Acquired neuromuscular disorders in the intensive care unit
Acquired neuromuscular disorders in the intensive care unit
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DOI：
10.1164/rccm.200302-191up
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发表时间：
2003-10-01
影响因子：
24.7
通讯作者：
Curtis, JR
中科院分区：
文献类型：
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作者：
Deem, S;Lee, CM;Curtis, JR
在重症监护病房(ICU)住院1周或更长时间(1-3周)的大多数患者中，都可以发现由于危重疾病而出现的神经肌肉异常。疾病的范围从局部疼痛或虚弱的孤立神经卡压，到轻度虚弱的废用性肌肉萎缩，到伴随着严重的、长期的虚弱的严重肌病或神经病变。这次更新的重点是与弥漫性、严重虚弱相关的障碍。获得性神经肌肉无力的患病率和影响可能比人们普遍认为的更大。超过50%的机械通气超过7天的患者会出现电生理异常(4)，25-33%的患者会出现临床明显的虚弱(5，6)。获得性神经肌肉功能障碍与脱离机械通气困难、住院费用增加和死亡率增加有关(3，7)。这一问题的潜在经济影响是巨大的，据估计，由于ICU后天性神经肌肉无力，每个患者平均多收66,000.00美元的医院费用(1996年美元)(8)。由于现有文献在报告、检测和术语上的不一致，很难对ICU获得性神经肌肉疾病进行明确的分类。例如，只有一些描述ICU虚弱症状的术语和相关的缩写包括危重病多发性神经病(CIP或CIPN)、神经肌肉疾病(NMD)、急性四肢瘫痪肌病(AQM)、危重疾病神经肌肉异常(CINMA)和ICU获得性瘫痪(ICUAP)。更复杂的是，研究表明，被诊断为重症多发性神经病(CIPN)的患者实际上可能有肌病，即使不是主要原因，也是导致虚弱的原因之一。这导致了一个额外的术语，危重疾病多发性神经病和肌病(CIPNM)，这反映了在ICU获得的虚弱综合征的肌病和神经病原因的难以区分。最后，尽管在严重急性哮喘和其他类型的呼吸衰竭患者中首次描述的所谓的急性四肢瘫痪肌病(AQM)通常被描述为一个独立的实体，但AQM和CIPNM之间存在重叠。鉴于上述警告，本更新集中于导致ICU严重弥漫性虚弱的三个原因：长期神经肌肉阻断、CIPNM和AQM，并讨论了这些疾病的共同和独特特征。我们的目标是提高人们的意识-
Neuromuscular abnormalities developing as a consequence of critical illness can be found in the majority of patients hospitalized in the intensive care unit (ICU) for 1 week or more (1–3). The spectrum of illness ranges from isolated nerve entrapment with focal pain or weakness, to disuse muscle atrophy with mild weakness, to severe myopathy or neuropathy with associated severe, prolonged weakness. This update focuses on disorders associated with diffuse, severe weakness. The prevalence and impact of acquired neuromuscular weakness is likely larger than generally recognized. Greater than 50% of patients mechanically ventilated for more than 7 days will develop electrophysiologic abnormalities (4), with 25–33% developing clinically overt weakness (5, 6). Acquired neuromuscular dysfunction is associated with difficulty in separating from mechanical ventilation, increased hospital costs, and increased mortality (3, 7). The potential economic impact of this problem is large, with one estimate of an average of $66,000.00 per patient in excess hospital charges attributable to acquired neuromuscular weakness in the ICU (1996 US dollars)(8). A clear classification of ICU-acquired neuromuscular disorders is difficult because of inconsistencies in reporting, testing, and terminology in the existing literature. For example, just some of the terms describing weakness syndromes in the ICU and the associated acronyms include critical illness polyneuropathy (CIP or CIPN), neuromuscular disorders (NMDs), acute quadriplegic myopathy (AQM), critical illness neuromuscular abnormalities (CINMAs), and ICU-acquired paresis (ICUAP). To complicate matters further, studies suggest that patients diagnosed with critical illness polyneuropathy (CIPN) may in fact have myopathy as a contributing if not primary cause of weakness. This has lead to the coining of an additional term, critical illness polyneuropathy and myopathy (CIPNM), which reflects the difficulty discriminating between myopathic and neuropathic causes of weakness syndromes acquired in the ICU. Last, although the so-called acute quadriplegic myopathy (AQM) first described in patients with severe acute asthma and other types of respiratory failure has often been described as a distinct entity, there is overlap between AQM and CIPNM. Given the above caveats, this update focuses on three causes of severe, diffuse weakness in the ICU: prolonged neuromuscular blockade, CIPNM, and AQM, and discusses the shared and unique features of these disorders. Our goal is to increase aware-