Critical Illness Polyneuropathy
| Classification according to ICD-10 | |
|---|---|
| G62.8 | Other specified polyneuropathies |
| ICD-10 online (WHO version 2019) | |
Under critical illness polyneuropathy (CIP) is defined as a disease of the peripheral nervous system , often associated with serious, intensive care occurs requiring treatment diseases. The main development factors are sepsis , multiple organ failure and long-term ventilation . This disease presents a neurological picture that has been known for decades but has long been misjudged.
Sepsis patients who were cared for in intensive care units for a long time developed sometimes pronounced forms of muscle atrophy (muscle atrophy ). The suspicion was that the immobilization of the patients in the intensive care units leads to an inactivity atrophy of the muscle tissue and thus the clinical picture would be explained. However, this does not explain the patient's complaints satisfactorily. Rather, a newly acquired disease seems to be involved in this process. This is known today as “critical illness polyneuropathy”.
The frequency of this disease is underestimated. About 70 percent of patients who are treated for sepsis in intensive care units for one to two weeks and who survive develop CIP.
pathology
The exact origin ( pathogenesis ) of CIP is still not known. It is believed that inflammatory mediators ( cytokines , interleukins , etc.), such as those channeled into the body by the immune system in sepsis and the systemic inflammatory response syndrome (SIRS) , play a crucial role in the genesis. These mediators, which to date have been classified only very incompletely, seem to have a toxic effect on the axons, especially the motor neurons of the peripheral nervous system , in the course of CIP . It is therefore an endogenous-toxic polyneuropathy . The damage to the motor neurons leads to paresis (paralysis) of the associated muscles. The consequence of this is their stunting. Sensory neurons seem to be largely, but not completely, spared in this disease process. The course of the CIP is monophasic and self-limiting.
Symptoms
Patients develop severe, flaccid, atrophic paralysis . All extremities are affected. The involvement of the diaphragmatic nerve ( phrenic nerve ) is problematic . This is rarely seen in the early stages of the disease, as most affected patients are artificially ventilated anyway. However, there are sometimes significant difficulties in attempting to wean patients off mechanical ventilation. It should be noted that in most cases the CIP does not reach the level of severity to cause the said withdrawal disorders. Otherwise, this type of illness is difficult to prove clinically. In the neurological statute, the aforementioned muscular atrophies are found with a peculiarly pasty tissue consistency. The muscle reflexes are greatly reduced or absent. Pain stimuli in the legs are not answered with a flexor reflex ( shortening reaction ), as would be expected physiologically, but are only expressed through a grimace on the face. This is a relatively typical sign of CIP, but it is not pathognomonic .
diagnosis
Electrophysiological testing is the method of choice. The corresponding findings in CIP are typically almost normal nerve conduction velocities (NLG) and distal motor latencies with amplitude-reduced or widened cumulative action potentials. The sensitive NLGs are practically normal. The myasthenia gravis , botulism and the Guillain-Barre syndrome are the classic differential diagnoses for CIP. In contrast to CIP, these are definitely accessible to drug therapy and must therefore be checked in every case.
therapy
Treatment is purely supportive. Treatment of the patient's basic disease is central. A causal therapy against the CIP does not exist to this day. There are various clinical experiments with NMDA antagonists. So far, however, there have been no tangible successes.
Careful care is extremely important to prevent and minimize pressure sores (pressure ulcers ). However, the spontaneous prognosis is unexpectedly good. If the patients survive the underlying disease, most of them regain their motor skills over the course of weeks and months. A restitutio ad integrum is likely, at least from the neurological point of view. In the convalescence phase, breathing support treatment with oxygen administration is often necessary.
The often very long ventilation phase can prove to be problematic for these patients. Secondary complications such as pneumonia , tracheomalacia and renewed sepsis represent a significant problem in medical care.
literature
- Klaus Poeck, Werner Hacke: Neurology . 11th edition. Springer, Berlin 2001, ISBN 3-540-41345-6 .
Individual evidence
- ↑ Alphabetical directory for the ICD-10-WHO version 2019, volume 3. German Institute for Medical Documentation and Information (DIMDI), Cologne, 2019, p. 161
