Πολυνευρομυοπάθεια του βαρέως πάσχοντος Μία συχνή επιπλοκή της. νοσηλείας στη Μονάδα Εντατικής Θεραπείας. Γεροβασίλη Βασιλική

Πολυνευρομυοπάθεια του βαρέως πάσχοντος Μία συχνή επιπλοκή της νοσηλείας στη Μονάδα Εντατικής Θεραπείας Γεροβασίλη Βασιλική Ειδικευόμενη Πνευμονολόγος, Διδάκτωρ ΕΚΠΑ 1. Εισαγωγή 20,.,,, 1952. Bjorn Ibsen 1953., 1970,.... 55.000.., ( ),.

. 2. Ιστορική Αναδρομή - Πολυνευρομυοπάθεια του βαρέως πάσχοντος: μία νόσος της σύγχρονης εποχής- ή μήπως όχι;.,,,.,, (460-380..),., 1892, William Osler «Principles and Practice of Medicine».,,» ( 1 1 ). 1961 Mertens 1971 Henderson.,,,

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(critical illness myopathy). 3. Ορισμοί-Ονοματολογία. Sine qua non,,. (critical illness polyneuropathy, CIP) (critical illness myopathy, CIM).,,. (Critical Illness Polyneuromyopathy, CIPNM) (ICU polyneuromyopathy), (ICU acquired paresis, ICU acquired weakness), / (Critical Illness Myopathy and/or Neuropathy, CRIMYNE).

,. (.. ICU acquired weakness), (.. critical illness polyneuromyopathy)., (ICU acquired weakness, ICU acquired paresis), (.. Guillain Barré). (critical illness polyneuromyopathy, CIPNM). 4. Επιδημιολογία, ( 1). 25% 90%.. 70% (30/43), 15 (35%)., 25%

1. (3) (25) ( 5 ),, Witt et al, 1991 (11) 43 >5, ( ) /EMG 70 % Kupfer et al, 1992 (30) 10,. /EMG 60 % Douglass et al, 1992 (31) 25 > 4. /EMG 36 % Coakley et al, 1993 (23) 23 >7 1 EMG 90 % Leitjen et al, 1995 (25) 50 >7 < 75 EMG 58 % Leitjen et al, 1996 (32) 38 >7 < 75 EMG 47 % Berek et al, 1996 (10) 22, <16 -- /EMG 82 % Thiele et al, 1997 (34) 44 >3, /EMG 16 % Hund et al, 1997 (35) 28, /EMG 71 % Mohr et al, 1997 (12) 33 /EMG 21 % Coackley et al, 1998 (24) 44 >7 /EMG 84 % Campellone et al, 1998 (36) 77 >7 >14 /EMG 9 % Tepper et al, 2000 (26) 22 EMG 86 % De Letter et al, 2000 (16) 98 > 3 -- /EMG 33 % Tennila et al, 2000 (29) 9 EMG 100% Garnacho-Montero et al, 73 > 10, EMG 68 % 2001 (28) De Jonghe et al, 2002 (20) 95 > 7 25% Bednarik et al, 2003 (37) 46 (> 2 ) /EMG 57 % Bednarik et al, 2005 (17) 61 (> 2 ) /EMG 57 % Garnacho-Montero et al, 64 >7, / EMG 53 % 2005 (27) Amaya Villar, 2005 (38) 26 > 48,, EMG 35 % Bercker et al, 2005 (39) 45 ARDS ( ) -- /EMG 60 % Lefaucheur et al, 2006 (40) 30 > 7 EMG 87 % Latronico et al, 2007 (22) 92 > 7 EMG 30 % Hermans et al, 2007 (18) 403 > 7 EMG 50 % Nanas et al, 2008 (15) 185 > 10 24 % Hough et al, 2008 (19) 128 ARDS ( ) /EMG 34 % Ali et al, 2008 (21) 136 > 5 25 % =, SIRS=Systemic Inflammatory Response Syndrome, =, ARDS=Acute Respiratory Distress Syndrome, G=, / G=

7 10.. (.., ), (.. 7-10, 3-10 ) (,, ). 7 58% 46%. / 76%-81%.. Nanas et al 185 10 25%. de Letter et al 98 3 33%.

,..., 15-28.,.

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2.. (, ).

20% ( 3). (Systemic Inflammatory Response Syndrome, SIRS),. Monk et al 21 1kg, Dual-Energy X-ray Absorptiometry (DEXA). 2/3 5 ( 4). 11,2 kg 33. 36%. 5.2. SIRS,., shunting.,.,. E- (vasa nervorum),

3. ( 5 10.. CSA (cross sectional area) (Berg et al, Eur J Appl Physiol. 2007;99(3):283-9)

4. DEXA Heymsfield et al 21. kg ( ), ( ) «-» ( ).Monk et al, Ann Surg. 1996;223(4):395-405

TNF-a IL-1.,. 5.3..,..,,.. 6. Παράγοντες Κινδύνου για την εμφάνιση της Πολυνευρομυοπάθειας του βαρέως πάσχοντος.,

,. 6.1. 6.1.1......,,,,,. 6.1.2...,.. 6.1.3.

