[Context, issues and perspectives of nutrition in hospitals]. / Contexte, enjeux et perspectives de la nutrition à l'hôpital.

Undernutrition is common in hospitals, and it worsens the vital and functional prognosis of patients. The earlier it is treated, the more effective it is. The prevention, detection, treatment and monitoring of undernutrition or the risk of undernutrition are a public health priority, which directly involves all carers. Management can be improved by their daily collaboration with a transversal nutrition unit.

[Nutrition and nursing]. / Nutrition et soins infirmiers.

Nutritional nursing care, whether prescribed or on its own role, is a fundamental aspect of the fight against undernutrition in hospital, which is a determinant of vital and functional prognosis. This care includes screening for undernutrition and its risk factors, assessment of intake and feeding difficulties, enrichment of oral nutrition, enteral and parenteral nutrition. Given the complexity and importance of these tasks, a multi-professional approach involving a transverse nutrition unit is beneficial.

Changes in cardiac arrest patients' temperature management after the 2013 "TTM" trial: results from an international survey.

BACKGROUND: Therapeutic hypothermia (TH between 32 and 34 °C) was recommended until recently in unconscious successfully resuscitated cardiac arrest (CA) patients, especially after initial shockable rhythm. A randomized controlled trial published in 2013 observed similar outcome between a 36 °C-targeted temperature management (TTM) and a 33 °C-TTM. The main aim of our study was to assess the impact of this publication on physicians regarding their TTM practical changes. METHODS: A declarative survey was performed using the webmail database of the French Intensive Care Society including 3229 physicians (from May 2014 to January 2015). RESULTS: Five hundred and eighteen respondents from 264 ICUs in 11 countries fulfilled the survey (16 %). A specific attention was generally paid by 94 % of respondents to TTM (hyperthermia avoidance, normothermia, or TH implementation) in CA patients, whereas 6 % did not. TH between 32 and 34 °C was declared as generally maintained during 12-24 h by 78 % of respondents or during 24-48 h by 19 %. Since the TTM trial publication, 56 % of respondents declared no modification of their TTM practice, whereas 37 % declared a practical target temperature change. The new temperature targets were 35-36 °C for 23 % of respondents, and 36 °C for 14 %. The duration of overall TTM (including TH and/or normothermia) was declared as applied between 12 and 24 h in 40 %, and between 24 and 48 h in 36 %. In univariate analysis, the physicians' TTM modification seemed related to hospital category (university versus non-university hospitals, P = 0.045), to TTM-specific attention paid in CA patients (P = 0.008), to TH durations (<12 versus 24-48 h, P = 0.01), and to new targets temperature (32-34 versus 35-36 °C, P < 0.0001). CONCLUSIONS: The TTM trial publication has induced a modification of current practices in one-third of respondents, whereas the 32-34 °C target temperature remained unchanged for 56 %. Educational actions are needed to promote knowledge translations of trial results into clinical practice. New international guidelines may contribute to this effort.

Efficacy and safety of sedation with dexmedetomidine in critical care patients: a meta-analysis of randomized controlled trials.

INTRODUCTION: Dexmedetomidine may help physicians target a low level of sedation. Unfortunately, the impact of dexmedetomidine on major endpoints remains unclear in intensive care unit (ICU). MATERIAL AND METHODS: To evaluate the association between dexmedetomidine use with efficacy and safety outcomes, two reviewers independently identified randomized controlled trials comparing dexmedetomidine with other sedative agents in non-post-cardiac surgery critically ill patients in the PubMed and Cochrane databases. Random effects models were considered if heterogeneity was detected using the DerSimonian and Laird estimation method. Statistical heterogeneity between results was assessed by examining forest plots, confidence intervals (CI) and by using the I(2) statistic. The risk of bias was assessed using the risk of bias tool. RESULTS: This meta-analysis included 1994 patients from 16 randomized controlled trials. Comparators were lorazepam, midazolam and propofol. Dexmedetomidine was associated with a reduction in ICU length of stays (WMD=-0.304; 95% CI [-0.477, -0.132]; P=0.001), mechanical ventilation duration (WMD=-0.313, 95% CI [-0.523, -0.104]; P=0.003) and delirium incidence (RR=0.812, 95% CI [0.680, 0.968]; P=0.020). Dexmedetomidine is also associated with an increase in the incidence of bradycardia (RR=1.947, 95% CI [1.387, 2.733]; P=0.001) and hypotension (RR=1.264; 95% CI [1.013, 1.576]; P=0.038). CONCLUSIONS AND RELEVANCE: In this first meta-analysis including only randomized controlled trials related to ICU patients, dexmedetomidine was associated with a 48h reduction in ICU length of stay, mechanical ventilation duration and delirium occurrence despite a significant heterogeneity among studies. Dexmedetomidine was also associated with an increase in bradycardia and hypotension.

