Abstract
Objective: The evaluation of incidences and relating factors of severe persisting critical illness polyneuropathy (CIP) in survivors of multiple organ failure (MOF). Design: Prospective study with an entry period of 24 months. Electrophysiological studies for the diagnosis of CIP were performed 1 or 2 days before the patients were discharged from the intensive care unit (ICU). Factors which might have been related to the development of CIP were identified by a retrospective chart analysis.
Setting: The interdisciplinary ICU of a university hospital.
Patients: Thirty-three patients who survived MOF. Sixteen of these critically ill patients developed severe sepsis due to nosocomial infections with gram-negative bacteria.
Results: In seven survivors of MOF and sepsis typical electrophysiological features of CIP, like spontaneous fibrillations and low compound muscle action potentials, were detectable at the time of discharge from the ICU. Seventeen patients with MOF following multiple trauma who developed no sepsis, and nine survivors of MOF with sepsis showed no signs of persisting CIP at the end of their ICU stay. Chart analysis revealed that eight survivors of MOF with sepsis and without the development of CIP had been treated with intravenous immunoglobulin (IVIG) with a dosage of 0.3 g/kg per day for 3 days immediately (within 24 h) after the diagnosis of sepsis. Four out of seven patients with MOF and sepsis who developed CIP were transferred to our ICU after the onset of sepsis and had not received IVIG treatment. The IVIG treatment in three patients was delayed for more than 24 h after the diagnosis of sepsis and was then omitted. Obviously not related to the development of CIP were aminoglycoside antibiotics, steroids, nutritional disturbances and episodes of hypotension or hypoxia. Neuromuscular blocking agents were not used during intensive care treatment.
Conclusions: A high incidence of severe CIP persisting until the day of discharge from the ICU was related to gram-negative sepsis but not to MOF alone. Retrospective chart analysis suggested that early application of IVIG may prevent or mitigate this severe complication. However, these results have to be confirmed in a prospective, placebo-controlled study.
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References
Bolton CF, Gilbert JJ, Hahn AF, Sibbald WJ (1984) Polyneuropathy in critically ill patients. J Neurol Neurosurg Psychiatry 47 1223–1231
Bolton CF, Young GB, Zochodne DW (1993) The neurological complications of sepsis. Ann Neurol 33: 94–100
Leijten FSS, De Weerd AW (1994) Critical illness polyneuropathy. A review of the literature, definition and pathophysiology. Clin Neurol Neurosurg 96: 10–19
Bolton CF (1993) Neuromuscular complications of sepsis. Intensive Care Med 19: 58–63
Bolton CF (1996) Sepsis and the systemic inflammatory response syndrome: Neuromuscular manifestations. Crit Care Med 24:1408–1416
Op de Coul AAW, Lambregts PCLA, Koeman J, Van Puyenbroek MJE, Ter Laak HL, Gabreels Festen AAWM (1985) Neuromuscular complications in patients given pavulon (pancuronium bromide) during artificial respiration. Clin Neurol Neurosurg 87:17–22
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
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
Lopez Messa JB, Garcia A (1990) Acute polyneuropathy in critically ill patients. Intensive Care Med 16: 159–162
Leijten FSS, Handrick-de Weerd JE, Poortvliet DCJ, De Weerd AW (1995) The role of polyneuropathy in motor convalescence after prolonged mechanical ventilation. JAMA 274:1221–1225
Goris JA, Te Boekhorst TPA, Nuytinck KS, Gimberère JSF (1985) Multiple organ failure. Arch Surg 120:1109–1115
Baker SP (1976) The injury severity score: An update. J Trauma 16: 882–885
Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RMH, Sibbald WJ (1992) ACCP/SCCM consensus conference. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 101: 1644–1655
Ramsay MAE, Savege TM, Simpson BRJ, Goodwin R (1974) Controlled sedation with alphaxalone-alphadalone. BMJ 2: 656–659
Stephan W, Dichtelmüller H, Schedel I (1985) Properties and efficacy of a human immunoglobulin M preparation for intravenous administration. Drug Res 35: 933–936
Bolton CF, Laverty DA, Brown JD, Witt NJ, Hahn AF, Sibbald WJ (1986) Critical ill polyneuropathy: electrophysiological studies and differentiation from Guilain-Barré syndrome. J Neurol Neurosurg Psychiatry 49: 563–573
Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13: 818–829
Thijs LG, Schneider AJ, Groeneveld ABJ (1990) The haemodynamics of septic shock. Intensive Care Med 16 [Suppl3]:S182-S186
Ellman H (1984) Capillary permeability in septic patients. Crit Care Med 12: 629–633
Hund EF, Fogel W, Krieger D, DeGeorgia M, Hacke W (1996) Critical illness polyneuropathy: clinical findings and outcomes of a frequent cause of neuromuscular weaning failure. Crit Care Med 24:1328–1333
Benzing G, Iannaccone ST, Bove KE, Keebler PJ, Shockley LL (1990) Prolonged myasthenic syndrome after one week of muscle relaxants. Pediatr Neurol 6:190–196
Segredo V, Matthay MA, Sharma ML, Gruenke LD, Caldwell JE, Miller RD (1990) Prolonged neuromuscular blockade after long-term administration of vecuronium in two critically ill patients. Anesthesiology 72: 566–570
Gooch JL, Suchyta MR, Balbierz JM, Petajan JH, Clemmer TP (1991) Prolonged paralysis after treatment with neuromuscular junction blocking agents. Crit Care Med 19:1125–1131
Werdan K, Pilz G (1996) Supplemental immune globulins in sepsis: a critical appraisal. Clin Exp immunol 104 (Supppl I): 83–90
Mouthon L, Kaveri SV, Spalter SH, Lacroix-Desmazes S, Lefranc C, Desai R, Kazatchkine MD (1996) Mechanisms of action of intravenous immune globulin in immune-mediated diseases. Clin Exp Immunol 104 (Suppl I): 3–9
Kress HG (1994) What is certain in the treatment with immunoglobulins? In: K Reinhart, K Eyrich, C Sprung (eds) Sepsis — Current perspectives in pathophysiology and therapy. Springer, Berlin Heidelberg New York, pp 449–463
Dominioni L, Diongini R, Zanello M, Chiaranda M, Dionigi R, Acquarolo A, Ballabio A, Sguotti C (1991) Effect of high-dose IgG on survival of surgical patients with sepsis scores of 20 or greater. Arch Surg 126: 236–240
Schedel I, Dreikhausen U, Nentwig B, Hoeckenschnieder M, Rauthman D, Balikciouglu S, Coldewey R, Deicher H (1991) Treatment of gram-negative septic shock with an immunoglobulin preparation: A prospective, randomized clinical trial. Crit Care Med 19:1104–1113
Pilz G, Kreuzer E, Kääb S, Appel R, Werdan K (1994) Early sepsis treatment with immunoglobulins after cardiac surgery in score-identified high-risk patients. Chest 105: 76–82
Pilz G, Appel R, Kreuzer E, Werdan K (1997) Comparison of early IgM-enriched immunoglobulin vs polyvalent IgG administration in score-identified postcardiac surgical patients at high risk for sepsis. Chest 111: 419–426
Wijdicks EFM, Fulgham JR (1994) Failure of high dose intravenous immunoglobulins to alter the clinical course of critical illness polyneuropathy [letter]. Muscle Nerve 17:1494–1495
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Mohr, M., Englisch, L., Roth, A. et al. Effects of early treatment with immunoglobulin on critical illness polyneuropathy following multiple organ failure and gram-negative sepsis. Intensive Care Med 23, 1144–1149 (1997). https://doi.org/10.1007/s001340050471
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DOI: https://doi.org/10.1007/s001340050471