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.
Intensive Care Unit Acquired weakness (ICUAW) includes 3 subcategories:
- Critical Illness Polyneuropathy (CIP)
- Chronic Illness Myopathy (CIM) .
- Chronic Disease Neuromyopathy (CINM).
The pathophysiology for CIP remains unclear and complex with human studies focusing on axonal degeneration .
It is hypothesized to be connected to:
- Chemical nutrient metabolites and toxic substances
- A long ICU stay
- The number of invasive procedures
- 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 .
Visser (2006)  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
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. 
- 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 .
- 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 
- 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 
- Critical illness myopathy (CIM): CIP and CIM frequently coexist during ICUAW .
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.
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. 48/60 indicates ICUAW or significant weakness and MRC score below 36/48 indicates severe weakness.
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.
- 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
- Optimising Nutrition
- 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. See Sedation in Critically Ill Patients
- 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.
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.).
Early mobilization facilitates and prolongs patient recovery and functional independence shortening ventilation and hospitalization. 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
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
- ↑ Paz JC, West MP. Acute care handbook for physical therapists e-book. Elsevier Health Sciences; 2019 Oct 12. Available:https://www.sciencedirect.com/book/9781455728961/acute-care-handbook-for-physical-therapists (accessed 26.12.2022)
- ↑ Appleton, R. and Kinsella, J., 2012. Intensive care unit-acquired weakness. Continuing Education in Anaesthesia, Critical Care and Pain, 12(2), pp.62-66.
- ↑ Jump up to:3.0 3.1 Zhou, C., Wu, L., Ni, F., Ji, W., Wu, J. and Zhang, H., 2014. Critical illness polyneuropathy and myopathy: a systematic review. Neural regeneration research, 9(1), p.101.
- ↑ Jump up to:4.0 4.1 4.2 Hermans, G. and Van den Berghe, G., 2015. Clinical review: intensive care unit acquired weakness. Critical care, 19(1), p.274.
- ↑ Jump up to:5.0 5.1 5.2 5.3 5.4 Visser, L.H., 2006. Critical illness polyneuropathy and myopathy: clinical features, risk factors and prognosis. European journal of neurology, 13(11), pp.1203-1212.
- ↑ Plaut T, Weiss L. Electrodiagnostic Evaluation Of Critical Illness Myopathy. InStatPearls [Internet] 2021 Mar 29. StatPearls Publishing. Available:https://www.ncbi.nlm.nih.gov/books/NBK562270/ (accessed 26.12.2022)
- ↑ Shepherd, S., Batra, A. and Lerner, D.P., 2017. Review of critical illness Myopathy and neuropathy. The Neurohospitalist, 7(1), pp.41-48.
- ↑ Pattanshetty, R.B. and Gaude, G.S., 2011. Critical illness myopathy and polyneuropathy-A challenge for physiotherapists in the intensive care units. Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine, 15(2), p.78.
- ↑ Latronico, N. and Gosselink, R., 2015. A guided approach to diagnose severe muscle weakness in the intensive care unit. Revista Brasileira de terapia intensiva, 27(3), pp.199-201.
- ↑ Renew JR, Ratzlaff R, Hernandez-Torres V, Brull SJ, Prielipp RC. Neuromuscular blockade management in the critically Ill patient. Journal of Intensive Care. 2020 Dec;8(1):1-5.Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7245849/ (accessed 26.12.2022)
- ↑ NICE (2009). Rehabilitation after critical illness in adults. Available at: https://www.nice.org.uk/guidance/cG83 [Accessed 26.12.2022].
- ↑ Needham, D.M., 2008. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. Jama, 300(14), pp.1685-1690.