Viva - ICU-AW Flashcards

1
Q

Definition of ICU-AW

A

Detectable weakness in critically patients for which no plausible aeotiology is found, other than being critically ill.

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2
Q

How it is divdided

A

Myopathy (CIM)
Neuropathy/Polyneuropathy (CIPN)
Both (Critical Illness Neuromyopathy, CINM)

Clinically they are indistinguishable

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3
Q

Risk factors

A

Aetiology is uncertain but risks:

Immobility
Severe sepsis
MOF
Excessive use of sedation
Corticosteroids
Uncontrolled sugars
Neuromuscular blockade

More common in women, neurological disease and the elderly. Also parenteral nutrition

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4
Q

Features of the weakness

A

Flaccid
Symmetrical
All for limbs
Sparing of the face

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5
Q

How is it graded

A

MRC Score, graded from 0-5

Three muscles in upper and lower limbs and left/right give a total of 60.

Less < 48 suggests polyneuropathy

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6
Q

How is the MRC scored

A

0-5

5 Normal
4 Moves against resitsance
3 Moves against gravity
2 Movement with gravity eliminated
1 Flicker/Contraction
0 Nothing
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7
Q

Muscles assessed in MRC

A
Arm abduction
Elbow flexion
Wrist extension
Hip flexion
Knee Extension
Foot dorsiflexion
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8
Q

Differentials of ICU-AW

A
Guillain Barre
Myasthenia
Lambert Eaton
Spinal cord injry
Rhabdo
Drug induced weakness
Myositis
Infective - botulism
Eletrolyte disturbance
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9
Q

How to investigate

A

Clinically MRC

Bloods - signs of infection, inflammatory markers
Renal, CK (mild elevation)
Electrolytes - rule out other causes, calcium etc
ESR
Auto antibodies
B12

MRI brainstem and spin

Nerve conduction, EMG, biopsy

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10
Q

What will nerve conduction show

A

CIM - normal

CIPN - decreased Compound Muscle Action Potential and sensory action potential. Conduction veloctiy normal

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11
Q

What woud EMG show

A

Needs a co-operative patient….

Small amplitude motor unit potential with short durations

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12
Q

Why would you do a biopsy

A

Diagnositc uncertainty
Exclude other diagnosis - demyelination

If it is CIM, this can be subclassified:

1) unspecific/uncomplicated
2) thick filament myopathy (loss of myosin with proteolyis)
3) Acute necrotising myopathy

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13
Q

Management

A

MDT
Prevention
Avoid risk factors

Early mobilisation and physio
Agressive sedation weaning protocol
Optimise nutrition and electrolytes
Stricy sugar control is an option but goes against the NICE-SUGAR trial

Electrical stimulation - can prevent (results vary)

Abdominal electrical stim prevents rectus abdominins and intercostal degradation

Limb, rebuilds after the event

FES - does not work
FES with cyling probably does not work
Cycling - does not work

Inspiratroy muscle training strenghtens the diaphgram but no mortality/weaning benefit demonstrated.

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