Neuromuscular problems are frequent complications in patients with severe disease that require admission to the intensive care unit (ICU). Weakness of limbs and respiratory muscles is most frequently due to critical illness polyneuro-and/or myopathy (CIP/CIM). As a consequence, patients face a delay in weaning from ventilatory support and rehabilitation. Recovery of strength often occurs within weeks to months but can be incomplete or not occur at all. CIP/CIM is associated with increased ICU stay and mortality rates. Prevention and treatment of CIP/CIM is therefore of great importance.
We searched for and analysed all randomised controlled trials that examined the effects of any treatment intervention on the incidence of CIP/CIM in adult patients admitted to an ICU. We ultimately found three trials that focused on two different interventions.
Two trials with 825 participants examined the effect of intensive insulin therapy, aiming to maintain blood glucose levels within the normal range (80 to 110 mg/dl), versus conventional insulin therapy, aiming to avoid hyperglycaemia (high blood sugar > 215 mg/dl), on the incidence of CIP/CIM in patients staying in ICU for at least one week. Pooling the results of both trials showed that intensive insulin therapy reduces the incidence of CIP/CIM, the duration of mechanical ventilation, the duration of ICU stay and mortality at 180 days. No significant effect on mortality at 30 days was noted. Intensive insulin therapy was associated with a significant increase in hypoglycaemia (low blood sugar), and recurrent hypoglycaemic events. Although no increase in mortality within 24 hours of hypoglycaemia was noted, hypoglycaemia remains an issue of concern when implementing intensive insulin therapy in critically ill patients, as it may cause neurological complications. In both trials, no clinical measurement of weakness of the limbs was reported, nor data on physical rehabilitation. Data were derived from subgroup analysis, which may also limit the conclusions.
The third trial compared corticosteroid therapy versus placebo in 180 patients with persisting acute respiratory distress syndrome. Results showed no evidence of an effect of corticosteroids on the incidence of CIP/CIM, no effect on mortality at 180 days, on new serious infections, on glucose levels on day 7 and a trend towards less episodes of suspected or probable pneumonia. The number of new events of shock was reduced. In this trial, only 92 of the 180 patients were prospectively evaluated for CIP/CIM.