关注重症监护病房获得性肌无力参考课件

1、关注重症监护病房获得性肌无力 Focus on ICU-AW盛志勇1 关注重症监护病房获得性肌无力 Focus on感觉 有点不可思议。2感觉 有点不可思议。2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.3当患者出现撤机困难时。肺部原发疾病3可能会忽略。Intensive care unit acquired weakness ICU-AW ICU获得性肌无力4可能会忽略。Intensive care unit ac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-

2、AWICU-AW:全球 100万 美国 7.5 万 5实际情况全球每年有13002000万人因需生命支持入住IC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

3、原因可以解释的一类综合征。（膈肌及肋间肌？）6定义 Definition ICUAW is a sClinical features associated with ICU-AW 7Clinical features associated wICU-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

4、原因8ICU-AW 危重病性肌病8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。9病因SIRS和MODS91010SIRS/MODS引起ICU-AWHematoxylin 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11SIRS/MODS引起ICU-AWHematoxylin a病理改变Selective thick filament loss

5、Predominant type II muscle fibre atrophy Muscle membrane inexcitability J Cachexia Sarcopenia Muscle (2010) 1:147157 12病理改变Selective thick filament l13131414ICU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 mus

6、cle strength for each week of bed rest. The interaction of critical illness with immobility may lead to even greater muscle lossImmobility and Disuse Atrophy约束/制动的影响15ICU住院时间与肌肉密度的关系Experiments in 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16ICU-AW后果脱机失败或脱机时间延长16Early mobilization and recovery in mechanically ve

7、ntilated patients in the ICU: a bi-national,multi-centre, prospective cohort study17Early mobilization and recover诊断18诊断18诊断19诊断19MEDICAL RESEARCH COUNCIL SCALE (MRCS)20MEDICAL RESEARCH COUNCIL SCALEICU-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

8、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)21ICU-AW 电生理学特征刺激运动神经干,诱发所刺激神经支配超声22超声2223232424How to do?25How to do?252626 the treatment group performed a passive or active exercise training session for 20 mins/day,using a bedside ergometer.27 the treatment group per结果Figure 3. A, Bo

9、xplot 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 andhospital discharge; p.05 compared with control g

10、roup28结果Figure 3. A, Boxplot of 6MWD 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。2929303031313232 p = 0.04833 p = 0.04833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。