Skip to main content

Advertisement

Log in

Critical illness polyneuromyopathy: the electrophysiological components of a complex entity

  • Original
  • Published:
Intensive Care Medicine Aims and scope Submit manuscript

Abstract

Objective

To evaluate the spectrum and time profile of electrophysiological parameters in the detection of neuromuscular involvement in critically ill patients and establish their correlation with biopsy findings.

Design

Prospective clinical and neurophysiological study.

Setting

One general and one neurological intensive care unit in a university hospital.

Patients

Forty-six critically ill patients with failure of at least two organ systems were enrolled and completed the 1-month follow up.

Interventions

Detailed clinical and electrophysiological evaluation including direct muscle stimulation was performed in all cases on entry and at the end of the follow-up. Muscle biopsy was performed in 11, and sural nerve biopsy in 5, cases.

Measurements and results

Electrophysiological signs of new or progressing neuromuscular involvement at the end of the first month were detected in 26 patients (56%) and could be classified into three groups: "pure motor syndrome" (12 cases), combined motor syndrome and sensory polyneuropathy (13 cases) and isolated sensory polyneuropathy (1 case). Direct muscle stimulation showed decreased muscle membrane excitability in 11 of these abnormal cases. Muscle biopsy disclosed various myopathic abnormalities in all 11 cases examined with motor syndrome, in 7 of them in association with denervation/re-innervation changes.

Conclusions

Electrophysiological and histological examinations showed significant overlapping of several pathogenic components of neuromuscular involvement in critically ill patients, namely decreased muscle excitability, myopathy, axonal motor neuropathy and sensory neuropathy. The characterisation of the electrophysiological components of a complex polyneuromyopathy is preferred to the strict categorisation of abnormalities into critical illness myopathy and polyneuropathy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1a–c.
Fig. 2a–c.

Similar content being viewed by others

References

  1. Bolton CF, Brown JD, Sibbald WJ (1983) The electrophysiological investigation of respiratory paralysis in critically ill patients. Neurology 33:186

    Google Scholar 

  2. Bolton CF, Gilbert JJ, Hahn AF, Sibbald WA (1984) Polyneuropathy in critically ill patients. J Neurol Neurosurg Psychiatry 47:1223–1231

    CAS  PubMed  Google Scholar 

  3. Lopez Messa JB, García A (1990) Acute polyneuropathy in critically ill patients. Intensive Care Med 16:159–162

    PubMed  Google Scholar 

  4. Zochodne DW, Bolton CF, Wells GA, Gilbert JJ, Hahn AF, Brown JD, Sibbald WA (1987) Critical illness polyneuropathy. A complication of sepsis and multiple organ failure. Brain 110:819–842

    PubMed  Google Scholar 

  5. Witt NJ, Zochodne DW, Bolton CF, Grand'Maison F, Wells G, Young GB, Sibbald WJ (1991) Peripheral nerve function in sepsis and multiple organ failure. Chest 99:176–184

    CAS  PubMed  Google Scholar 

  6. MacFarlane IA, Rosenthal FD (1977) Severe myopathy after status asthmaticus. Lancet 2:615–620

    CAS  Google Scholar 

  7. Barohn RJ, Jackson CE, Rogers SJ, Ridings LW, McVey AL (1994) Prolonged paralysis due to non-depolarizing neuromuscular blocking agents and corticosteroids. Muscle Nerve 17:647–654

    CAS  PubMed  Google Scholar 

  8. Helliwel TR, Coakley JH, Wagenmakers AJ, Griffiths RD, Campbell IT, Green CJ, McClelland P, Bone JM (1991) Necrotizing myopathy in critically ill patients. J Pathol 164:307–314

    CAS  PubMed  Google Scholar 

  9. Latronico N, Fenzi F, Recupero D, Guarneri B, Tomelleri G, Tonin P, De Maria G, Antonini L, Rizzuto N, Candiani A. (1996) Critical illness myopathy and neuropathy. Lancet 347:1579–1582

