关注重症监护病房获得性肌无力

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,关注重症监护病房获得性肌无力 Focus on ICU-AW,盛志勇,感觉,有点不可思议。,当患者出现撤机困难时。,肺部原发疾病,心功能,液体负荷,电解质紊乱,镇静药物,神经系统,.,可能会忽略。,Intensive care unit acquired weakness,ICU-AW,ICU获得性肌无力,实际情况,全球每年有13002000万人因需生命支持入住ICU,.,美国每年有75万人接受机械通气，其中30万人5天以上,将近25%的机械通气将发生ICU-AW,ICU-AW:全球 100万,美国 7.5 万,定义 Definition,ICUAW is a syndrome of generalized limb weakness that develops while the patient is critically ill and for which there is no alternative explanation other than the critical illness itself,ICU获得性肌无力是指重症患者所发生的、以肢体肌力减弱为主要表现，除了疾病本身无其他原因可以解释的一类综合征。（,膈肌及肋间肌？,）,Clinical features associated with ICU-AW,ICU-AW,危重病性肌病,( critical illness myopathy ，CIM),危重病性多发性神经病,( critical illness polyneuropathy，CIP ),危重病性多发性神经肌肉病,( critical illness polyneuromyopathy ，CIPNM),CIM 和/ 或CIP 是ICU-AW的主要原因,病因,SIRS和MODS,高血糖,皮质激素的应用,神经肌肉阻滞剂,长期卧床、活动限制、延迟自主性物理运动,。,SIRS/MODS引起ICU-AW,Hematoxylin and eosin (,HE,) staining showing inflammatory cell infiltrate into muscle incritical illness myopathy.,微血管受损缺血神经损伤肌肉细胞凋亡肌细胞丢失,病理改变,Selective thick filament loss,Predominant type II muscle fibre atrophy,Muscle membrane inexcitability,J Cachexia Sarcopenia Muscle (2010) 1:147157,ICU住院时间与肌肉密度的关系,Experiments in healthy volunteers reveal that muscle atrophy begins within hours of immobility,14 resulting in a 45% loss of muscle strength for each week of bed rest. The interaction of critical illness with immobility may lead to even greater muscle loss,Immobility and Disuse Atrophy,约束/制动的影响,ICU-AW后果,脱机失败或脱机时间延长,肢体功能障碍,死亡率增高,Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national,multi-centre, prospective cohort study,诊断,诊断,MEDICAL RESEARCH COUNCIL SCALE (MRCS),ICU-AW 电生理学特征,刺激运动神经干,诱发所刺激神经支配的肌肉.在该肌肉记录运动电位,称为复合肌肉动作电位, CMAP(compound muscle action potential),刺激远端神经，在近端神经干记录动作电位，称之为感觉神经动作电位SNAP,(Sensory nerve action potential),超声,How to do?,the treatment group performed a passive or active exercise training session for 20 mins/day,using a bedside ergometer.,结果,Figure 3.,A,Boxplot,of 6MWD at hospital discharge.,6MWD, 6-min walking distance. *,p ,.05 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 and,hospital discharge; ,p,.05 compared 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 hospital discharge.,结论：早期功能锻炼可以提高ICU存活患者肌肉力量、功能锻炼恢复能力和自我感觉状态。,结论：虽然电刺激不能防止ICU-AW的发生，但可以减轻肌无力程度，帮助脱机。,总结,积极控制原发病，维持内环境稳定,避免肌松、糖皮质激素的使用,避免过度镇静,避免过度休息与制动,制定合理的机械通气方案，尽早脱机，缩短在ICU停留时间,早期、适当的功能锻炼可能减少ICU-AW的发生率,