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Intervention Review

Interventions for preventing critical illness polyneuropathy and critical illness myopathy

  1. Greet Hermans2,
  2. Bernard De Jonghe3,
  3. Frans Bruyninckx4,
  4. Greet Van den Berghe1,*

Editorial Group: Cochrane Neuromuscular Disease Group

Published Online: 21 JAN 2009

Assessed as up-to-date: 30 OCT 2007

DOI: 10.1002/14651858.CD006832.pub2


How to Cite

Hermans G, De Jonghe B, Bruyninckx F, Van den Berghe G. Interventions for preventing critical illness polyneuropathy and critical illness myopathy. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD006832. DOI: 10.1002/14651858.CD006832.pub2.

Author Information

  1. 1

    Catholic University of Leuven, University Hospitals, Department of Intensive Care Medicine, Leuven, Belgium

  2. 2

    Catholic University of Leuven, University Hospitals Leuven, Department of General Internal Medicine, Medical Intensive Care Unit, Leuven, Belgium

  3. 3

    Centre Hospitalier de Poissy-Saint-Germain, Réanimation Médico-Chirurgicale, Poissy, France

  4. 4

    Catholic University of Leuven, University Hospitals Leuven, Physical Medicine and Rehabilitation, Leuven, Belgium

*Greet Van den Berghe, Department of Intensive Care Medicine, Catholic University of Leuven, University Hospitals, Herestraat 49,3000, Leuven, Belgium. Greta.vandenberghe@med.kuleuven.be.

Publication History

  1. Publication Status: New
  2. Published Online: 21 JAN 2009

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Critical illness polyneuro-and/or myopathy (CIP/CIM) is an important and frequent complication in the intensive care unit (ICU), causing delayed weaning from mechanical ventilation. It may increase ICU stay and mortality.

Objectives

To examine the ability of any intervention to prevent the occurrence of CIP/CIM.

Search methods

We searched the Cochrane Neuromuscular Disease Group Trials Register (October 2007), MEDLINE (January 1950 to April 2008), EMBASE (January 1980 to October 2007), checked bibliographies and contacted trial authors and experts in the field.

Selection criteria

All randomised controlled trials (RCTs), examining the effect of any intervention on the incidence of CIP/CIM in adult medical or surgical ICU patients. The primary outcome measure was the incidence of CIP/CIM after at least seven days in ICU, based on electrophysiological or clinical examination.

Data collection and analysis

Two authors independently extracted the data.

Main results

Three out of nine identified trials, provided data on our primary outcome measure. Two trials examined the effects of intensive insulin therapy versus conventional insulin therapy. Eight hundred and twenty-five out of 2748 patients randomised, were included in the analysis. The incidence of CIP/CIM was significantly reduced with intensive insulin therapy in the population screened for CIP/CIM (relative risk (RR) 0.65, 95% confidence interval (CI) 0.55 to 0.78) and in the total population randomised (RR 0.60, 95% CI 0.49 to 0.74). Duration of mechanical ventilation, duration of ICU stay and 180-day mortality but not 30-day mortality, were significantly reduced with intensive insulin therapy, in both the total and the screened population. Intensive insulin therapy significantly increased hypoglycaemic events and recurrent hypoglycaemia. Death within 24 hours of the hypoglycaemic event was not different between groups. The third trial examined the effects of corticosteroids versus placebo in 180 patients with prolonged acute respiratory distress syndrome. No significant effect of corticosteroids on CIP/CIM was found (RR 1.09, 95% CI 0.53 to 2.26). No effect on 180-day mortality, new serious infections and glycaemia at day seven was found. A trend towards fewer episodes of pneumonia and reduction of new events of shock was shown.

Authors' conclusions

Substantial evidence shows that intensive insulin therapy reduces the incidence of CIP/CIM, the duration of mechanical ventilation, duration of ICU stay and 180-day mortality. There was a significant associated increase in hypoglycaemia. Further research needs to identify the clinical impact of this and strategies need to be developed to reduce the risk of hypoglycaemia. Limited evidence shows no significant effect of corticosteroids on the incidence of CIP/CIM, or on any of the other secondary outcome measures, except for a significant reduction of new episodes of shock. Strict diagnostic criteria for the purpose of research should be defined. Other interventions should be investigated in randomised controlled trials.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Interventions to reduce neuromuscular complications acquired during the acute phase of critical illness

Neuromuscular problems are frequent complications in patients with severe disease that require admission to the intensive care unit (ICU). Weakness of limbs and respiratory muscles is most frequently due to critical illness polyneuro-and/or myopathy (CIP/CIM). As a consequence, patients face a delay in weaning from ventilatory support and rehabilitation. Recovery of strength often occurs within weeks to months but can be incomplete or not occur at all. CIP/CIM is associated with increased ICU stay and mortality rates. Prevention and treatment of CIP/CIM is therefore of great importance.

We searched for and analysed all randomised controlled trials that examined the effects of any treatment intervention on the incidence of CIP/CIM in adult patients admitted to an ICU. We ultimately found three trials that focused on two different interventions.

Two trials with 825 participants examined the effect of intensive insulin therapy, aiming to maintain blood glucose levels within the normal range (80 to 110 mg/dl), versus conventional insulin therapy, aiming to avoid hyperglycaemia (high blood sugar > 215 mg/dl), on the incidence of CIP/CIM in patients staying in ICU for at least one week. Pooling the results of both trials showed that intensive insulin therapy reduces the incidence of CIP/CIM, the duration of mechanical ventilation, the duration of ICU stay and mortality at 180 days. No significant effect on mortality at 30 days was noted. Intensive insulin therapy was associated with a significant increase in hypoglycaemia (low blood sugar), and recurrent hypoglycaemic events. Although no increase in mortality within 24 hours of hypoglycaemia was noted, hypoglycaemia remains an issue of concern when implementing intensive insulin therapy in critically ill patients, as it may cause neurological complications. In both trials, no clinical measurement of weakness of the limbs was reported, nor data on physical rehabilitation. Data were derived from subgroup analysis, which may also limit the conclusions.

