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Clinical review: intensive care unit acquired weakness

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Abstract

A substantial number of patients admitted to the ICU because of an acute illness, complicated surgery, severe trauma, or burn injury will develop a de novo form of muscle weakness during the ICU stay that is referred to as “intensive care unit acquired weakness” (ICUAW). This ICUAW evoked by critical illness can be due to axonal neuropathy, primary myopathy, or both. Underlying pathophysiological mechanisms comprise microvascular, electrical, metabolic, and bioenergetic alterations, interacting in a complex way and culminating in loss of muscle strength and/or muscle atrophy. ICUAW is typically symmetrical and affects predominantly proximal limb muscles and respiratory muscles, whereas facial and ocular muscles are often spared. The main risk factors for ICUAW include high severity of illness upon admission, sepsis, multiple organ failure, prolonged immobilization, and hyperglycemia, and also older patients have a higher risk. The role of corticosteroids and neuromuscular blocking agents remains unclear. ICUAW is diagnosed in awake and cooperative patients by bedside manual testing of muscle strength and the severity is scored by the Medical Research Council sum score. In cases of atypical clinical presentation or evolution, additional electrophysiological testing may be required for differential diagnosis. The cornerstones of prevention are aggressive treatment of sepsis, early mobilization, preventing hyperglycemia with insulin, and avoiding the use parenteral nutrition during the first week of critical illness. Weak patients clearly have worse acute outcomes and consume more healthcare resources. Recovery usually occurs within weeks or months, although it may be incomplete with weakness persisting up to 2 years after ICU discharge. Prognosis appears compromised when the cause of ICUAW involves critical illness polyneuropathy, whereas isolated critical illness myopathy may have a better prognosis. In addition, ICUAW has shown to contribute to the risk of 1-year mortality. Future research should focus on new preventive and/or therapeutic strategies for this detrimental complication of critical illness and on clarifying how ICUAW contributes to poor longer-term prognosis.

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Abbreviations

ARDS:

Acute respiratory distress syndrome

CIM:

Critical illness myopathy

CIP:

Critical illness polyneuropathy

CMAP:

Compound muscle action potential

EMG:

Electromyography

EMS:

Electrical muscle stimulation

GDF-15:

Growth and differentiation factor-15

ICUAW:

Intensive care unit acquired weakness

MOF:

Multiple organ failure

MRC:

Medical Research Council

NCS:

Nerve conduction studies

PICS:

Post intensive care syndrome

SIRS:

Systemic inflammatory response syndrome

SNAP:

Sensory nerve action potential

VIDD:

Ventilator-induced diaphragmatic dysfunction

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Acknowledgements

This work was supported by the Research Foundation-Flanders (FWO), Belgium (G.0399.12, G.0592.12). GH received a Postdoctoral Fellowship from the Clinical Research Fund (KOF) of the University Hospitals Leuven, Belgium. GVdB, via the University of Leuven, receives structural research financing via the Methusalem program, funded by the Flemish Government (METH08/07), and holds an ERC Advanced grant (AdvG-2012-321670) from the Ideas Program of the EU FP7.

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  1. Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium

    Greet Hermans & Greet Van den Berghe

  2. Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium

    Greet Hermans

  3. Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium

    Greet Van den Berghe

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  1. Greet Hermans
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  2. Greet Van den Berghe
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Correspondence to Greet Hermans.

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The authors declare that they have no competing interests.

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Hermans, G., Van den Berghe, G. Clinical review: intensive care unit acquired weakness. Crit Care 19, 274 (2015). https://doi.org/10.1186/s13054-015-0993-7

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