What is the management of Intensive Care Unit (ICU) acquired weakness?

From the Guidelines

Management of ICU-acquired weakness (ICUAW) should primarily focus on prevention, early mobilization, and supportive care, as recommended by the most recent guideline on positioning and early mobilisation in the critically ill by an expert panel 1.

Key Strategies

• Prevention strategies include minimizing sedation, avoiding neuromuscular blocking agents when possible, controlling hyperglycemia, and preventing electrolyte abnormalities, particularly hypokalemia, hypophosphatemia, and hypomagnesemia.
• Early physical therapy and mobilization are crucial and should begin as soon as the patient is hemodynamically stable, typically within 24-48 hours of ICU admission.
• Nutritional support is essential, with a focus on adequate protein intake and appropriate caloric provision.

Rehabilitation

• For patients with persistent weakness after ICU discharge, a structured rehabilitation program including physical therapy, occupational therapy, and respiratory therapy should be continued, as outlined in the guideline on multimodal rehabilitation for patients with post-intensive care syndrome 1.
• This approach is supported by earlier recommendations from the European Respiratory Society and European Society of Intensive Care Medicine task force on physiotherapy for critically ill patients 1, although the most recent and highest quality evidence should be prioritized.

Outcome Improvement

• The goal of these strategies is to improve morbidity, mortality, and quality of life outcomes for patients with ICUAW, by addressing the underlying critical illness polyneuropathy and myopathy, resulting from systemic inflammation, microvascular dysfunction, and disuse atrophy.
• By prioritizing prevention and early intervention, healthcare providers can effectively manage ICUAW and promote better patient outcomes, as emphasized in the most recent guideline 1.

From the Research

Management of ICU Acquired Weakness

The management of ICU acquired weakness (ICUAW) involves a multifaceted approach, including prevention, diagnosis, and treatment.

• Prevention strategies include:
  • Aggressive treatment of sepsis 2
  • Early mobilization 2, 3
  • Preventing hyperglycemia with insulin 2
  • Avoiding the use of parenteral nutrition during the first week of critical illness 2
• Diagnosis of ICUAW is typically made by bedside manual testing of muscle strength and the severity is scored by the Medical Research Council sum score 2.
  • Additional electrophysiological testing may be required for differential diagnosis in cases of atypical clinical presentation or evolution 2, 4
• Treatment and functional management of ICUAW involve early rehabilitation 3, 5 and may continue in long-term care hospitals, inpatient rehabilitation facilities, or skilled nursing facilities 5.

Risk Factors and Prognosis

ICUAW is associated with several risk factors, including:

• High severity of illness upon admission 2
• Sepsis 2, 5
• Multiple organ failure 2
• Prolonged immobilization 2, 5
• Hyperglycemia 2, 6
• Older patients 2
• The use of corticosteroids and neuromuscular blocking agents 2, 6 The prognosis of ICUAW appears to be compromised when the cause involves critical illness polyneuropathy, whereas isolated critical illness myopathy may have a better prognosis 2.