    CAS  PubMed  Google Scholar 

  10. Bolton CF, Breuer AC (1999) Critical illness polyneuropathy. Muscle Nerve 22:419–424

    Article  CAS  PubMed  Google Scholar 

  11. Lacomis D, Zochodne DW, Bird SJ (2000) Critical illness myopathy. Muscle Nerve 23:1785–1788

    Article  CAS  PubMed  Google Scholar 

  12. Op de Coul AAW, Lambregts PCLA, Koeman J, van Puyenbroek PJ, Ter Laak HJ, Gabreels-Festen AA (1985) Neuromuscular complications in patients given Pavulon (pancuronium bromide) during artificial ventilation. Clin Neurol Neurosurg 87:17–22

    PubMed  Google Scholar 

  13. Lycklama A, Nijeholt J, Troost J (1987) Critical illness polyneuropathy. In: Vinken PJ, Bruyn GW, Klawans HL (eds) Handbook of Clinical Neurology Vol.51, revised series 7. Elsevier/North Holland, Amsterdam, pp 575–585

  14. Wijdicks EF, Litchy WJ, Harrison BA, Gracey DR (1994) The clinical spectrum of critical illness polyneuropathy. Mayo Clin Proc 69:955–959

    CAS  PubMed  Google Scholar 

  15. Gorson KC, Ropper AH (1993) Acute respiratory failure neuropathy: a variant of critical illness polyneuropathy. Crit Care Med 21:267–271

    CAS  PubMed  Google Scholar 

  16. Trojaborg W, Weimer LH, Hays AP (2001) Electrophysiologic studies in critical illness associated weakness: myopathy or neuropathy—a reappraisal. Clin Neurophysiol 112:1586–1593

    Google Scholar 

  17. Coakley JH, Nagendran K, Yarwood GD, Honavar M, Hinds CJ (1998) Patterns of neurophysiological abnormality in prolonged critical illness. Intensive Care Med 24:801–807

    Google Scholar 

  18. Gutmann L, Gutmann L (1999) Critical illness neuropathy and myopathy. Arch Neurol 56:527–528

    Article  CAS  PubMed  Google Scholar 

  19. Schwarz J, Planck J, Briegel J, Straube A (1997) Single-fibre electromyography, nerve conduction studies and conventional electromyography in patients with critical-illness polyneuropathy: evidence for a lesion of terminal motor axons. Muscle Nerve 20:696–701

    Google Scholar 

  20. Tepper M, Rakic S, Haas JA, Woittiez AJJ (2000) Incidence and onset of critical illness polyneuropathy in patients with septic shock. Neth J Med 56:211–214

    Google Scholar 

  21. Tennila A, Salmi T, Pettila V, Roine RO, Varpula T, Takkunen O (2000) Early signs of critical illness polyneuropathy in ICU patients with systemic inflammatory response syndrome or sepsis. Intensive Care Med 26:1360–1363

    PubMed  Google Scholar 

  22. Rich MM, Teener JW, Raps EC, Schotland DL, Bird SJ (1996) Muscle is electrically inexcitable in acute quadriplegic myopathy. Neurology 46:731–736

    CAS  PubMed  Google Scholar 

  23. Rich MM, Bird SJ, Raps EC, Mc Cluskey LF, Teener JW (1997) Direct muscle stimulation in acute quadriplegic myopathy. Muscle Nerve 20:665–673

    Article  CAS  PubMed  Google Scholar 

  24. Rich MM, Pinter MJ (2003) Crucial role of sodium channel fast inactivation in muscle fibre inexcitability in a rat model of critical illness myopathy. J Physiol 547:555–566

    Article  CAS  PubMed  Google Scholar 

  25. Rich MM, Pinter MJ (2001) Sodium channel inactivation in an animal model of acute quadriplegic myopathy. Ann Neurol 50:26–33

