ICU Acquired Weakness Mobilisation Nutrition. ICU Acquired Weakness CRITICALLY ILL 20/10/2017. X. Wittebole Critical Care Department

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1 ICU Acquired Weakness Mobilisation Nutrition X. Wittebole Critical Care Department CRITICALLY ILL 2 ICU Acquired Weakness 1915: Sr W. OSLER The Principles of Medicine VIIIth Edition «Neuromuscular Dysfunction in patients with sepsis» Olsen CW. J Am Med Assoc.1956; 160(1):39-41 MacFarlane IA et al. Lancet.1977; 2(8038):615 Bolton CF et al. J Neurol Neurosurg Psychiatry.1985; 47(11):

2 ICU Acquired Weakness Stevens RD et al. Crit Care Med.2009; 37: S299-S308 4 DEFINITION: ICU Acquired Weakness ICU-acquired weakness designates clinically detected weakness in critically ill patients in whom there is no plausible etiology other than critical illness. 3 sub-categories Stevens RD et al. Crit Care Med.2009; 37: S299-S308 5 ICU Acquired Weakness 3 DISTINCT FORMS: CRITICAL ILLNESS POLYNEUROPATHY Affects the limbs (particularly lower extremities) Symetric pattern Weakness is most notable in proximal neuromuscular areas Facial and ocular muscles are rarely involved No demyelination ( Guillain-Barré) CRITICAL ILLNESS MYOPATHY Primary myopathy Difficult to distinguish from CIP by means of a bedside examination 6 2

3 ICU Acquired Weakness 3 DISTINCT FORMS: CRITICAL ILLNESS POLYNEUROPATHY Affects the limbs (particularly lower extremities) Symetric pattern Weakness is most notable in proximal neuromuscular areas Facial and ocular muscles are rarely involved MIXED No demyelination ( Guillain-Barré) CRITICAL ILLNESS MYOPATHY Primary myopathy Difficult to distinguish from CIP by means of a bedside examination 7 ICU Acquired Weakness 3 DISTINCT FORMS: CRITICAL ILLNESS POLYNEUROPATHY Affects the limbs (particularly lower extremities) Symetric pattern Weakness is most notable in proximal neuromuscular areas Facial and ocular muscles are rarely involved No demyelination ( Guillain-Barré) + CRITICAL ILLNESS MYOPATHY Primary myopathy Difficult to distinguish from CIP by means of a bedside examination VENTILATOR INDUCED DIAPHRAGMATIC DYSFUNCTION (VIDD) Involvement of the respiratory muscles 8 ICU Acquired Weakness HOW TO TRANSLATE? Polyneuropathie des soins intensifs??? Myopathie des soins intensifs??? 9 3

4 ICU Acquired Weakness HOW TO TRANSLATE? Polyneuropathie des soins intensifs??? Myopathie des soins intensifs??? Critical Illness Polyneuropathy Critical Illness Myopathy NEURO- ou MYOPATHIE DU PATIENT CRITIQUE 10 Friedrich O et al. Physiol Rev.2015; 95: NERVE: Polyneuropathy with axonal degeneration Microvascular injury with nerve ischemia Sodium channel dysfunction Mitochondrial injury MUSCLE: Skeletal muscle wasting Microvascular ischemia Catabolism Immobility Kress and Hall. NEJM.2014; 370:

Batt et al. AJRCCM.2013; 187(3):238-246 13 C.I.N. or C.I.P.

to the nerve and axonal death Mitochondrial dysfunction Channelopathy (Natrium) Small Fiber Neuropathy Nonlength-dependent small fiber neuropathy Responsible of

5 Batt et al. AJRCCM.2013; 187(3): C.I.N. or C.I.P. Axonal degeneration Microvascular changes in the endoneuriom Vascular permeability Penetration of toxic factors into the nerve ends Nerve edema Impaired energy delivery to the nerve and axonal death Mitochondrial dysfunction Channelopathy (Natrium) Small Fiber Neuropathy Nonlength-dependent small fiber neuropathy Responsible of neuropathic pain, stocking and glove sensory loss, numbness, cold extremities, burning pain. Autonomic dysfunction Axonal degeneration of the vagal nerve and sympathic chain documented on autopsy findings Hermans G et al. Crit Care.2015; 19: Batt et al. AJRCCM.2013; 187(3):

microcorculation Denervation Protein synthesis / breakdown imbalance Muscle atrophy

6 C.I.M. Inflammation Immobilisation Endocrine stress response Nutrition Deficit Impaired microcorculation Denervation Protein synthesis / breakdown imbalance Muscle atrophy (Myosin loss) Disorganisation of sarcomeres Ultrastructural abnormalities Electrical hypoexcitability 16 Friedrich O et al. Physiol Rev.2015; 95: Puthucheary et al. JAMA

7 Puthucheary et al. JAMA.2013 Puthucheary et al. JAMA.2013 Puthucheary et al. JAMA

(Manual Muscle Testing MRC Score) Electromyography

8 Levine S et al. NEJM.2008; 358: Hermans G et al. Cochrane Database Syst Rev.2014;CD DIAGNOSIS Physical Examination (Manual Muscle Testing MRC Score) Electromyography Nerve Conduction Studies Direct Muscle Stimulation Muscle or Nerve Biopsy Fan et al. AJRCCM.2014; 190(12):

9 DIAGNOSIS lack of consensus on surveillance, diagnostic method, timing of evaluation Fan et al. AJRCCM.2014; 190(12): Jolley SE. Chest.2016; 150(5): Hermans G et al. AJRCCM.2014;190(4):

Physiol Rev.2015; 95:1025-1109 29 WHAT CAN WE DO?

