Critical Illness Polyneuropathy (CIP)

Introduction

Clinicians in Intensive Care Unit

Critical Illness Polyneuropathy (CIP) is a comprehensive diffuse weakness with rapid or minimal onset in critically ill patients most commonly sepsis respiratory failure multisystem organ failure or septic inflammatory response syndrome (SIRS). Clinical presentation includes late weakness damage and loss of sensation as well as paresthesia and reduced or absent deep tendon reflexes.[1]

Intensive Care Unit Acquired weakness (ICUAW) includes 3 subcategories:

1. Critical Illness Polyneuropathy (CIP)
2. Chronic Illness Myopathy (CIM) .
3. Chronic Disease Neuromyopathy (CINM)[2].

Pathological Process

The pathophysiology for CIP remains unclear and complex with human studies focusing on axonal degeneration [3].

It is hypothesized to be connected to:

• Chemical nutrient metabolites and toxic substances
• A long ICU stay
• The number of invasive procedures
• Hyperglycemia
• Decreased albumin level
• The Severity of multisystem organ failure.

There were risks including several of the above ie. Sepsis; THE LORD; Multi Organ Failure (MOF); Female Gender; Prolonged Organ Dysfunction; Length of ICU Stay; Ionotropic Support; Mental Behavior; Low Serum Albumin; High blood sugar levels; Arterial Stenosis; Corticosteroids[4] .

[4].

Clinical Presentation

Visser (2006) [5] reports that clinical features of CIP typically include:

• Soft Tissue: Mainly in the lower extremities. This should be assumed if there is a decrease in limb motion following pain stimulation of the distal limb. Mild weakness can be identified in a harmonic fashion.
• Absence of Facial Disease: Scalp nerves are rarely affected.
• Tissue Damage: Found in one-third of patients
• Decreased Nerve Conduction: Motor sensation is usually present at the onset of the disease but decreases over time.
• It is difficult to wean from a Ventilator
• Loss of Sensation: Although difficult to evaluate with a sedated or intubated patient.
• Cognitive Disturbance: It is suggested that cerebral palsy is also common

Diagnostic Procedures

ICU unit

Although rarely performed, the gold standard for diagnosing critical illness neuropathy remains the electrodiagnostic test. This includes nerve conduction studies and needle electromyography. However, while EMG is the best method for diagnosing CIP, performing Completion of studies in an ICU setting, including electrical interference edema, hypothermia, peripheral edema, or limiting patient participation in the examination. [6]

• Currently no validated biomarkers are available.
• Although infrequently performed CIP will exhibit features of denervation and reinnervation, small muscle fiber-type grouping and fiber group atrophy with extensive axonal degeneration of motor and sensory nerves. Muscle biopsy may show absence of thick filaments, which is common In association with CIM, there is evidence of CIP-related denervation and reinnervation changes and axonal degeneration [7].

Differential Diagnosis

• Guillain-barre syndrome (GBS)
• Trauma: If muscle weakness occurs after trauma, spinal cord or head injury should be ruled out, as spinal cord shock can cause muscle weakness and loss of reflexes [5]
• Neuromuscular blockade: Prolonged neuromuscular blockade can lead to the development of acute quadriplegic myopathy, identifiable by repeated nerve stimulation. This can be reversed by giving cholinesterase inhibitors. Sensation and reflexes are usually unaffected [5]
• Critical illness myopathy (CIM): CIP and CIM frequently coexist during ICUAW[8] .

Coincident illness include:

• Eaton-Lambert Syndrome: A rare autoimmune disorder that causes muscle weakness in the body
• Myasthenia Gravis: A rare, chronic disease that often affects the optic nerve and eyelids eating away at swallowing and speech and other parts of the body.
• Vasculitis: Inflammation of blood vessels.

Outcome Measures

The Oxford Muscle Grading System helps diagnose CIP. A two-dimensional test of shoulder abduction elbow flexion wrist extension hip flexion knee extension and dorsiflexion of the ankle will yield a total score of 60[4]. 48/60 indicates ICUAW or significant weakness and MRC score below 36/48 indicates severe weakness[9].

Management

Semirecumbent positioning

When CIP is identified, an interprofessional team of physicians physiotherapists occupational therapists speech therapists nutritionists social workers and case managers work together to plan for early mobilization and aggression dressing in many aspects.

Medical management

1. Glycemic Control: Studies have shown that acute insulin therapy for hyperglycemia reduced the risk of acute polyneuropathy and myopathy and reduced the duration of ventilation a it is supported by length of intensive care unit stay and 180-day mortality
2. Optimising Nutrition
3. Treatment of Sepsis: Effective and prompt treatment of sepsis is likely to reduce the incidence of CIP. Treatment strategies to reduce this risk are based on the use of semi- recumbent positioning with low-intensity mechanical ventilation and inappropriate or inappropriate use of sedation well vasoconstrictors[5]. See Sedation in Critically Ill Patients
4. The potent neuromuscular relaxants of neuromuscular blockers (NMBAs) prevent neuromuscular disease and paralysis: Several studies have shown an association between ICUAW and neuromuscular dysfunction between the inhibitors. It is recommended that constant vigilance is needed when using NMBAs in critically ill patients choosing the appropriate NMBA for each individual followed by an evidence-based protocol to ensure appropriate sedation and analgesia measured by neuromuscular restricted and dangerous physical therapy lives at a time when reduced mobility[10][5].

Physiotherapy

Early mobility ICU

The duration of retirement is now being recognized as an important factor to address when managing CIP.

Early rehabilitation is a key focus of the NICE guidelines (2009 guidelines reviewed December 2022 no new evidence affects the recommendations in this guideline.)[11].

Early mobilization facilitates and prolongs patient recovery and functional independence shortening ventilation and hospitalization[12]. Treatment should be tailored to the patient’s description and may include:

• Passive range of movement to maintain muscle length and prevent contractures due to prolonged bed rest.
• Supported active/dynamic exercises to improve strength and endurance.
• When placed in bed to improve lung function.
• Sit on the edge of the bed for easy trunk control / balance.
• To sit in a chair to improve lung function (either by pat slide hoist standing hoist or transfers).
• Mobilizing improves lung function cardiovascular strength muscle strength and promotes independence.

Be careful by reviewing the Basic Capacity for Initial Discharge in the ICU and the Basic Communication Protocol for Critical Care Patients

Resources

NICE Guidelines (2009): Adjustment after Critical Illness

Cochrane Review: Interventions for the prevention of acute polyneuropathy and acute myopathy

A hospital management system for emergency physical therapy and mobilization of critically ill patients: an integration of evidence and expert opinion and translation into practice.

Guidelines for the Delivery of Critical Care Services