Interventions for preventing critical illness polyneuropathy and critical illness myopathy.

BACKGROUND: Critical illness polyneuropathy or myopathy (CIP/CIM) is a frequent complication in the intensive care unit (ICU) and is associated with prolonged mechanical ventilation, longer ICU stay and increased mortality. This is an interim update of a review first published in 2009 (Hermans 2009). It has been updated to October 2011, with further potentially eligible studies from a December 2013 search characterised as awaiting assessment. OBJECTIVES: To systematically review the evidence from RCTs concerning the ability of any intervention to reduce the incidence of CIP or CIM in critically ill individuals. SEARCH METHODS: On 4 October 2011, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, and EMBASE. We checked the bibliographies of identified trials and contacted trial authors and experts in the field. We carried out an additional search of these databases on 6 December 2013 to identify recent studies. SELECTION CRITERIA: All randomised controlled trials (RCTs), examining the effect of any intervention on the incidence of CIP/CIM in people admitted to adult medical or surgical ICUs. The primary outcome was the incidence of CIP/CIM in ICU, based on electrophysiological or clinical examination. Secondary outcomes included duration of mechanical ventilation, duration of ICU stay, death at 30 and 180 days after ICU admission and serious adverse events from the treatment regimens. DATA COLLECTION AND ANALYSIS: Two authors independently extracted the data and assessed the risk of bias in included studies. MAIN RESULTS: We identified five trials that met our inclusion criteria. Two trials compared intensive insulin therapy (IIT) to conventional insulin therapy (CIT). IIT significantly reduced CIP/CIM in the screened (n = 825; risk ratio (RR) 0.65, 95% confidence interval (CI) 0.55 to 0.77) and total (n = 2748; RR 0.70, 95% CI 0.60 to 0.82) population randomised. IIT reduced duration of mechanical ventilation, ICU stay and 180-day mortality, but not 30-day mortality compared with CIT. Hypoglycaemia increased with IIT but did not cause early deaths.One trial compared corticosteroids with placebo (n = 180). The trial found no effect of treatment on CIP/CIM (RR 1.27, 95% CI 0.77 to 2.08), 180-day mortality, new infections, glycaemia at day seven, or episodes of pneumonia, but did show a reduction of new shock events.In the fourth trial, early physical therapy reduced CIP/CIM in 82/104 evaluable participants in ICU (RR 0.62. 95% CI 0.39 to 0.96). Statistical significance was lost when we performed a full intention-to-treat analysis (RR 0.81, 95% CI 0.60 to 1.08). Duration of mechanical ventilation but not ICU stay was significantly shorter in the intervention group. Hospital mortality was not affected but 30- and 180-day mortality results were not available. No adverse effects were noticed.The last trial found a reduced incidence of CIP/CIM in 52 evaluable participants out of a total of 140 who were randomised to electrical muscle stimulation (EMS) versus no stimulation (RR 0.32, 95% CI 0.10 to 1.01). These data were prone to bias due to imbalances between treatment groups in this subgroup of participants. After we imputed missing data and performed an intention-to-treat analysis, there was still no significant effect (RR 0.94, 95% CI 0.78 to 1.15). The investigators found no effect on duration of mechanical ventilation and noted no difference in ICU mortality, but did not report 30- and 180-day mortality.We updated the searches in December 2013 and identified nine potentially eligible studies that will be assessed for inclusion in the next update of the review. AUTHORS' CONCLUSIONS: There is moderate quality evidence from two large trials that intensive insulin therapy reduces CIP/CIM, and high quality evidence that it reduces duration of mechanical ventilation, ICU stay and 180-day mortality, at the expense of hypoglycaemia. Consequences and prevention of hypoglycaemia need further study. There is moderate quality evidence which suggests no effect of corticosteroids on CIP/CIM and high quality evidence that steroids do not affect secondary outcomes, except for fewer new shock episodes. Moderate quality evidence suggests a potential benefit of early rehabilitation on CIP/CIM which is accompanied by a shorter duration of mechanical ventilation but without an effect on ICU stay. Very low quality evidence suggests no effect of EMS, although data are prone to bias. Strict diagnostic criteria for CIP/CIM are urgently needed for research purposes. Large RCTs need to be conducted to further explore the role of early rehabilitation and EMS and to develop new preventive strategies.

