關(guān)注重癥監(jiān)護(hù)病房獲得性肌無(wú)力

1、關(guān)注重癥監(jiān)護(hù)病房獲得性肌無(wú)力 Focus on ICU-AW,盛志勇,感覺 有點(diǎn)不可思議。。。,當(dāng)患者出現(xiàn)撤機(jī)困難時(shí)。。。,肺部原發(fā)疾病心功能液體負(fù)荷電解質(zhì)紊亂鎮(zhèn)靜藥物神經(jīng)系統(tǒng)…….,可能會(huì)忽略。。。,Intensive care unit acquired weakness ICU-AW

2、 ICU獲得性肌無(wú)力,實(shí)際情況,全球每年有1300—2000萬(wàn)人因需生命支持入住ICU.美國(guó)每年有75萬(wàn)人接受機(jī)械通氣，其中30萬(wàn)人>5天以上將近25%的機(jī)械通氣將發(fā)生ICU-AWICU-AW:全球 100萬(wàn) 美國(guó) 7.5 萬(wàn),定義 Definition,ICUAW is a syndrome of generalized limb weakness that develops wh

3、ile the patient is critically ill and for which there is no alternative explanation other than the critical illness itself,ICU獲得性肌無(wú)力是指重癥患者所發(fā)生的、以肢體肌力減弱為主要表現(xiàn)，除了疾病本身無(wú)其他原因可以解釋的一類綜合征。（膈肌及肋間??？？）,Clinical features associated wi

4、th ICU-AW,ICU-AW,危重病性肌病 ( critical illness myopathy ，CIM) 危重病性多發(fā)性神經(jīng)病 ( critical illness polyneuropathy，CIP ) 危重病性多發(fā)性神經(jīng)肌肉病 ( critical illness polyneuromyopathy ，CIPNM) CIM 和/ 或CIP 是ICU-AW的主要原因,病因,SIR

5、S和MODS高血糖皮質(zhì)激素的應(yīng)用神經(jīng)肌肉阻滯劑長(zhǎng)期臥床、活動(dòng)限制、延遲自主性物理運(yùn)動(dòng)。。。。,SIRS/MODS引起ICU-AW,Hematoxylin and eosin (HE) staining showing inflammatory cell infiltrate into muscle incritical illness myopathy.,,微血管受損缺血\神經(jīng)損傷\肌肉細(xì)胞凋亡\肌細(xì)胞丟失,病理改變,Sele

6、ctive thick filament loss Predominant type II muscle fibre atrophy Muscle membrane inexcitability J Cachexia Sarcopenia Muscle (2010) 1:147–157,ICU住院時(shí)間與肌肉密度的關(guān)系,,Experiments in healthy vol

7、unteers reveal that muscle atrophy begins within hours of immobility,14 resulting in a 4–5% loss of muscle strength for each week of bed rest. The interaction of critical illness with immobility may lead to even greater

8、muscle loss,Immobility and Disuse Atrophy,約束/制動(dòng)的影響,ICU-AW后果,脫機(jī)失敗或脫機(jī)時(shí)間延長(zhǎng)肢體功能障礙死亡率增高,Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national,multi-centre, prospective cohort study,診斷

9、,診斷,,MEDICAL RESEARCH COUNCIL SCALE (MRCS),ICU-AW 電生理學(xué)特征,刺激運(yùn)動(dòng)神經(jīng)干,誘發(fā)所刺激神經(jīng)支配的肌肉.在該肌肉記錄運(yùn)動(dòng)電位,稱為復(fù)合肌肉動(dòng)作電位, CMAP(compound muscle action potential),刺激遠(yuǎn)端神經(jīng)，在近端神經(jīng)干記錄動(dòng)作電位，稱之為感覺神經(jīng)動(dòng)作電位SNAP(Sensory nerve action potential),,超聲,How to

10、 do?,,the treatment group performed a passive or active exercise training session for 20 mins/day,using a bedside ergometer.,結(jié)果,Figure 3. A, Boxplot of 6MWD at hospital discharge. 6MWD, 6-min walking distance. *p < .0

11、5 compared with control group.,Isometric quadriceps force at ICU discharge and at hospital discharge.QF, quadriceps force; hospital, day of hospital discharge. *p<.01 between ICU andhospital discharge; ?p<.05 comp

12、ared with control group,Conclusions :Early exercise training in critically ill intensive care unit survivors enhanced recovery of functional exercise capacity, self-perceived functional status, and muscle force at hospit