Cin Cim Class

8/22/2019 Cin Cim Class

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CIN CIM

Prevalence time course early lab

diagnosis in severe sepsis

Moderater:Dr RK Singh


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Objectives

Definition of CIN CIM.

Prevalence & Manifestations.

Diagnosis High Risk Cases

Management


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Critical Illness Neuropathy and Myopathy

Critical illness Polyneuropathy ( CIP ) , first

described by Bolton and coleagues in 1986.

Most common acquired neuromuscular

condition in adult ICU.

Almost affects 50 % of patients with sepsis

and MODS.

Neurology Clin. 28 (2010)961-977


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Spectrum of manifestation

Critically ill patient.

Symmetric weakness.

Flaccidity.

Different degree of muscle atrophy.

Reduction or absence of DTR.

Distal loss of sensation.

Facial and opthalmic muscle are less affected.

Different degree of encephalopathy.

Symptoms may start after 3 days of illness.


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NeuromuscularWeaknessRelated to

Critical Illness

Critically ill

ICU settings

Respiratorydysfunction,Ventilated

FlaccidWeakness

Incidence:

Adults, 25% of ICU patients.

Pediatrics, less common.


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How common is critical illness

polyneuropahy & myopathy

Early development of critical illness mypathy

and neuropathy in patients with severe sepsis.

48 patients with severe sepsis in ICU.

Abnormal nerve conduction study (NCS) in

63 %.

50 % of the ptients developed neuromusculardysfunction.

Neurology, 2006 67:1421-5


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Onset time of critical illness myopathy

and/or neuropathy during ICU stay

Multi-center study.

92 ICU patients.

Daily measurement

of action potentialamplitude andnerve conductionvelocity

30 % developedeither CIMP orCINP

Critical Care 2007, 11:R11


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What about children?

How common is CIN CIM?

All children admitted to PICU of Sick Children

Hospital of Toronto over 1 year of age were

evaluated 3 times /week.

Muscle weakness, reduced DTR, inability to

wean MV.

Incidence :14/830 (1.7 %).

3 children under 3 years(0.7 % ) and 11 above

10 years of age (5.1 %)

Neurology 2003 ;61:1779-1782


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ICU Related Neuromuscular weakness

Critical illnessMyopathy

Critical illnessMyopathy

Mixed Type ofboth

ProlongedNMJ blockade

Others

Rhabdomyolysis Cachectic myopathy MyopathiesGBS


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CRITICAL ILLNESS MYOPATHY


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Type of Critical illness Myopathy

Acute necrotizing myopathy

Occur after sepsis and trauma

Generalized muscle weakness

High serum creatine kinase

Myoglobinuria

Myopathy associated with NMB or Corticosteroid

Diffuse muscle weakness

Muscle atrophy


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Incidence

ARDS

3%

OrganTransplant

7%

SevereSepsis

33%

MOF

50 %

Steroid


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CRITICAL

ILLNESSMYOPATHY

Increasedseverity of

disease

SystemicInflammatoryResponse

Steroid

NMB

Hyperglycemia

IV

Steroid

NMB

Strongest factor


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Risk Factors

Sepsis

SIRS

Hyperosmolarity

TPN

GCS


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Muscle weakness in critically ill children

Neurology 2003 ;61:1779-1782

840 patients

14 patients (ave. 12 y/o) developed weakness(1.7 %).

Age distribution 3


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ICU ,

ventilated,

paralysed

IV steroid

for

several

days

CIM

Increased CK (Around D4) ;50-80% might

be without CIM

Failure to wean not related to

cardiopulmonary disease

Flaccid proximal quadriparesis

Normal sensation,DTR normal/decreased

DIAGNOSTIC CRITERIA

Muscle BX, Electron Microscope Loss ofmyosin

Electrphysiological study, Nerve

conduction study,EMG


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Pathology

Scattered atrophic fibers.

Loss of ATPase activity.

Loss of myosin thick filaments.


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Normal

Nerve Stimulation

Direct

muscle

stimulation

Neuropathy

Nerve Stimulation

Direct

muscle

stimulation

Myopathy

Nerve Stimulation

Direct

muscle

stimulation


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Prevention

Management Supportive

Rehabilitation

Avoide the Occurance

PrognosisRecovery withinweeks to months.

Variabe residual

weaknessICU stay ,Morbidity,Mortality.


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CRITICAL ILLNESS POLYNEUROPATHY


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Mechanism

(not clear)

Axonal Degeration

70 %

Intact nerves 30 %


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High Sugar SIRS

Low

Albumin

Sepsis

Crtical Illness

Neuropathy

Major Factors


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CIM CIP

Incidence More common Less Common

Motor system Proximal Distal

Sensory function Preserved Affected

DTR Usually Normal Usually Absent

Facial M Cranial N Preserved Usually Preserved

Prognosis Better, Weeks to months

, Residual weakness

Weeks to months

,Residual Weakness,May

remain quadreplegic

Management Supportive,Preventive,

Insulin

Supportive,Preventive,

Insulin


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ICU ,

ventilated,

paralysedCIP

Sepsis,SIRS

,MOF

DIAGNOSTIC CRITERIA

Failure to wean not related to

cardiopulmonary disease

Flaccid Quadriparesis

Abnormal sensation distally, Cranial N

preserved,DTR Absent or Decreased

Normal CK,Normal CSF proteins

Electrophysiological study,NCS,EMG

Muscle Bx (Treatable Condition)

It is difficult to differenciate

CIM & CIP clinically


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Normal nerve

Nerve Action Potential:

Normal amplitude &

conduction velocity

Axonal Neuropathy:

Nerve Action Potential:

Reduced amplitude & Normalconduction velocity

Demyelinating Neuropathy:

Reduced conduction velocity ,

normal amplitude


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Loss of myelinated

nerve fibers

Dgenerating Myelin

Custers of Schwann

cells without nerve

fibers


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Cin Cim Class

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