Physical restraint in mechanically ventilated ICU patients: a survey of French practice.

PURPOSE: To characterize the perceived utilization of physical restraint (PR) in mechanically ventilated intensive care unit (ICU) patients and to identify clinical and structural factors influencing PR use. METHODS: A questionnaire was personally handed to one intensivist in 130 ICUs in France then collected on-site 2 weeks later. RESULTS: The questionnaire was returned by 121 ICUs (response rate, 93 %), 66 % of which were medical-surgical ICUs. Median patient-to-nurse ratio was 2.8 (2.5-3.0). In 82 % of ICUs, PR is used at least once during mechanical ventilation in more than 50 % of patients. In 65 % of ICUs, PR, when used, is applied for more than 50 % of mechanical ventilation duration. Physical restraint is often used during awakening from sedation and when agitation occurs and is less commonly used in patients receiving deep sedation or neuromuscular blockers or having severe tetraparesis. In 29 % of ICUs, PR is used in more than 50 % of awake, calm and co-operative patients. PR is started without written medical order in more than 50 % of patients in 68 % of ICUs, and removed without written medical order in more than 50 % of patients in 77 % of ICUs. Only 21 % of ICUs have a written local procedure for PR use. CONCLUSIONS: This survey in a country with a relatively high patient-to-nurse ratio shows that PR is frequently used in patients receiving mechanical ventilation, with wide variations according to patient condition. The common absence of medical orders for starting or removing PR indicates that these decisions are mostly made by the nurses.

Hormonal status in protracted critical illness and in-hospital mortality.

INTRODUCTION: The aim of this study was to determine the relationship between hormonal status and mortality in patients with protracted critical illness. METHODS: We conducted a prospective observational study in four medical and surgical intensive care units (ICUs). ICU patients who regained consciousness after 7 days of mechanical ventilation were included. Plasma levels of insulin-like growth factor 1 (IGF-1), prolactin, thyroid-stimulating hormone, follicle-stimulating hormone, luteinizing hormone, estradiol, progesterone, testosterone, dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS) and cortisol were measured on the first day patients were awake and cooperative (day 1). Mean blood glucose from admission to day 1 was calculated. RESULTS: We studied 102 patients: 65 men and 37 women (29 of the women were postmenopausal). Twenty-four patients (24%) died in the hospital. The IGF-1 levels were higher and the cortisol levels were lower in survivors. Mean blood glucose was lower in women who survived, and DHEA and DHEAS were higher in men who survived. CONCLUSIONS: These results suggest that, on the basis of sex, some endocrine or metabolic markers measured in the postacute phase of critical illness might have a prognostic value.

Intermittent subglottic secretion drainage and ventilator-associated pneumonia: a multicenter trial.

RATIONALE: Ventilator-associated pneumonia (VAP) causes substantial morbidity and mortality. The influence of subglottic secretion drainage (SSD) in preventing VAP remains controversial. OBJECTIVES: To determine whether SSD reduces the overall incidence of microbiologically confirmed VAP. METHODS: Randomized controlled clinical trial conducted at four French centers. A total of 333 adult patients intubated with a tracheal tube allowing drainage of subglottic secretions and expected to require mechanical ventilation for ≥48 hours was included. Patients were randomly assigned to undergo intermittent SSD (n = 169) or not (n = 164). MEASUREMENTS AND MAIN RESULTS: Primary outcome was the overall incidence of VAP based on quantitative culture of distal pulmonary samplings performed after each clinical suspicion. Other outcomes included incidence of early- and late-onset VAP, duration of mechanical ventilation, and hospital mortality. Microbiologically confirmed VAP occurred in 67 patients, 25 of 169 (14.8%) in the SSD group and 42 of 164 (25.6%) in the control group (P = 0.02), yielding a relative risk reduction of 42.2% (95% confidential interval, 10.4-63.1%). Using the Day 5 threshold, the beneficial effect of SSD in reducing VAP was observed in both early-onset VAP (2 of 169 [1.2%] patients undergoing SSD vs. 10 of 164 [6.1%] control patients; P = 0.02) and late-onset VAP (23 of 126 [18.6%] patients undergoing SSD vs. 32 of 97 [33.0%] control patients; P = 0.01). VAP was clinically suspected at least once in 51 of 169 (30.2%) patients undergoing SSD and 60 of 164 (36.6%) control patients (P = 0.25). No significant between-group differences were observed in duration of mechanical ventilation and hospital mortality. CONCLUSIONS: Subglottic secretion drainage during mechanical ventilation results in a significant reduction in VAP, including late-onset VAP. Clinical trial registered with www.clinicaltrials.gov (NCT00219661).