    Article  CAS  PubMed  Google Scholar 

  26. Op de Coul AAV, Verheul AAW, Leyten ACM, Schellens RLLA, Teepen JLJM (1991) Critical illness polyneuromyopathy after artificial respiration. Clin Neurol Neurosurg 93:27–33

    PubMed  Google Scholar 

  27. De Letter MA, van Doorn PA, Savelkoul HF, Laman JD, Schmitz PI, Op de Coul AA, Visser LH, Kros JM, Teepen JL, van der Meche FG (2000) Critical illness polyneuropathy and myopathy (CIPNM): evidence for local immune activation by cytokine-expression in the muscle tissue. J Neuroimmunol 106:206–213

    Article  PubMed  Google Scholar 

  28. Breuer AC (1999) An outdated concept. Muscle Nerve 22:422–424

    Article  Google Scholar 

  29. Vincent JL, de Mendonca A, Cantraine F, Moreno R, Takala J, Suter PM, Sprung CL, Colardyn F, Blecher S (1998) Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on "sepsis-related problems" of the European Society of Intensive Care Medicine. Crit Care Med 26:1793–1800

    CAS  PubMed  Google Scholar 

  30. Moreno R, Vincent JL, Matos R, Mendonca A, Cantraine F, Thijs L, Takala J, Sprung C, Antonelli M, Bruining H, Willatts S (1999) The use of maximum SOFA score to quantify organ dysfunction/failure in intensive care. Results of a prospective, multicentre study. Working Group on Sepsis-related Problems of the ESICM. Intensive Care Med 25:686–696

    Article  PubMed  Google Scholar 

  31. Aid to the examination of peripheral nervous system (1976) Memorandum No.45. HMSO, London

  32. Bone RC, Sprung CL, Sibald WBJ (1992) Definitions for sepsis and organ failure. Crit Care Med 20:724–726

    CAS  PubMed  Google Scholar 

  33. Stalberg E, Nandedkar SD, Sanders DB, Falck B (1996) Quantitative motor unit potential analysis. J Clin Neurophysiol 13:401–422

    Google Scholar 

  34. Dubowitz V (1985) Definition of pathological changes seen in muscle biopsies. In: Dubowitz (ed) Muscle biopsy: a practical approach. Balliére Tindal, East Sussex, pp 82–129

  35. Geller TJ, Kaiboriboon K, Fenton GA, Hayat GR (2001) Vecuronium-associated axonal motor neuropathy: a variant of critical illness polyneuropathy? Neuromuscul Disord 11:579–582

    Google Scholar 

  36. Gooch JL, Suchyta MR, Balbierz MJ, Petajan JH, Clemmer TP (1991) Prolonged paralysis after treatment with neuromuscular junction agents. Crit Care Med 19:1125–1131

    CAS  PubMed  Google Scholar 

  37. Bazzi P, Moggio M, Prelle A, Sciacco M, Messina S, Barbieri S, Tonin P, Tomelleri G, Battistel A, Adobbati L, Checcarelli N, Veschi G, Scarlato G (1999) Critically ill patients: immunological evidence of inflammation in muscle biopsy. Clin Neuropathol 18:23–30

    CAS  PubMed  Google Scholar 

  38. Hund E (1999) Myopathy in critically ill patients. Crit Care Med 27:2544–2547

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Josef Bednarik.

Additional information

The study was supported by the Internal Grant Agency of the Ministry of Health of The Czech Republic-Grant No NF/5980-3

An editorial regarding this article can be found in the same issue (http://dx.doi.org/10.1007/s00134-003-1884-y)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Bednarik, J., Lukas, Z. & Vondracek, P. Critical illness polyneuromyopathy: the electrophysiological components of a complex entity. Intensive Care Med 29, 1505–1514 (2003). https://doi.org/10.1007/s00134-003-1858-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00134-003-1858-0

Keywords

Navigation