1. Critical IllnessCritical Illness Polyneuropathy (CIP)Polyneuropathy (CIP) Current Opionion in Critical CareCurrent Opionion in Critical Care vol 8(4) August 2002, pp. 302-310vol 8(4) August 2002, pp. 302-310 Presented by RiPresented by Ri

2. Critical Illness PolyneuropathyCritical Illness Polyneuropathy (CIP)(CIP) DefinitionDefinition EpidemiologyEpidemiology OnsetOnset DiagnosisDiagnosis Risk factorRisk factor TherapyTherapy Prognosis and OutcomePrognosis and Outcome 3. DefinitionDefinition An acute, predominantly motor axonalAn acute, predominantly motor axonal polyneuropathy occurring in critically illpolyneuropathy occurring in critically ill patients.patients. Flaccid tetraparesis, failure to weanFlaccid tetraparesis, failure to wean Cranial nerves are sparedCranial nerves are spared -- Movement discrepancy about painMovement discrepancy about pain Distal > proximal with muscle atrophyDistal > proximal with muscle atrophy DTR or absent (13~100%)DTR or absent (13~100%) - CIP cant be r/o with DTR presence- CIP cant be r/o with DTR presence 4. EpidemiologyEpidemiology 5. OnsetOnset Few study have addressedFew study have addressed Evidence of very early onset of CIPEvidence of very early onset of CIP - 80% within 72hr (Dutch study)- 80% within 72hr (Dutch study) - 100% in 2~5 days- 100% in 2~5 days (Finland study)(Finland study) 6. DiagnosisDiagnosis Clinical presentationClinical presentation Laboratory parametersLaboratory parameters Electrophysiologic studiesElectrophysiologic studies Nerve and muscle biopsyNerve and muscle biopsy Additional techniqueAdditional technique Differential diagnosisDifferential diagnosis 7. Clinical PresentationClinical Presentation Difficulty weaning from ventilatorDifficulty weaning from ventilator Distal weakness with DTR Distal weakness with DTR - encephalopathy- encephalopathy - sedation- sedation - specificity of DTR test- specificity of DTR test 8. Laboratory ParametersLaboratory Parameters Not diagnosticNot diagnostic Creakine kinase levelsCreakine kinase levels - Normality do not rule out N-M disease- Normality do not rule out N-M disease - marginally raised or normal in CIP- marginally raised or normal in CIP - other contributing factor- other contributing factor (convulsions, ischemia..)(convulsions, ischemia..) 9. Electrophysiologic StudiesElectrophysiologic Studies Nerve conduction studiesNerve conduction studies andand EMGEMG - valuable and sensitive- valuable and sensitive - pure axonal polyneuropathy- pure axonal polyneuropathy - severity quantification- severity quantification 10. Electrophysiologic StudiesElectrophysiologic Studies Nerve conduction studiesNerve conduction studies:: - amplitude of compound motor AP- amplitude of compound motor AP - severe muscle atrophy?- severe muscle atrophy? - amplitude of sensory nerve AP- amplitude of sensory nerve AP - tissue edema?- tissue edema? - latency and velocity are unchanged- latency and velocity are unchanged - repetitive stimulation r/o N-M synapse dz- repetitive stimulation r/o N-M synapse dz - muscle biopsy r/o myopathy- muscle biopsy r/o myopathy 11. Electrophysiologic StudiesElectrophysiologic Studies Electromyographic studiesElectromyographic studies:: - signs of denervation- signs of denervation - spontaneous activity with fibrillations- spontaneous activity with fibrillations - positive sharp waves- positive sharp waves - diaphramatic denervation:- diaphramatic denervation: - diaphramatic needle EMG- diaphramatic needle EMG - phrenic nerve conduction study + EMG- phrenic nerve conduction study + EMG 12. Nerve and muscle biopsyNerve and muscle biopsy Have not been performed as routine.Have not been performed as routine. No inflammatory changes were foundNo inflammatory changes were found Nerve biopsy:Nerve biopsy: - No demyelination was found- No demyelination was found - Discrepancy between histologic and- Discrepancy between histologic and electrophysiologic studieselectrophysiologic studies - Early impairment of axonal transport and- Early impairment of axonal transport and transmembrane potentialtransmembrane potential Normal histological study cannot r/o CIPNormal histological study cannot r/o CIP 13. Nerve and muscle biopsyNerve and muscle biopsy Muscle biopsyMuscle biopsy - Atrophy of type II fibers: denervation- Atrophy of type II fibers: denervation - Fiber necrosis in 30%- Fiber necrosis in 30% - Primary or secondary?- Primary or secondary? - No clear relationship with neurophysiology- No clear relationship with neurophysiology - Low motor amplitudes with normal sensory- Low motor amplitudes with normal sensory neurography, and little spontaneous activityneurography, and little spontaneous activity Critical Illness Myo- and (poly)NeuropathyCritical Illness Myo- and (poly)Neuropathy - CRIMYNE- CRIMYNE 14. Additional TechniqueAdditional Technique Quantitative EMGQuantitative EMG Muscle fiber excitability by direct muscleMuscle fiber excitability by direct muscle stimulationstimulation - differentiate myopathy and neuropathy- differentiate myopathy and neuropathy 15. Differential diagnosisDifferential diagnosis 16. Differential diagnosisDifferential diagnosis 17. Risk factorsRisk factors Systemic inflammatory response syndrome /or sepsisSystemic inflammatory response syndrome /or sepsis SteroidsSteroids Neuromuscular blocking agentsNeuromuscular blocking agents Aminoglycoside antibioticsAminoglycoside antibiotics Total parenteral nutritionTotal parenteral nutrition Vasopressor support (>3d)Vasopressor support (>3d) Immune mechanisms (neurotoxic factor)Immune mechanisms (neurotoxic factor) Neurologic failure (GCS3d) Immune mechanisms (neurotoxic factor)Immune mechanisms (neurotoxic factor) Neurologic failure (GCS