Hormonal status and ICU-acquired paresis in critically ill patients.

BACKGROUND: The pathogenesis of intensive care unit-acquired paresis (ICUAP), a frequent and severe complication of critical illness, is poorly understood. Since ICUAP has been associated with female gender in some studies, we hypothesized that hormonal dysfunction might contribute to ICUAP. OBJECTIVE: To determine the relationship between hormonal status, ICUAP and mortality in patients with protracted critical illness. DESIGN: Prospective observational study. SETTING: Four medical and surgical ICUs. PATIENTS: ICU patients mechanically ventilated for >7 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Plasma levels of insulin growth factor-1 (IgF1), prolactin, thyroid stimulating hormone (TSH), follicular stimulating hormone (FSH), luteinizing hormone (LH), estradiol, progesterone, testosterone, dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulphate (DHEAS) and cortisol were measured on the first day patients were awake (day 1). Mean blood glucose from admission to day 1 was calculated. ICUAP was defined as Medical Research Council sum score <48/60 on day 7. RESULTS: We studied 102 patients (65 men and 37 women, 29 post-menopausal), of whom 24 (24%) died during hospitalization. Among the 86 patients tested at day 7, 39 (49%) had ICUAP, which was more frequent in women (63% versus men 36%, p = 0.02). Mean blood glucose was higher in patients with ICUAP. Estradiol/testosterone ratio was greater in men with ICUAP. CONCLUSION: ICUAP 7 days after awakening was associated with increased blood glucose and with biological evidence of hypogonadism in men, while an association with hormonal dysfunction was not detected in women.

Weakness in the ICU: a call to action.

Muscle weakness is prevalent in critically ill patients and can have a dramatic effect on short- and long-term outcomes, yet there are currently no interventions with proven efficacy in preventing or treating this complication. In a new randomized trial, researchers found that serial electrical muscle stimulation significantly mitigated ultrasound-defined muscle atrophy, and the treatment was not linked to adverse effects. Although preliminary, these results, together with other recent studies, indicate a paradigm shift to a proactive approach in managing neuromuscular complications in the ICU.

Presence and severity of intensive care unit-acquired paresis at time of awakening are associated with increased intensive care unit and hospital mortality.

OBJECTIVES: To assess whether the presence and severity of intensive care unit-acquired paresis are associated with intensive care unit and in-hospital mortality. DESIGN: Prospective, observational study. SETTING: Two medical, one surgical, and one medico-surgical intensive care units in two university hospitals and one university-affiliated hospital. PATIENTS: A total of 115 consecutive patients were enrolled after > 7 days of mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The Medical Research Council score (from 0-60) was used to evaluate upper and lower limb strength at time of awakening, identified as the ability to follow five commands. Intensive care unit-acquired paresis was defined as a Medical Research Council score <48. Patients were followed-up until hospital discharge. The primary end point was hospital mortality. At awakening, median Medical Research Council score was 41 (interquartile range, 21-52), and 75 (65%) patients had intensive care unit-acquired paresis. Hospital non-survivors had a significantly lower Medical Research Council score at awakening (21 [11-43]) vs. 41 [28-53]; p = .008) and a significantly higher rate of intensive care unit-acquired paresis (85.1% vs. 58.4%; p = .02) compared to survivors. After multivariate risk adjustment, intensive care unit-acquired paresis was independently associated with higher hospital and intensive care unit mortality (odds ratio for hospital mortality, 2.02; 95% confidence interval, 1.03-8.03; p = .048). Each Medical Research Council point decrease was associated with a significantly higher hospital mortality (odds ratio, 1.03; 95% confidence interval, 1.01-1.05; p = .033). CONCLUSIONS: Both the presence and severity of intensive care unit-acquired paresis at the time of awakening are associated with increased intensive care unit and hospital mortality; the mechanisms underlying this association need further study.

