Use of Neurostimulation As a Tool for Reconditioning the Neuromuscular System of Patients Admitted to the ICU for Septic Shock (STIMUREA)

Use of Neurostimulation As a Tool for Reconditioning the Neuromuscular System of Patients Admitted to the ICU for Septic Shock: a Single-center Randomized Pilot Study

Patients hospitalized in the ICU are likely to develop sarcopenia due to a progressive and generalized decrease in muscle mass that is responsible for generalized muscle weakness known as resuscitation neuromyopathy. This neuromyopathy is known make weaning from mechanical ventilation more difficult, which prolongs the hospitalization of patients in the ICU and in hospital. The factors identified as being partly responsible for this neuromyopathy are: immobilization, undernutrition, prolonged duration of mechanical ventilation, inflammation (notably secondary to sepsis), and multivisceral failure. These factors are essentially found in patients in septic shock, which represents about 20% of patients admitted to the ICU, with a mortality rate close to 50%. If the management of septic shock is now well codified (i.e. vascular filling, antibiotics and/or treatment of the infectious focus by surgery +/- organ replacement therapy) as well as the early rehabilitation of ICU patients, no treatments has yet been proven to be effective in limiting the appearance of resuscitation neuromyopathy. For the last ten years, research using electrostimulation (ES) to improve muscle contraction seems to give encouraging results, both for length of hospital stay and the duration of mechanical ventilation, notably through the preservation or a significant increase in muscle strength. On the other hand, other studies did not show a significant effect on muscle strength. These conflicting results are partly related to the heterogeneity of the populations included in the studies and to the different ES approaches used to assess and recondition motor function.

In the present STIMUREA study, an original approach is proposed based on experimental research work carried out for many years within U1093 (Pr Charalambos Papaxanthis) which focuses on ES, not of the muscle surface as in most studies carried out in the ICU, but an approach based on ES of the motor nerve. Indeed, the intensity of ES used in previous studies was based on a maximum tolerated intensity leading to a direct recruitment of the most fatiguable motor units (via the activation of motor axons) but leading, in fine, to a decrease in muscle strength. The U1093 research team and previous studies have shown that protocols using high stimulation frequencies (100Hz) associated with pulse widths of 1ms and delivered at low intensities (5-10% of the maximum voluntary contraction, MVC) at the level of the motor nerve, could increase the force developed during the contraction, while decreasing the discomfort induced by the high intensities. This increase in force would be due to the indirect activation of motor neurons via large diameter sensory afferents, thus leading to a recruitment of motor units similar to that observed during voluntary contractions. In a very recent study conducted in our laboratory (INSERM U1093), it was demonstrated that the application of ES to the motor nerve at low intensities did not induce discomfort in healthy subjects, but could induce substantial strength gains (+25%) with adaptations occurring at both in the muscles and the nerves.

The proposed study is an innovative, randomized, pilot study based on motor nerve ES in a highly selected population of ICU patients in septic shock and therefore with a high risk of developing neuromyopathy, which is responsible for a significant increase in morbidity and mortality.

Study Overview

• Status: Terminated
• Conditions: Septic Shock
• Intervention / Treatment: Other: Usual care; Other: Electrostimulation; Other: Evaluation of the neuromuscular system

• Study Type: Interventional
• Enrollment (Actual): 8
• Phase: Not Applicable

Contacts and Locations

Study Locations

• France
  • Dijon, France
    • Chu Dijon Bourgogne

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Age ≥ 18 years

• Admitted to the ICU for :

  • Sepsis as defined by the presence of an infection, of known or suspected origin + organ dysfunction with a SOFA score ≥ 2
  • Or septic shock defined by sepsis with persistent hypotension requiring vasopressors to maintain mean artérial blood pressure ≥ 65 mmHg and serum lactate level > 2 mmol/l despite adequate vascular filling
• After obtaining informed consent from a relative/trusted person or patient included in an emergency situation
• Patient affiliated to national health insurance.

