Simplified electrophysiological evaluation of peripheral nerves in critically ill patients: the Italian multi-centre CRIMYNE study

Nicola Latronico, Guido Bertolini, Bruno Guarneri, Marco Botteri, Elena Peli, Serena Andreoletti, Paola Bera, Davide Luciani, Anna Nardella, Elena Vittorielli, Bruno Simini, Andrea Candiani, Nicola Latronico, Guido Bertolini, Bruno Guarneri, Marco Botteri, Elena Peli, Serena Andreoletti, Paola Bera, Davide Luciani, Anna Nardella, Elena Vittorielli, Bruno Simini, Andrea Candiani

Abstract

Introduction: Critical illness myopathy and/or neuropathy (CRIMYNE) is frequent in intensive care unit (ICU) patients. Although complete electrophysiological tests of peripheral nerves and muscles are essential to diagnose it, they are time-consuming, precluding extensive use in daily ICU practice. We evaluated whether a simplified electrophysiological investigation of only two nerves could be used as an alternative to complete electrophysiological tests.

Methods: In this prospective, multi-centre study, 92 ICU patients were subjected to unilateral daily measurements of the action potential amplitude of the sural and peroneal nerves (compound muscle action potential [CMAP]). After the first ten days, complete electrophysiological investigations were carried out weekly until ICU discharge or death. At hospital discharge, complete neurological and electrophysiological investigations were performed.

Results: Electrophysiological signs of CRIMYNE occurred in 28 patients (30.4%, 95% confidence interval [CI] 21.9% to 40.4%). A unilateral peroneal CMAP reduction of more than two standard deviations of normal value showed the best combination of sensitivity (100%) and specificity (67%) in diagnosing CRIMYNE. All patients developed the electrophysiological signs of CRIMYNE within 13 days of ICU admission. Median time from ICU admission to CRIMYNE was six days (95% CI five to nine days). In 10 patients, the amplitude of the nerve action potential dropped progressively over a median of 3.0 days, and in 18 patients it dropped abruptly within 24 hours. Multi-organ failure occurred in 21 patients (22.8%, 95% CI 15.4% to 32.4%) and was strongly associated with CRIMYNE (odds ratio 4.58, 95% CI 1.64 to 12.81). Six patients with CRIMYNE died: three in the ICU and three after ICU discharge. Hospital mortality was similar in patients with and without CRIMYNE (21.4% and 17.2%; p = 0.771). At ICU discharge, electrophysiological signs of CRIMYNE persisted in 18 (64.3%) of 28 patients. At hospital discharge, diagnoses in the 15 survivors were critical illness myopathy (CIM) in six cases, critical illness polyneuropathy (CIP) in four, combined CIP and CIM in three, and undetermined in two.

Conclusion: A peroneal CMAP reduction below two standard deviations of normal value accurately identifies patients with CRIMYNE. These should have full neurological and neurophysiological evaluations before discharge from the acute hospital.

Figures

Figure 1
Figure 1
Flow chart of electrophysiological investigations. CMAP, compound muscle action potential; CRIMYNE, critical illness myopathy and/or neuropathy; ICU, intensive care unit; SD, standard deviation; SNAP, sensory nerve action potential.
Figure 2
Figure 2
Onset time of critical illness myopathy and/or neuropathy during intensive care unit (ICU) stay.
Figure 3
Figure 3
Kaplan-Meier curves comparing the times of onset of critical illness myopathy and/or neuropathy (CRIMYNE) and multi-organ failure (MOF). No difference between the onset times of CRIMYNE and MOF was observed (log-rank test 1.03, p = 0.311). ICU, intensive care unit.

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