...,. 6.1.4. /.,. 6.1.5.,, Acinetobacter Baumanni,..,. 6.2. 6.2.1., SIRS SIRS. SIRS,

.. SIRS,., Nanas et al gram-. 6.2.2. Apache II (Acute Physiology and Chronic Health Evaluation), Apache III SOFA (Sequential Organ Failure Assessment). 6.2.3..,. de Jonghe et al., Nanas et al. 6.2.4.. 6.2.5.

.,,.,,. 6.2.6.,...... 6.2.7...

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..,. (,, ),. 2. ( ) ( ). / 8. Κλινική Σημασία 8.1.., (.. ) (weaning). 40.

. Garnacho- Montero et al. 15 ( 1-74) 2 (0-29) ( 5). 41.2% 13.3%. de Jonghe et al.. de Jonghe et al,. Garnacho-Montero et al ( 6).,..

5. Kaplan-Mayer. 64 7 /.. 15 ( 1-74) 2 (0-29) 13. (Garnacho- Montero et al, Crit Care Med. 2005;33(2):349-54). 6. Kaplan-Mayer. 64 7 /... (Garnacho- Montero et al, Crit Care Med. 2005;33(2):349-54).

9. / 9.1..,. Gravis. MRC (Medical Research Council). MRC 0 5, 0 5. MRC 12 (6, 3 3 ) ( 2). 0 5 : 0: 1: 2: 3: 4:

5: 60 (12 * 5). MRC 48 15,20,27,28,53,54. 48,.,. 9.2... ( )......

Εικόνα 2. MRC (Medical Research Council). 12 (6, 3 3 ). 0 5 0 5. 60 (12*5). <48/60.

, 4-7.,. 9.3. -..... 9.4.,...,. 10. Πρόληψη.. 11. Θεραπεία

12. Πρόγνωση 12.1....,,,... 12.2. ( ) Bolton 1984. 3,..,. 25%.

editorial Latronico : 2 1-5, :,.

1. Osler W. The Principles and Practice of Medicine. New York: D. Appleton 1982 2..Bolton CF, Gilbert JJ, Hahn AF, Sibbald WJ. Polyneuropathy in critically ill patients. J Neurol Neurosurg Psychiatry. 1984;47:1223-31 3. Schweickert WD, Hall J.ICU-acquired weakness. Chest. 2007;131:1541-9. 4. Nanas S, Kritikos K, Angelopoulos E, Siafaka A, Tsikriki S, Poriazi M, Kanaloupiti D, Kontogeorgi M, Pratikaki M, Zervakis D, Routsi C, Roussos C.Predisposing factors for critical illness polyneuromyopathy in a multidisciplinary intensive care unit. Acta Neurol Scand. 2008;118:175-81. 5. de Letter MA, Schmitz PI, Visser LH, Verheul FA, Schellens RL, Op de Coul DA, van der Meché FG.Risk factors for the development of polyneuropathy and myopathy in critically ill patients. Crit Care Med. 2001;29:2281-6 6. De Jonghe B, Sharshar T, Lefaucheur JP, Authier FJ, Durand-Zaleski I, Boussarsar M, Cerf C, Renaud E, Mesrati F, Carlet J, Raphaël JC, Outin H, Bastuji-Garin S; Paresis acquired in the intensive care unit: a prospective multicenter study.jama. 2002;288:2859-67 7. Garnacho-Montero J, Amaya-Villar R, García-Garmendía JL, Madrazo-Osuna J, Ortiz-Leyba C. Effect of critical illness polyneuropathy on the withdrawal from mechanical ventilation and the length of stay in septic patients. Crit Care Med. 2005;33:349-54. 8. Garnacho-Montero J, Madrazo-Osuna J, García-Garmendia JL, Ortiz-Leyba, Jiménez-Jiménez FJ, Barrero-Almodóvar A, Garnacho-Montero MC, Moyano-Del- Estad MR. Critical illness polyneuropathy: risk factors and clinical consequences. A cohort study in septic patients Intensive Care Med. 2001;27:1288-96. 9. Berg HE, Eiken O, Miklavcic L, Mekjavic IB Hip, thigh and calf muscle atrophy and bone loss after 5-week bedrest inactivity. Eur J Appl Physiol. 2007;99:283-9.

10. Monk DN, Plank LD, Franch-Arcas G, Finn PJ, Streat SJ, Hill GL Sequential changes in the metabolic response in critically injured patients during the first 25 days after blunt trauma. Ann Surg. 1996;223:395-405. 11. De Jonghe B, Sharshar T, Hopkinson N, Outin H. Paresis following mechanical ventilation. Curr. Opin. Crit. Care 2004;10: 47-52. 12. Fletcher SN, Kennedy DD, Ghosh IR, Misra VP, Kiff K, Coakley JH, Hinds CJ.Persistent neuromuscular and neurophysiologic abnormalities in long-term survivors of prolonged critical illness.crit Care Med. 2003;31:1012-6.