Exclusion Criteria:

• Patient with a contraindication to the application of ES (e.g. pacemaker, defibrillator)
• Patient with a diagnosis of deep vein thrombosis and/or pulmonary embolism, confirmed and treated within the last 48 hours
• Patient with cardiac arrest prior to study inclusion
• Patient for whom a decision to limit or stop treatment has been made by the medical team
• Patients with a very poor prognosis in the very short term due to major co-morbidities (Child Pugh score C cirrhosis, terminal cancer, neuro-evolutionary disease with no treatment plan...)
• Patients with known neuro-orthopaedic and sensory disorders prior to inclusion, whether of originating in the spinal cord, nerve or brain.
• Person subject to a legal protection measure (curatorship, guardianship)
• Pregnant, parturient or breastfeeding women.

Secondary Exclusion Criteria:

- Patients receiving curare therapy

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Standard support	Other: Usual care; Standard management offered in the intensive care unit; Other: Evaluation of the neuromuscular system; Will be performed within 48 hours of admission to the ICU and at D7 of admission. Includes: electrical stimulations (at an intensity to obtain 10% of the maximum M wave) in the leg at different frequencies with recording of the force developed by force sensor; maximum and submaximal electrical stimulation of the leg with recording of the electrophysiological response by surface electrodes applied to the leg muscles, to evaluate muscular and spinal excitability.; MRC scale to assess the motor function of different muscle groups of the lower and upper of the lower and upper limbs, depending on the patient's clinical condition.; Maximum Voluntary Contractions (MVC) to evaluate the muscular strength of the plantar flexors, depending on the patient's clinical condition.
Experimental: Standard treatment coupled with electro-stimulation sessions	Other: Usual care; Standard management offered in the intensive care unit; Other: Electrostimulation; The patients included will receive throughout their stay, in addition to the standard care offered in the department, electrical nerve stimulation. The ES will be applied to the tibial nerve to allow contraction of the plantar flexors. The protocol will be applied twice a day, 5-7 days a week and will have the following characteristics: stimulation frequency 100Hz, pulse width 1ms, intensity allowing the development of 5-10% of the maximum tetanic force obtained during the force-frequency relation, contraction time 20s, recovery time 20s, for a total of 25 contractions per session.; Other: Evaluation of the neuromuscular system; Will be performed within 48 hours of admission to the ICU and at D7 of admission. Includes: electrical stimulations (at an intensity to obtain 10% of the maximum M wave) in the leg at different frequencies with recording of the force developed by force sensor; maximum and submaximal electrical stimulation of the leg with recording of the electrophysiological response by surface electrodes applied to the leg muscles, to evaluate muscular and spinal excitability.; MRC scale to assess the motor function of different muscle groups of the lower and upper of the lower and upper limbs, depending on the patient's clinical condition.; Maximum Voluntary Contractions (MVC) to evaluate the muscular strength of the plantar flexors, depending on the patient's clinical condition.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
change of the muscle force in newton meters (Nm) of the plantar flexors in response to electrical stimulation of the tibial nerve	change of muscle strength between inclusion and at Day 7 (between Day 7 and Day 8) of admission in the intensive care unit	Between inclusion and Day 7 of admission in the intensive care unit

Collaborators and Investigators

• Sponsor: Centre Hospitalier Universitaire Dijon

Study record dates

Study Major Dates

• Study Start (Actual): March 25, 2022
• Primary Completion (Actual): June 11, 2024
• Study Completion (Actual): June 11, 2024

Study Registration Dates

• First Submitted: January 25, 2022
• First Submitted That Met QC Criteria: February 24, 2022
• First Posted (Actual): February 25, 2022

Study Record Updates

• Last Update Posted (Actual): March 25, 2025
• Last Update Submitted That Met QC Criteria: February 17, 2025
• Last Verified: February 1, 2025

More Information

Terms related to this study

• Keywords: reanimation neuromyopathy
• Additional Relevant MeSH Terms: Pathologic Processes; Infections; Sepsis; Systemic Inflammatory Response Syndrome; Inflammation; Shock; Shock, Septic
• Other Study ID Numbers: ANDREU AOI 2021

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No