关注重症监护病房获得性肌无力参考课件.ppt

1、关注重症监护病房获得性肌无力 Focus on ICU-AW盛志勇1 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可能会忽略。nIntensive care unit acquired weakness ICU-AW ICU获得性肌无力4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-AWICU-AW:全球 100万 美国 7.5 万 5定义 Definition ICUAW is a syndrome of generalized lim

2、b 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原因可以解释的一类综合征。（膈肌及肋间肌？）6Clinical features associated with ICU-AW 7ICU-AW 危重病性肌病 (critical illness myopathy，CI

3、M)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的主要原因8病因nSIRS和MODSn高血糖n皮质激素的应用n神经肌肉阻滞剂n长期卧床、活动限制、延迟自主性物理运动n。910SIRS/MODS引起ICU-AWHematoxylin and eosin(HE)staining showing inflammatory cell infiltrate into muscle incritical ill

4、ness myopathy.微血管受损缺血神经损伤肌肉细胞凋亡肌细胞丢失11病理改变Selective thick filament loss Predominant type II muscle fibre atrophy Muscle membrane inexcitability J Cachexia Sarcopenia Muscle(2010)1:147157 121314ICU住院时间与肌肉密度的关系Experiments in healthy volunteers reveal that muscle atrophy begins within hours of immobili

5、ty,14 resulting in a 45%loss of muscle 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-AW后果n脱机失败或脱机时间延长n肢体功能障碍n死亡率增高16Early mobilization and recovery in mechanically ventilated patie

6、nts in the ICU:a bi-national,multi-centre,prospective cohort study17诊断18诊断19MEDICAL RESEARCH COUNCIL SCALE(MRCS)20ICU-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)21超声222324How to do?2526

7、the treatment group performed a passive or active exercise training session for 20 mins/day,using a bedside ergometer.27结果Figure 3.A,Boxplot 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 discha

8、rge.QF,quadriceps force;hospital,day of hospital discharge.*p.01 between ICU andhospital discharge;p.05 compared with control group28n 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.n 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。29303132 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。34353637总结n积极控制原发病，维持内环境稳定n避免肌松、糖皮质激素的使用n避免过度镇静n避免过度休息与制动n制定合理的机械通气方案，尽早脱机，缩短在ICU停留时间n早期、适当的功能锻炼可能减少ICU-AW的发生率38