10 35% Matched Population 30% p < y mortality % 25% 20% 15% 10% 17% 31% 5% 0% not weak weak Hermans G et al. AJRCCM.2014;190(4): RISK FACTORS Friedrich O et al. Physiol Rev.2015; 95: WHAT CAN WE DO? ASSESS NUTRITIONAL STATUS AVOID NEURO-MYO TOXIC AGENTS EARLY MOBILISATION? INSULIN THERAPY? NUTRITION? 30 10

11 Wishmeyer P et al. Crit Care.2015; 19:S6 31 Wishmeyer P et al. Crit Care.2015; 19:S6 32 NUTRITION STATUS 33 11

12 NUTRITION STATUS Taylor BE et al. Crit Care Med NUTRITION STATUS Lefrant JY et al. Ann Fr Anesth Rean NUTRITION STATUS Mice study Critical Care Patients study / D7 In Vivo biopsies of the vastus lateralis Post mortem biopsies of the rectus abdominis Goossens C et al. J Cachexia Sarcopenia Muscle.2016; 36 12

EARLY MOB In every movement of the body, whenever one

13 EARLY MOB In every movement of the body, whenever one begins to endure pain, it will be relieved by rest. HIPPOCRATES AN Hippocrates. The genuine works of Hippocrates. London: The Sydenham society, HILTON, , Guy s Hospital Lancet Ries E. JAMA.1899;XXXIII(8): Ries E. JAMA.1899;XXXIII(8):

EARLY MOB Ries E. JAMA.1899;XXXIII(8):454-6.

thrombosis, Pulmonary edema, Bone atrophy, Muscle-wasting, Vasomotor

14 EARLY MOB Ries E. JAMA.1899;XXXIII(8): EARLY MOB Bedrest is associated with: Atelectasis, Venous thrombosis, Pulmonary edema, Bone atrophy, Muscle-wasting, Vasomotor instability, Constipation, Backache Allen C et al. Lancet.1999; 354: EARLY MOB Needham. JAMA.2008;300:

(6) Make B et al. Chest.1984; 86:358-65.

APACHE II > 10 NMBA for 7 days 3 hours, 3 times a day of

15 EARLY MOB Burns RJ. Chest ventilator dependent patients COPD (10) Restrictive (6) Make B et al. Chest.1984; 86: critically ill patients with major trauma or sepsis and APACHE II > 10 NMBA for 7 days 3 hours, 3 times a day of continuous passive motion Muscle biopsy at day 1 and day 7 Fibre area surface Griffiths R et al. Nutrition.1995;11:

Muscle g protein / g wet weight p = 0,04 between groups Ratio of muscle protein to DNA Significant decrease in group1 Griffiths R et al. Nutrition.1995;11:428-32.

both groups (more pronounced in A) Nava S et al. Arch Phys Med Rehabil.1998; 79:849-54.

16 Muscle g protein / g wet weight p = 0,04 between groups Ratio of muscle protein to DNA Significant decrease in group1 Griffiths R et al. Nutrition.1995;11: patients admitted bc of acute COPD exacerbation Randomization 3/1 Stepwise rehabilitation program vs usual care + : Increased MIP in group A Decreased dyspnea VAS in both groups (more pronounced in A) Nava S et al. Arch Phys Med Rehabil.1998; 79: ICU patients on MV for less than 72 hours Ususal care (with daily sedation interruption) vs early exercise and mobility Increased functional status Decreased delirium Decreased MV duration ICU length of stay Schweickert et al. Lancet.2009;373:

Schweickert et al. Lancet.2009;373: 1874-82. 49 E.M.

glycemic goals. Pathel BK et al. Chest.2014; 146:583-9.

17 Schweickert et al. Lancet.2009;373: E.M. significantly reduces insulin requirements (two thirds) to achieve similar glycemic goals. Pathel BK et al. Chest.2014; 146: Orthopaedic patients Muscle Surface Area Maintenance of CSA and muscle protein syntehsis Gibson JNA et al. Lancet.1988; 8614:

18 52 53 Hermans G et al. Cochrane Database Syst Rev.2014;CD

19 NUTRITION Lefrant JY et al. Ann Fr Anesth Rean.2014 Taylor BE et al. Crit Care Med.2016 Hurt RT et al. Nutr Clin Pract ! Patient insuffisant rénal épuré et patient obèse Lefrant JY et al. Ann Fr Anesth Rean Taylor BE et al. Crit Care Med

20 Taylor BE et al. Crit Care Med Taylor BE et al. Crit Care Med Taylor BE et al. Crit Care Med

21 Critical Care Nutrition. Canadian Clinical Practice guidelines 2015: summary of revisions to the recommendations. %20CPGs%202015%20vs% pdf

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Critical Illness Neuropathy

Critical Illness Neuropathy JILL McEWEN, MD FRCPC Clinical Professor & Director Undergraduate Education Program Department of Emergency Medicine University of British Columbia Vancouver, BC Canada Immediate