Critical illness polyneuropathy: Clinical findings and outcomes of a frequent cause of neuromuscular weaning failure
Critical illness polyneuropathy: Clinical findings and outcomes of a frequent cause of neuromuscular weaning failure
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DOI：
10.1097/00003246-199608000-00010
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发表时间：
1996-08-01
影响因子：
8.8
通讯作者：
Hacke, W
中科院分区：
文献类型：
--
作者：
Hund, EF;Fogel, W;Hacke, W
目的：描述神经肌肉原因导致无法脱离机械通气支持的危重患者的临床和电生理特征和结局。设计：前瞻性、连续病例系列。设置：大学医院的神经科、神经外科和内科重症监护室。患者：3年期间7例无法脱离机械通气的患者，肺部并发症不能解释。干预措施：测量和主要结果：所有患者在发病后3 ~ 6周（中位数4.5周）进行详细的电诊断检查，并在3个月至3.5年后对存活的患者进行重复检查，原发疾病包括各种颅内和内科疾病。所有患者均出现中度至重度肢体无力伴明显肌肉萎缩，3例患者腱反射减弱，2例颅内病变患者腱反射增强，2例患者腱反射消失，肌电图显示严重急性失神经支配，近端肌肉明显受累，肌肉和神经活检显示严重神经源性萎缩和轴突变性，无炎症。没有原发性肌病的证据。2例患者死于败血症并发症，存活者中，3例患者复查时除1例患者出现腓神经麻痹外，无进一步无力。2例患者仍处于恢复期，病情明显改善，但仍显示近端肌肉轻微无力。通过电生理学，慢性神经源性损伤的迹象是显而易见的，在所有幸存者在follow-up.Conclusions：危重病多发性神经病是一个常见的原因，神经肌肉脱机失败的危重患者，无论类型的原发性疾病，近端（包括面部和椎旁）肌肉的参与是惊人的。腱反射通常被保留。中枢神经系统损伤的患者也可能发生重症多发性神经病，后者的腱反射甚至可能被夸大，重症多发性神经病的恢复通常很快，临床上完全，尽管电诊断研究不完全。残余周围神经损伤（通常为腓神经）是不完全恢复的最常见特征，强调需要进行仔细的电生理检查，以澄清危重患者神经肌肉紊乱的性质和程度，未能认识到这些患者神经病变的发展可能会导致关于他们脱离呼吸机的能力的错误结论。
Objective: To describe clinical and electrophysiologic features and outcomes of critically ill patients with neuromuscular causes of failure to wean from mechanical ventilator support.Design: A prospective, consecutive, case series.Setting: Neurological, neurosurgical, and medical intensive care units in a university hospital.Patients: Seven patients during a 3-yr period with failure to wean from mechanical ventilation not explained by pulmonary complications.Interventions: Muscle and nerve biopsy in three patients.Measurements and Main Results: Detailed electrodiagnostic studies were done in all patients 3 to 6 wks (median 4.5) after the onset of the acute illness and were repeated 3 months to 3.5 yrs later in those patients who survived, primary illnesses included various intracranial and medical conditions. All patients had moderate-to-severe limb weakness with marked muscle atrophy, Tendon reflexes were decreased in three patients, exaggerated in two patients with intracranial lesions, and absent in two patients, Electromyography demonstrated severe acute denervation, with striking involvement of proximal muscles, Muscle and nerve biopsies showed severe neurogenic atrophy and axonal degeneration without inflammation. There was no evidence of primary myopathy. Two patients died of complications of sepsis, Of the survivors, three patients had no further weakness at the time of reexamination, except for peroneal nerve palsy in one patient, Two patients, still in the recovery period, showed markedly improved conditions but still showed slight weakness of the proximal muscles. By electrophysiology, signs of chronic neurogenic damage were demonstrable in all survivors at follow-up.Conclusions: Critical illness polyneuropathy is a frequent cause of neuromuscular weaning failure in critically ill patients, regardless of the type of primary illness, Involvement of proximal (including facial and paraspinal) muscles is striking. Tendon reflexes are often preserved. Patients with central nervous system injury may likewise develop critical illness polyneuropathy, In these latter patients, tendon reflexes may even be exaggerated, Recovery from critical illness polyneuropathy is usually rapid and clinically complete, although incomplete on electrodiagnostic study. Residual peripheral nerve lesion, generally of the peroneal nerve, is the most frequent feature of incomplete recovery, The need for careful electrophysiologic testing is emphasized to clarify the nature and extent of neuromuscular disturbances in critically ill patients, Failure to recognize the development of neuropathy in these patients may read to erroneous conclusions about the ability to wean them from the ventilator.