Frequency and clinical impact of preserved bispectral index activity during deep sedation in mechanically ventilated ICU patients.

OBJECTIVE: Despite an overall correlation between the bispectral index of the EEG (BIS) and clinical sedation assessment, unexpectedly high BIS values can be observed at deep sedation levels. We assessed the frequency, interindividual variability and clinical impact of high BIS values during clinically deep sedation. DESIGN AND SETTING: Prospective observational study in two university-affiliated intensive care units. PATIENTS: Sixty-two mechanically ventilated patients requiring intravenous sedation and analgesia for >or=24 h. MEASUREMENTS AND MAIN RESULTS: Paired measurements of BIS and sedation measured on the adaptation to intensive care environment (ATICE) score were obtained every 3 h until awakening. A paired measurement with BIS >60 at deep sedation (ATICE Awakeness

Interventions for preventing critical illness polyneuropathy and critical illness myopathy.

BACKGROUND: Critical illness polyneuro-and/or myopathy (CIP/CIM) is an important and frequent complication in the intensive care unit (ICU), causing delayed weaning from mechanical ventilation. It may increase ICU stay and mortality. OBJECTIVES: To examine the ability of any intervention to prevent the occurrence of CIP/CIM. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Register (October 2007), MEDLINE (January 1950 to April 2008), EMBASE (January 1980 to October 2007), checked bibliographies and contacted trial authors and experts in the field. SELECTION CRITERIA: All randomised controlled trials (RCTs), examining the effect of any intervention on the incidence of CIP/CIM in adult medical or surgical ICU patients. The primary outcome measure was the incidence of CIP/CIM after at least seven days in ICU, based on electrophysiological or clinical examination. DATA COLLECTION AND ANALYSIS: Two authors independently extracted the data. MAIN RESULTS: Three out of nine identified trials, provided data on our primary outcome measure. Two trials examined the effects of intensive insulin therapy versus conventional insulin therapy. Eight hundred and twenty-five out of 2748 patients randomised, were included in the analysis. The incidence of CIP/CIM was significantly reduced with intensive insulin therapy in the population screened for CIP/CIM (relative risk (RR) 0.65, 95% confidence interval (CI) 0.55 to 0.78) and in the total population randomised (RR 0.60, 95% CI 0.49 to 0.74). Duration of mechanical ventilation, duration of ICU stay and 180-day mortality but not 30-day mortality, were significantly reduced with intensive insulin therapy, in both the total and the screened population. Intensive insulin therapy significantly increased hypoglycaemic events and recurrent hypoglycaemia. Death within 24 hours of the hypoglycaemic event was not different between groups. The third trial examined the effects of corticosteroids versus placebo in 180 patients with prolonged acute respiratory distress syndrome. No significant effect of corticosteroids on CIP/CIM was found (RR 1.09, 95% CI 0.53 to 2.26). No effect on 180-day mortality, new serious infections and glycaemia at day seven was found. A trend towards fewer episodes of pneumonia and reduction of new events of shock was shown. AUTHORS' CONCLUSIONS: Substantial evidence shows that intensive insulin therapy reduces the incidence of CIP/CIM, the duration of mechanical ventilation, duration of ICU stay and 180-day mortality. There was a significant associated increase in hypoglycaemia. Further research needs to identify the clinical impact of this and strategies need to be developed to reduce the risk of hypoglycaemia. Limited evidence shows no significant effect of corticosteroids on the incidence of CIP/CIM, or on any of the other secondary outcome measures, except for a significant reduction of new episodes of shock. Strict diagnostic criteria for the purpose of research should be defined. Other interventions should be investigated in randomised controlled trials.

Intensive care unit-acquired weakness: risk factors and prevention.

