Maximum inspiratory pressure, a surrogate parameter for the assessment of ICU-acquired weakness (original) (raw)
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Critical Care, 2015
Introduction: Intensive care unit-acquired weakness (ICU-AW) is a significant problem. There is currently widespread variability in the methods used for manual muscle testing and handgrip dynamometry (HGD) to diagnose ICU-AW. This study was conducted in two parts. The aims of this study were: to determine the inter-rater reliability and agreement of manual muscle strength testing using both isometric and through-range techniques using the Medical Research Council sum score and a new four-point scale, and to examine the validity of HGD and determine a cutoff score for the diagnosis of ICU-AW for the new four-point scale. Methods: Part one involved evaluation of muscle strength by two physical therapists in 29 patients ventilated >48 hours. Manual strength testing was performed by both physical therapists using two techniques: isometric and through range; and two scoring systems: traditional six-point Medical Research Council scale and a new collapsed four-point scale. Part two involved assessment of handgrip strength conducted on 60 patients. A cutoff score for ICU-AW was identified for the new four-point scoring system. Results: The incidence of ICU-AW was 42% (n = 25/60) in this study (based on HGD). In part one the highest reliability and agreement was observed for the isometric technique using the four-point scale (intraclass correlation coefficient = 0.90: kappa = 0.72 respectively). Differences existed between isometric and through-range scores (mean difference = 1.76 points, P = 0.005). In part two, HGD had a sensitivity of 0.88 and specificity of 0.80 for diagnosing ICU-AW. A cutoff score of 24 out of 36 points was identified for the four-point scale.
Brazilian Journal of Health Review
Introduction: With scientific and technological advances, the survival of critically ill patients has increased over the years. However, some patients require prolonged invasive mechanical ventilation (IMV), which can increase the length of stay in the intensive care unit (ICU) and lead to ICU-acquired muscle weakness (ICUAW). There are several tools to diagnose ICUAW, however, most of them depend on patient collaboration, and often, due to sedation, this becomes unfeasible. Objective: To describe the ICUAW assessment instruments in critically ill patients. Methodology: A bibliographic search was carried out in PubMed, MedLine (International Literature and Health), LILACS (Latin America and the Caribbean in Health Sciences) and Cochrane databases between 1995 and December 2019 using the keywords: muscle weakness, muscle strength and intensive care unit. Conclusion: The assessment of muscle weakness is of great importance to verify the health status of critically ill patients admitte...
PloS one, 2014
An early diagnosis of Intensive Care Unit-acquired weakness (ICU-AW) using muscle strength assessment is not possible in most critically ill patients. We hypothesized that development of ICU-AW can be predicted reliably two days after ICU admission, using patient characteristics, early available clinical parameters, laboratory results and use of medication as parameters. Newly admitted ICU patients mechanically ventilated ≥2 days were included in this prospective observational cohort study. Manual muscle strength was measured according to the Medical Research Council (MRC) scale, when patients were awake and attentive. ICU-AW was defined as an average MRC score <4. A prediction model was developed by selecting predictors from an a-priori defined set of candidate predictors, based on known risk factors. Discriminative performance of the prediction model was evaluated, validated internally and compared to the APACHE IV and SOFA score. Of 212 included patients, 103 developed ICU-AW....
