关注重症监护病房获得性肌无力参考课件.ppt

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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

2、25%的机械通气将发生ICU-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

3、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？）,6,定义 Definition ICUAW is a s,Clinical features associated with ICU-AW,7,Clinical features associated w,ICU-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

4、ICU-AW的主要原因,8,ICU-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MODS9,10,10,SIRS/MODS引起ICU-AW,Hematoxylin 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,11,SIRS/MODS引起ICU-AWHematoxylin a,病理改变,Selectiv

5、e thick filament loss Predominant type II muscle fibre atrophy Muscle membrane inexcitability J Cachexia Sarcopenia Muscle(2010)1:147157,12,病理改变Selective thick filament l,13,13,14,14,ICU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 res

6、ulting 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 loss,Immobility and Disuse Atrophy,约束/制动的影响,15,ICU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,16,ICU-AW后果脱机失败或脱机时间延长16,Early mobilizatio

7、n and recovery in mechanically ventilated patients in the ICU:a bi-national,multi-centre,prospective cohort study,17,Early mobilization and recover,诊断,18,诊断18,诊断,19,诊断19,MEDICAL RESEARCH COUNCIL SCALE(MRCS),20,MEDICAL RESEARCH COUNCIL SCALE,ICU-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,CM

8、AP(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,ICU-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22,23,23,24,24,How to do?,25,How to do?25,26,26,the treatment group performed a passive or active exercise training session for 20 mins/day,using a bedsi

9、de ergometer.,27,the treatment group per,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 discharge.QF,quadriceps force;hospital,day of hospital discharge.*p.01 between ICU a

10、ndhospital discharge;p.05 compared with control group,28,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。,29,29,30,30,31,31,32,32,p=0.048,33,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。,34,结论：虽然电刺激不能防止ICU-AW的发生，但可以减轻肌无力,35,35,36,36,37,37,总结,积极控制原发病，维持内环境稳定避免肌松、糖皮质激素的使用避免过度镇静避免过度休息与制动制定合理的机械通气方案，尽早脱机，缩短在ICU停留时间早期、适当的功能锻炼可能减少ICU-AW的发生率,38,总结积极控制原发病，维持内环境稳定38,