A new two-tier strength assessment approach to the diagnosis of weakness in intensive care: an observational study (original) (raw)
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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.
Acquired Weakness, Handgrip Strength, and Mortality in Critically Ill Patients
American Journal of Respiratory and Critical Care Medicine, 2008
Rationale: ICU-acquired paresis (ICUAP) is common in survivors of critical illness. There is significant associated morbidity, including prolonged time on the ventilator and longer hospital stay. However, it is unclear whether ICUAP is independently associated with mortality, as sicker patients are more prone and existing studies have not adjusted for this. Objectives: To test the hypothesis that ICUAP is independently associated with increased mortality. Secondarily, to determine if handgrip dynamometry is a concise measure of global strength and is independently associated with mortality. Methods: A prospective multicenter cohort study was conducted in intensive care units (ICU) of five academic medical centers. Adults requiring at least 5 days of mechanical ventilation without evidence of preexisting neuromuscular disease were followed until awakening and were then examined for strength. Measurements and Main Results: We measured global strength and handgrip dynamometry. The primary outcome was in-hospital mortality and secondary outcomes were hospital and ICU-free days, ICU readmission, and recurrent respiratory failure. Subjects with ICUAP (average MRC score of , 4) had longer hospital stays and required mechanical ventilation longer. Handgrip strength was lower in subjects with ICUAP and had good test performance for diagnosing ICUAP. After adjustment for severity of illness, ICUAP was independently associated with hospital mortality (odds ratio [OR], 7.8; 95% confidence interval [CI], 2.4-25.3; P 5 0.001). Separately, handgrip strength was independently associated with hospital mortality (OR, 4.5; 95% CI, 1.5-13.6; P 5 0.007). Conclusions: ICUAP is independently associated with increased hospital mortality. Handgrip strength is also independently associated with poor hospital outcome and may serve as a simple test to identify ICUAP. Clinical trial registered with www.clinicaltrials.gov (NCT00106665).
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....
Physical Therapy, 2012
Background Paresis acquired in the intensive care unit (ICU) is common in patients who are critically ill and independently predicts mortality and morbidity. Manual muscle testing (MMT) and handgrip dynamometry assessments have been used to evaluate muscle weakness in patients in a medical ICU, but similar data for patients in a surgical ICU (SICU) are limited. Objective The purpose of this study was to evaluate the predictive value of strength measured by MMT and handgrip dynamometry at ICU admission for in-hospital mortality, SICU length of stay (LOS), hospital LOS, and duration of mechanical ventilation. Design This investigation was a prospective, observational study. Methods One hundred ten patients were screened for eligibility for testing in the SICU of a large, academic medical center. The Acute Physiology and Chronic Health Evaluation (APACHE) II score, diagnoses, and laboratory data were collected. Measurements were obtained by MMT quantified with the sum (total) score on ...
Journal of Critical Care, 2013
Dynamometry is an objective tool for volitional strength evaluation that may overcome the limited sensitivity of the Medical Research Council scale for manual muscle tests, particularly at grades 4 and 5. The primary aims of this study were to investigate the reliability, minimal detectable change, and time to peak muscle force, measured with portable dynamometry, in critically ill patients. Materials and methods: Isometric hand grip, elbow flexion, and knee extension were measured with portable dynamometry. Results: Interrater consistency (intraclass correlation coefficient [95% confidence interval]) (0.782 [0.321-0.930] to 0.946 [0.840-0.982]) and test-retest agreement (0.819 [0.390-0.943] to 0.918 [0.779-0.970]) were acceptable for all dynamometry forces, with the exception of left elbow flexion. Despite generally good reliability, a mean change (upper 95% confidence interval) of 2.8 (7.8) kg, 1.9 (5.2) kg, and 2.6(7.1) kg may be required from a patient's baseline force measurement of right grip, elbow flexion, and knee extension to reflect real force changes. There was also a delay in the time for critically ill patients to generate peak muscle forces, compared with healthy controls (P ≤ .001). Conclusions: Dynamometry can provide reliable measurements in alert critically ill patients, but moderate changes in strength may be required to overcome measurement error, during the acute recovery period. Deficits in force timing may reflect impaired neuromuscular control.
Maximum inspiratory pressure, a surrogate parameter for the assessment of ICU-acquired weakness
BMC Anesthesiology, 2011
Background: Physical examination has been advocated as a primary determinant of ICU-acquired weakness (ICU-AW). The purpose of the study is to investigate ICU-AW development by using Maximum Inspiratory Pressure (MIP) as a surrogate parameter of the standardized method to evaluate patients' peripheral muscle strength. Methods: Seventy-four patients were recruited in the study and prospectively evaluated in a multidisciplinary university ICU towards the appearance of ICU-AW. APACHE II admission score was 16 ± 6 and ICU stay 26 ± 18 days. ICU-AW was diagnosed with the Medical Research Council (MRC) scale for the clinical evaluation of muscle strength. MIP was measured using the unidirectional valve method, independently of the patients' ability to cooperate. Results: A significant correlation was found between MIP and MRC (r = 0.68, p < 0.001). Patients that developed ICU-AW (MRC<48) had a longer weaning period compared to non ICU-AW patients (12 ± 14 versus 2 ± 3 days, p < 0.01). A cut-off point of 36 cmH 2 O for MIP was defined by ROC curve analysis for ICU-AW diagnosis (88% sensitivity,76% specificity). Patients with MIP below the cut-off point of 36 cmH 2 O had a significant greater weaning period (10 ± 14 versus 3 ± 3 days, p = 0.004) also shown by Kaplan-Meier analysis (log-rank:8.2;p = 0.004). Conclusions: MIP estimated using the unidirectional valve method may be a potential surrogate parameter for the assessment of muscle strength compromise, useful for the early detection of ICU-AW.
Muscle strength as a predictor of loss of functional status in hospitalized patients
Nutrition, 2002
OBJECTIVE: The incidence of protein-calorie malnutrition in hospitalized adult patients can reach 30% to 50% and adversely affect clinical outcome. We evaluated the efficacy of muscle strength to predict functional derangement and detect early changes in nutrition status in hospitalized patients.METHODS: Patients hospitalized at medical and surgical wards from two different hospitals in Santiago, Chile, were studied during their hospital stay. Subjective Global Assessment of nutrition status and laboratory parameters were measured on admission. Anthropometric measures, handgrip dynamometry, and maximal inspiratory and expiratory pressures were measured on admission and discharge. The Karnofsky index was used to assess functional status. Twice weekly, caloric balance was calculated with indirect calorimetry and assessment of dietary intake.RESULTS: From the initial selection of patients (n = 70), 50 patients (26 men and 24 women) completed the study. Median hospital stay was 10 d. Su...