2010
The authors correlate the findings of MIP testing in ventilated patients with MRC examination when awake, and relate both of these (the latter being well studied in the past) with weaning outcomes. The major strength of this study is the ability to predict weakness/respiratory involvement early, using a one-way valve that allows measurement of MIP in non-cooperative patients. This technique was feasible in a greater proportion of the cohort than MRC testing. Major concerns include: 1. The diagnosis here is really "ICU-acquired weakness" (ICU-AW) and not truly CIPNM-although the former is itself a well-described surrogate for the latter. However, in this study the authors use yet another surrogate of (this time respiratory) weakness (MIP), to predict a surrogate (MRC grading), and do not provide any "confirmatory" (i.e. more diagnostic) testing such as EMG/NCS. While the use of MRC grading to diagnose ICU-AW is reasonble, and the explanation of ICU-AW as being based on CIPNM is also founded-it is more of a leap between MIP and CIPNM. i.e. There is no gold standard to really know if those with lower MIP have neuropathic or myopathic abnormalities. All we that say is they are weak. This might require the focus of the paper to be (slightly) shifted towards ICU-AW and less focus on "CIPNM" (a clinical/EMG diagnosis). 2. This is a relatively small study (74 patients) made even smaller by the fact that over HALF the patients could not have MRC and MIP testing done concurrently (i.e. no diagnosis of ICU-AW / CIPNM made in 50%+). This makes it hard to interpret the results of the study as it relates to the ICU-AW / CIPNM. 3. The relationship (as acknowledged by the authors) between abnormal respiratory parameters (e.g. MIP) and weakness/neuropathy has previously been reported (i.e. De Jonghe 2007, reference 17). While this is discussed in the submission, it still remains unclear how this paper differs and offers novel findings (apart from the use of a valve which allows MIP measurement at closer
Critical Care, 2013
Introduction: Impaired skeletal muscle function has important clinical outcome implications for survivors of critical illness. Previous studies employing volitional manual muscle testing for diagnosing intensive care unit-acquired weakness (ICU-AW) during the early stages of critical illness have only provided limited data on outcome. This study aimed to determine inter-observer agreement and clinical predictive value of the Medical Research Council sum score (MRC-SS) test in critically ill patients. Methods: Study 1: Inter-observer agreement for ICU-AW between two clinicians in critically ill patients within ICU (n = 20) was compared with simulated presentations (n = 20). Study 2: MRC-SS at awakening in an unselected sequential ICU cohort was used to determine the clinical predictive value (n = 94) for outcomes of ICU and hospital mortality and length of stay. Results: Although the intra-class correlation coefficient (ICC) for MRC-SS in the ICU was 0.94 (95% CI 0.85-0.98), κ statistic for diagnosis of ICU-AW (MRC-SS <48/60) was only 0.60 (95% CI 0.25-0.95). Agreement for simulated weakness presentations was almost complete (ICC 1.0 (95% CI 0.99-1.0), with a κ statistic of 1.0 (95% CI 1.0-1.0)). There was no association observed between ability to perform the MRC-SS and clinical outcome and no association between ICU-AW and mortality. Although ICU-AW demonstrated limited positive predictive value for ICU (54.2%; 95% CI 39.2-68.6) and hospital (66.7%; 95% CI 51.6-79.6) length of stay, the negative predictive value for ICU length of stay was clinically acceptable (88.2%; 95% CI 63.6-98.5). Conclusions: These data highlight the limited clinical applicability of volitional muscle strength testing in critically ill patients. Alternative non-volitional strategies are required for assessment and monitoring of muscle function in the early stages of critical illness.
Intensive care unit–acquired weakness: unanswered questions and targets for future research
F1000Research
Intensive care unit–acquired weakness (ICU-AW) is the most common neuromuscular impairment in critically ill patients. We discuss critical aspects of ICU-AW that have not been completely defined or that are still under discussion. Critical illness polyneuropathy, myopathy, and muscle atrophy contribute in various proportions to ICU-AW. Diagnosis of ICU-AW is clinical and is based on Medical Research Council sum score and handgrip dynamometry for limb weakness and recognition of a patient’s ventilator dependency or difficult weaning from artificial ventilation for diaphragmatic weakness (DW). ICU-AW can be caused by a critical illness polyneuropathy, a critical illness myopathy, or muscle disuse atrophy, alone or in combination. Its diagnosis requires both clinical assessment of muscle strength and complete electrophysiological evaluation of peripheral nerves and muscles. The peroneal nerve test (PENT) is a quick simplified electrophysiological test with high sensitivity and good spe...
Profile of muscle weakness in a medical-surgical intensive care unit
Journal of Critical Care, 2017
111 patients, 17.1% had CCI. ICU mortality was 73.7% CCI vs 12.3% non-CCI (P b .001). Preliminary analysis was not able to link CCI to any preadmission variables, but COPD and previous stroke may be relevant with a bigger sample. CCI patients had higher SAPS III (71.39 × 50.67, P b .001), were more likely to be nonsurgical (44% × 5.3%, P = .001), were 2× more likely to be admitted for shock or respiratory failure and 5 × more likely to be admitted for sepsis, and had more days sedated (10.06 × 1.16), without nutrition (4.89 × 2.27), and in vasopressors (19.89 × 4.5), all P b .001. ICU length of stay was 19.89 × 4.5 days, P b .001. Conclusion: CCI was common and related to nonsurgical and severe admissions. ICU mortality and length of stay in CCI patients were strikingly high. Data suggest the need for further refinement of predmission cathegories and patient factors to identify these patients earlier.