,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,*,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,*,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,*,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,*,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,*,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,*,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,*,*,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,CRITICAL ILLNESS NEUROMYOPATHY,CRITICAL ILLNESS NEUROMY,1,Abbreviations,CIP critical illness polyneuropathy,CIM critical illness myopathy,CMAP compound muscl action potentials,SNAP sensory nerve action potential,EMG electromyogram,SIRS systematic inflammatory response syndrome,Abbreviations,2,HISTORICAL REVIEW,In 1955 observed a polyneuropathy after shock or cardiac arrest,In 1961 described,“,coma-polyneuropathies,”,In 1971 described a polyneuropathy in patients with burns,in 1977 severe polyneuropathy about septic patients,HISTORICAL REVIEW,3,By 1983 the term“critical illness polyneuropathy”,（,CIP,）,was,applied,Recently the termed“critical illness myopathy”,（,CIM,）,was,applied,4,Studies about Aetiologyvariously,The various factors associated with the SIRS CIP and CIM(,Fig.,1,),A simplified depiction of theoretical mechanisms of dysfunction in CIP and CIM.(,Fig.2,),Disorder of microcirculation,（,Fig.3,),Studies about Aetiologyvari,5,Adapted with permission from Bolton.,Figure.1,Adapted with permission from,6,Adapted with permission fromBolton25.,Figure.,2,Adapted with permission fromBo,7,Figure.3,Schematic,theoretical presentation of disturbances in the microcirculation to various organs,including brain,peripheral nerve,and muscle,in SIRS.,Figure.3 Schematic,theor,8,重症疾病性神经肌肉病(英文课件)-资料,9,Incidence,50%70%SIRS,20%,50%ICU,重症疾病性神经肌肉病(英文课件)-资料,10,Weakness of limb and respiratory muscle,Tendon reflexes absent or decrease,Distal loss to pain,temperature,and vibration,Clinical Features,Clinical Features,11,The diagnostic criteria for CIP are shown in following Table,Diagnosis,Diagnosis,12,Diagnostic criteria for CIP,The patient is critically ill(sepsis and multiple organ failure,SIRS),Difficulty weaning patient from ventilator afternonneuromuscular causes such as heart and lung diseasehave been excluded,Possible limb weakness,Electrophysiologic evidence of axonal motor and sensory polyneuropathy,13,Decline in the CMAP amplitude firstly(,Fig.4,),Dcline in the SNAP amplitude,Motor unit potentials may be reduced in number,Single-fiber EMG indicate dysfunction of terminal motor axons,Electrophysiologic Features,Electrophysiologic Features,14,Measurement of compound thenar muscle action,potentials at the onset of sepsis,(A)and 3 weeks later(B).,FIG.4,Measurement of compound,15,Peripheral axonal degeneration.,Moderate loss of dorsal root ganglion cells,Central chromatolysis of anterior horn cells,No inflammation in the peripheral nervous system,Morphologic Features,Morphologic Features,16,Muscle biopsy,Acute and chronic denervation,Occasional myopathic changes,Muscle biopsy,17,Pathology of critical illness polyneuropathy.There is chromatolysis of anterior horn cells,(A);,severe axonal degeneration in this cross-section of superficial peripheral nerve,(B),and longitudinal section of deep peroneal nerve,(C);,and acute and chronic denervation of intercostal muscle,(D),Pathology of critical,18,Axonal variants of Guillain,Barre syndrome,Develop earlier,Often associated with,CJ,infection,Abnormal cerebral spinal fluid,Differential Diagnosis,Differential Diagnosis,19,Transient neuromuscular blockade,Repetitive nerve stimulation,Measurement of anti-MuSK(muscle specific receptor tyrosine kinase)antibodies,Transient neuromuscular block,20,Treatment of sepsis and multiple organ dysfunction syndrome,Management of difficulty in weaning from the ventilator,Attempts at direct treatment of CIP(still unproven),Physiotherapy and rehabilitation,Treatment,Treatment of sepsis and multip,21,Two newer research approaches are being explored,Intensive insulin therapy,The administration of recombinant human activated protein C,22,Recovery depends on the distance,Recovery for weeks in mild cases and months in severe cases,Slowing of nerve conduction may have a poor prognosis,Prognosis,Recovery depends on the distan,23,重症疾病性神经肌肉病(英文课件)-资料,24,Incidence,At least one-third of ICU patients,（,treated for status asthmaticus,）,In 7%of patients after transplantation,Incidence,25,Clinical Features,Major feature is flaccid weakness,Tendon reflexes depressed,Ophthalmoplegia may be present,Myalgias are uncommon,Clinical Features,26,Diagnostic criteria of CIM,SNAP amplitudes 80%of the lower limit of normal,Needle EMG with short-duration,low-amplitude MUPs with early or normal full recruitment,with or without fibrillation potentials,Absence of a decremental response on repetitive nerve stimulation,Diagnosis,Diagnosis,27,Muscle histopathologic findings of myopathy with myosin loss,CMAP amplitudes 80%of the lower limit of normal in two or more nerves without conduction block,Elevated serum creatine kinase(CK,）,Demonst