The third trial compared corticosteroid therapy versus placebo in 180 patients with persisting acute respiratory distress syndrome. Results showed no evidence of an effect of corticosteroids on the incidence of CIP/CIM, no effect on mortality at 180 days, on new serious infections, on glucose levels on day 7 and a trend towards less episodes of suspected or probable pneumonia. The number of new events of shock was reduced. In this trial, only 92 of the 180 patients were prospectively evaluated for CIP/CIM.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

重症神經病變及重症肌肉病變之預防措施

重症神經病變(CIP)及/或重症肌肉病變(CIM)是加護病房中一種重要並常見會導致延長脫離呼吸器的併發症。它會增加滯留加護病房的時間及死亡率。

目標

調查任何有可能預防發生CIP/CIM的措施。

搜尋策略

我們搜索了Cochrane Neuromuscular Disease Group Trials Register (October 2007), Medline (January 1950 至 April 2008), EMBASE (January 1980至October 2007), 也調查了其參考書目和聯絡了那些試驗的作者以及在那些領域的專家。

選擇標準

包括所有研究會影響在成人內外科加護病房CIP/CIM發生率措施的隨機對照試驗。主要的研究指標為在加護病房待七天以上,根據神經電生理檢查或臨床診斷,CIP/CIM的發生率。

資料收集與分析

兩位作者分別獨立進行擷取資料。

主要結論

九個試驗中有三個提供我們所認定的主要研究指標。兩個試驗調查了積極胰島素治療及一般胰島素治療所產生之效果差異。2748病人中有825位納入分析。CIP/CIM的發生率在積極使用胰島素治療組中,不論是在全部篩檢CIP/CIM組群中 (RR 0.65, 95% confidence interval (CI) 0.55 to 0.78),還是在所有隨機抽樣組中(RR 0.60, 95% CI 0.49 to 0.74)都顯著下降。呼吸器使用時間,加護病房停留時間及180天死亡率在積極使用胰島素治療組中,不論是在所有隨機抽樣人中或是在篩檢組中都顯著下降。30天死亡率則沒有兩組間差異。積極使用胰島素治療顯著增加了低血糖事件及再發性低血糖。但是24小時內因低血糖事件死亡者則在各組別中沒有差別。第三個試驗比較類固醇與安慰劑在180位長期急性呼吸窘迫症候群的效果。對於CIP/CIM的發生,類固醇使用並沒有顯著意義(RR 1.09, 95% CI 0.53 to 2.26)。對180天死亡率,新發生的嚴重感染及第七天血糖狀態並沒有影響。在肺炎及減少休克的新事件發生上有較低的趨勢。

作者結論

重要的證據顯示積極使用胰島素治療可以減少CIP/CIM的發生率,呼吸器使用時間,加護病房停留時間及180天死亡率。但會增加低血糖的發生。需要更多未來研究去找出它的臨床影響及減少發生低血糖的策略。有限的證據顯示類固醇對CIP/CIM的發生率或任何其他次要研究目標都沒有顯著影響,但對新發生的休克,類固醇有顯著減少效果。為了研究目的,應該給予嚴格診斷標準與定義。其他的措施應以隨機對照試驗方式去探討。

翻譯人

本摘要由新光醫院劉子洋翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

減少重症疾病在急性期發生神經肌肉併發之措施: 在加護病房患有嚴重疾病的病患中,神經肌肉病變是常見的併發症。四肢及呼吸肌無力經常是因重症神經病變及重症肌肉病變(CIP/CIM)所造成。其後果會導致病人延後脫離呼吸器及復健。肌力可能會在數週至數月間恢復或甚至完全沒有恢復。CIP/CIM與延長加護病房滯留及死亡率有關,因此預防及治療CIP/CIM十分重要。我們搜查及分析了所有會影響加護病房患者發生CIP/CIM治療措施的隨機對照試驗。最終我們發現三個針對兩種不同措施的試驗。兩個包括825個案的試驗,分析目標為維持血糖在正常值(80至110mg/dl)的積極胰島素治療,不同於目標為防止高血糖(高血糖>215mg/dl)的一般性治療,對留在加護病房一週以上病人發生CIP/CIM發生率的影響。綜合兩個試驗結果發現積極胰島素治療將減少CIP/CIM發生率,呼吸器使用時間,加護病房停留時間及180天死亡率。對30天死亡率沒有顯著影響。積極胰島素治療顯著增加低血糖血糖值及再發性低血糖事件。雖然於24小時內低血糖並沒有增加死亡率,低血糖在使用積極胰島素治療重症病患依然值得關注,因為其可能造成神經併發症。兩個試驗都沒有報導四肢力量或復健資料。資料是從次分組分析中取得,也可能會影響整體的結論。第三個試驗比較180個持續性急性呼吸窘迫症使用類固醇及安慰劑之差異。結果顯示類固醇對CIP/CIM發生率沒有影響,對180天死亡率,新發生之嚴重感染,第七天血糖值都沒有影響,也有傾向顯示較少出現疑似肺炎。新發生之休克事件也減少。在這試驗中,180病人中只有92人是用前贍性方法評估CIP/CIM。