. Increased attention to this matter allows to take the necessary preventions, early recognition and to make the appropriate approach.

The new COVID-19 coronavirus infection, which has become a pandemic, is a very dangerous disease, the clinical picture of which can vary from mild to extremely severe forms of the course. Currently, there are no complete data on the pathogenetic mechanism of SARS-CoV-2, but there are extensive data on the probable risk factors for the development of extremely severe forms of COVID-19. The study of such factors becomes most suitable in terms of preventing their development and influence on the course of the disease in individuals with compromised immune systems and patients with impaired neuromuscular transmission. The article describes two clinical cases of extremely severe COVID-19 in patients with impaired neuromuscular transmission. Based on the analysis of the course of diseases, the conclusions are made about the possible aggravation and mutual activation of the immunopathological process with the launch of the cascade mechanism of the cytokine storm. An assumption has been made about the influence of human leukocyte antigen (HLA) on the severity of COVID-19, which is confirmed by a positive dynamics against the background of administration of IVIG, glucocorticosteroids (GCS), virusinactivated plasma and extracorporeal detoxification methods.

Coronavirus disease 2019 (COVID-19) is the most dramatic pandemic of the new millennium and patients with serious infection can stay in intensive care unit (ICU) for weeks in a clinical scenario of systemic inflammatory response syndrome, likely related to the subsequent development of critical illness polyneuropathy (CIP). It is in fact now accepted that COVID-19 ICU surviving patients can develop CIP; moreover, prone positioning-related stretch may favor the onset of positioning-related peripheral nerve injuries (PNI). Therefore, the urgent need to test drug candidates for the treatment of these debilitating sequelae is emerged even more. For the first time in medical literature, we have successfully treated after informed consent a 71-year-old Italian man suffering from post-COVID-19 CIP burdened with positioning-related PNI of the left upper extremity by means of ultramicronized palmitoylethanolamide 400 mg plus ultramicronized luteolin 40 mg (Glìalia), two tablets a day 12 hours apart for 6 months. In the wake of our pilot study, a larger clinical trial to definitively ascertain the advantages of this neuroprotective, neurotrophic, and anti-inflammatory therapy is advocated., (© 2024 Society for Indian Hand Surgery and Micro Surgeons. Published by Elsevier B.V. All rights reserved.)

There has been tremendous growth in patients requiring critical care with severe infections. During a prolonged stay in the intensive care unit (ICU), patients develop critical illness polyneuropathy (CIP). The early identification of neurological involvement requires special attention during ICU care. We describe two cases who developed complete motor weakness after a prolonged stay in ICU. Patients were successfully managed with pyridostigmine and testosterone hormonal therapy initially and later with pyridostigmine only. The present case series highlights the need for early recognition, assessment, and novel management of CIP in ICU patients. However, the role of nutrition, physiotherapy, and supportive care is equally essential for the successful outcome in these patients.

Background: Diagnosis of intensive care unit acquired weakness (ICUAW) is challenging. Pathogenesis of underlying critical illness polyneuromyopathy (CIPNM) remains incompletely understood. This exploratory study investigated whether longitudinal neuromuscular ultrasound examinations and cytokine analyses in correlation to classical clinical and electrophysiological assessment contribute to the understanding of CIPNM. Methods: Intensive care unit patients were examined every 7 days until discharge from hospital. Clinical status, nerve conduction studies, electromyography as well as ultrasound of peripheral nerves and tibial anterior muscle were performed. Cytokine levels were analyzed by a bead-based multiplex assay system. Results: Of 248 screened patients, 35 patients were included at median of 6 days (IQR: 8) after admission to intensive care unit. Axonal damage was the main feature of CIPNM. At the peak of CIPNM (7 days after inclusion), nerve ultrasound showed cross-sectional area increase of tibial nerve as a sign of inflammatory edema as well as hypoechoic nerves as a possible sign of inflammation. Cytokine analyses showed signs of monocyte and macrophage activation at this stage. Fourteen days after inclusion, cytokines indicated systemic immune response as well as profiles associated to neovascularization and regeneration. Conclusions: Exploratory neuromuscular ultrasound and cytokine analyses showed signs of inflammation like macrophage and monocyte activation at the peak of CIPNM followed by a systemic immune response parallel to axonal damage. This underlines the role of both axonal damage and inflammation in pathogenesis of CIPNM. [ABSTRACT FROM AUTHOR]