Diagnosis
CIP and CIM are a major cause of ICU-acquired weakness (ICUAW). Current guidelines recommend a clinical diagnosis of ICUAW, made by manually testing the muscle strength with the use of the Medical Research Council (MRC) sum score or handgrip dynamometry.CIP/CIM is often not identified until a patient is unable to be successfully weaned from a mechanical ventilator. Early detection of the condition is difficult, because these patients are often sedated and intubated, and thus unable to cooperate with a thorough neuromuscular physical examination. The use of conventional nerve conduction studies is time-consuming and requires specialized personnel; however, simplified electrophysiologic tests can be used as screening tools in the critically ill to confirm or exclude CIP/CIM. The peroneal nerve test is a validated, high-sensitivity, minimally invasive, non-volitional and quick diagnostic test which can accurately exclude CIP/CIM if the result is normal. Moreover, patients with disuse atrophy and muscle deconditioning have normal electrophysiological tests even if muscle strength is severely reduced Hence, these tests are important to define the cause of muscle weakness and can be helpful to refine the prognosis. Laboratory values
The serum creatine phosphokinase (CPK) can be mildly elevated. While the CPK is often a good marker for damage to muscle tissue, it is not a helpful marker in CIP/CIM, because CIP/CIM is a gradual process and does not usually involve significant muscle cell death (necrosis). Also, even if necrosis is present, it may be brief and is therefore easily missed.
The muscles of the face are usually spared, but in rare cases, the eye muscles may be weakened, leading to ophthalmoplegia.Respiratory difficulties can be caused by atrophy of the muscles between the ribs (intercostals), atrophy of the diaphragm muscle, and degeneration of the nerve that stimulates the diaphragm (phrenic nerve). This can prolong the time it takes to wean a person off of a breathing machine (mechanical ventilation) by as much as 7 – 13 days.Deep tendon reflexes may be lost or diminished, and there may be bilateral symmetric flaccid paralysis of the arms and legs. The nervous system manifestations are typically limited to peripheral nerves, as the central nervous system is usually unaffected. Cause
The causes of CIP and CIM are unknown, though they are thought to be a possible neurological manifestation of systemic inflammatory response syndrome. Pathology
Nerve biopsy would show axonal neuropathy, but it is no longer indicated. A muscle biopsy of critical illness myopathy would show selective loss of thick filaments in muscle, demonstrating the loss of myosin and the presence of muscle cell death (necrosis). When muscles lose stimulation from neurons, they can undergo degeneration. However, when critical illness myopathy occurs, it is not solely due to loss of innervation of the muscle. With critical illness myopathy, no other cause of the muscle degeneration can be found.Unlike Guillain Barre Syndrome, another neurological disorder that causes weakness, patients with critical illness polyneuropathy do not have loss of the myelin sheath that normally surrounds neurons (demyelination).