Simplified electrophysiological evaluation of peripheral nerves in critically ill patients: the Italian multi-centre CRIMYNE study.

INTRODUCTION: Critical illness myopathy and/or neuropathy (CRIMYNE) is frequent in intensive care unit (ICU) patients. Although complete electrophysiological tests of peripheral nerves and muscles are essential to diagnose it, they are time-consuming, precluding extensive use in daily ICU practice. We evaluated whether a simplified electrophysiological investigation of only two nerves could be used as an alternative to complete electrophysiological tests. METHODS: In this prospective, multi-centre study, 92 ICU patients were subjected to unilateral daily measurements of the action potential amplitude of the sural and peroneal nerves (compound muscle action potential [CMAP]). After the first ten days, complete electrophysiological investigations were carried out weekly until ICU discharge or death. At hospital discharge, complete neurological and electrophysiological investigations were performed. RESULTS: Electrophysiological signs of CRIMYNE occurred in 28 patients (30.4%, 95% confidence interval [CI] 21.9% to 40.4%). A unilateral peroneal CMAP reduction of more than two standard deviations of normal value showed the best combination of sensitivity (100%) and specificity (67%) in diagnosing CRIMYNE. All patients developed the electrophysiological signs of CRIMYNE within 13 days of ICU admission. Median time from ICU admission to CRIMYNE was six days (95% CI five to nine days). In 10 patients, the amplitude of the nerve action potential dropped progressively over a median of 3.0 days, and in 18 patients it dropped abruptly within 24 hours. Multi-organ failure occurred in 21 patients (22.8%, 95% CI 15.4% to 32.4%) and was strongly associated with CRIMYNE (odds ratio 4.58, 95% CI 1.64 to 12.81). Six patients with CRIMYNE died: three in the ICU and three after ICU discharge. Hospital mortality was similar in patients with and without CRIMYNE (21.4% and 17.2%; p = 0.771). At ICU discharge, electrophysiological signs of CRIMYNE persisted in 18 (64.3%) of 28 patients. At hospital discharge, diagnoses in the 15 survivors were critical illness myopathy (CIM) in six cases, critical illness polyneuropathy (CIP) in four, combined CIP and CIM in three, and undetermined in two. CONCLUSION: A peroneal CMAP reduction below two standard deviations of normal value accurately identifies patients with CRIMYNE. These should have full neurological and neurophysiological evaluations before discharge from the acute hospital.

Arterial versus plethysmographic dynamic indices to test responsiveness for testing fluid administration in hypotensive patients: a clinical trial.

In the present study, we compared indices of respiratory-induced variation obtained from direct arterial blood pressure measurement with analogous indices obtained from the plethysmogram measured by the pulse oximeter to assess the value of these indices for predicting the cardiac output increase in response to a fluid challenge. Thirty-two fluid challenges were performed in 22 hypotensive patients who were also monitored with a pulmonary artery catheter. Hemodynamic and plethysmographic data were collected before and after intravascular volume expansion. Patients were classified as nonresponders if their cardiac index did not increase by 15% from baseline. Nonresponding patients had both lower arterial pulse variation ([10 +/- 4]% vs [19 +/- 13]%, P = 0.020) and lower plethysmographic pulse variation ([12 +/- 7]% vs [21 +/- 14]%, P = 0.034) when compared with responders. Fluid responsiveness was similarly predicted by arterial and plethysmographic pulse variations (area under ROC curve 0.74 vs 0.72, respectively, P = 0.90) and by arterial and plethysmographic systolic variation (area under ROC curve 0.64 vs 0.72, respectively, P = 0.50). Nonresponders were identified by changes in pulse variation both on arterial and plethysmographic waveform (area under ROC curve 0.80 vs 0.87, respectively, P = 0.40) and by changes in arterial and plethysmographic systolic variations (area under ROC curve 0.84 vs 0.80, respectively, P = 0.76). In the population studied, plethysmographic dynamic indices of respiratory-induced variation were just as useful for predicting fluid responsiveness as the analogous indices derived from direct arterial blood pressure measurement. These plethysmographic indices could provide a noninvasive tool for predicting the cardiac output increase by administering fluid.