Intensive care unit-acquired weakness, the main clinical sign of critical illness neuromyopathy, is an increasingly recognized cause of prolonged mechanical ventilation and delayed return to physical self-sufficiency. Identifying risk factors and developing preventive measures are therefore important goals. Several studies on risk factors for critical illness neuromyopathy including prospective observational studies with a multivariate analysis of potential risk factors were conducted over the last decade. A large body of data is also available from two large prospective randomized trials comparing the effect of strict vs. conventional blood-glucose control on intensive care unit mortality and on secondary outcomes including the occurrence of critical illness neuromyopathy. Five central risk factors and their related potential measures to prevent intensive care unit-acquired weakness can be identified including multiple organ failure, muscle inactivity, hyperglycemia, and use of corticosteroids and neuromuscular blockers. Although strong evidence regarding the efficacy of preventive measures is still lacking, the results of available studies are promising and cast doubt on the widespread belief that the treatment of intensive care unit-acquired weakness is essentially supportive. Early identifying and treating conditions leading to multiple organ failure, especially severe sepsis and septic shock, avoiding unnecessary deep sedation and excessive blood glucose levels, promoting early mobilization, and carefully weighing the risks and benefits of corticosteroids might contribute to reduce the incidence and severity of intensive care unit-acquired weakness.

A framework for diagnosing and classifying intensive care unit-acquired weakness.

Neuromuscular dysfunction is prevalent in critically ill patients, is associated with worse short-term outcomes, and is a determinant of long-term disability in intensive care unit survivors. Diagnosis is made with the help of clinical, electrophysiological, and morphological observations; however, the lack of a consistent nomenclature remains a barrier to research. We propose a simple framework for diagnosing and classifying neuromuscular disorders acquired in critical illness.

Staged laparoscopic adjuvant intraperitoneal chemohyperthermia after complete resection for locally advanced colorectal or gastric cancer: a preliminary experience.

BACKGROUND: Cytoreductive surgery followed by intraperitoneal chemohyperthermia (IPCH) is a promising treatment for patients with peritoneal carcinomatosis, a disease with dismal prognosis. METHODS: We describe our preliminary experience with staged adjuvant laparoscopic IPCH after complete resection in patients with locally or regionally advanced colorectal or gastric cancer. RESULTS: Twenty-one patients underwent resection for colorectal (N = 16) or gastric cancer (N = 5) followed by staged laparoscopic IPCH. No conversion to laparotomy was required. No major operative incident occurred. Mean duration of hospital stay was 12 days (range 9-23 days). No mortality occurred in the 30-day postoperative period. Four patients developed major complications (19%). One patient (5%) was reoperated. Mean follow-up period was 15.5 months (range 9-29 months). Three patients died, including two of cancer-related causes. No patient developed peritoneal carcinomatosis during the follow-up period. CONCLUSION: Staged laparoscopic adjuvant IPCH after open or laparoscopic resection in selected patients with colorectal or gastric cancer is feasible and reasonably safe. However, additional data are required to determine the effect on long-term survival.

Clinical review: Critical illness polyneuropathy and myopathy.

Critical illness polyneuropathy (CIP) and myopathy (CIM) are major complications of severe critical illness and its management. CIP/CIM prolongs weaning from mechanical ventilation and physical rehabilitation since both limb and respiratory muscles can be affected. Among many risk factors implicated, sepsis, systemic inflammatory response syndrome, and multiple organ failure appear to play a crucial role in CIP/CIM. This review focuses on epidemiology, diagnostic challenges, the current understanding of pathophysiology, risk factors, important clinical consequences, and potential interventions to reduce the incidence of CIP/CIM. CIP/CIM is associated with increased hospital and intensive care unit (ICU) stays and increased mortality rates. Recently, it was shown in a single centre that intensive insulin therapy significantly reduced the electrophysiological incidence of CIP/CIM and the need for prolonged mechanical ventilation in patients in a medical or surgical ICU for at least 1 week. The electrophysiological diagnosis was limited by the fact that muscle membrane inexcitability was not detected. These results have yet to be confirmed in a larger patient population. One of the main risks of this therapy is hypoglycemia. Also, conflicting evidence concerning the neuromuscular effects of corticosteroids exists. A systematic review of the available literature on the optimal approach for preventing CIP/CIM seems warranted.

Critical illness neuromuscular syndromes.

Critical illness neuromyopathy (CINM) is suggested by bilateral diffuse weakness predominant in the proximal part of the limbs after improvement of the acute phase of critical illness. Although muscle and peripheral nerve are often involved in combination, muscle involvement alone is increasingly identified on electrophysiologic investigation, including direct muscle stimulation. CINM frequently involves the respiratory muscles and may result in delayed weaning and prolonged mechanical ventilation. Besides muscle immobilization and prolonged sepsis-induced multiorgan failure, which are risk factors for CINM, hyperglycemia and use of corticosteroids might have a deleterious effect on the neuromuscular system in critically ill patients, suggesting opportunities for preventive interventions.