Neuromuscular Weakness in the ICU

  • Marc-Alain BabiEmail author


Critical illness muscular and nerve weakness is a common occurrence among patients who are critically ill or are admitted to intensive care units. Weakness is frequently observed in patients with multiple organ failure and severe systemic disease and may also be associated with treatments administered in the intensive care unit. Neuromuscular weakness in the ICU is most often due to critical illness myopathy, critical illness polyneuropathy, or a combination of both. Some authors apply the term “intensive care unit-acquired weakness” for patients who are admitted to intensive care units with systemic disease and subsequently develop clinically detected weakness but no other clear explanation of their weakness other than their primary critical care illness. This chapter reviews the neuromuscular weaknesses commonly encountered in the intensive care unit.


Weakness Neuromuscular weakness Critical illness myopathy Critical illness neuropathy Myopathy Neuropathy Intensive care Paraplegia Failure to wean 


  1. 1.
    Stevens RD, Marshall SA, Cornblath DR, et al. A framework for diagnosing and classifying intensive care unit-acquired weakness. Crit Care Med. 2009;37:S299–308.CrossRefGoogle Scholar
  2. 2.
    Koch S, Spuler S, Deja M, et al. Critical illness myopathy is frequent: accompanying neuropathy protracts ICU discharge. J Neurol Neurosurg Psychiatry. 2011;82:287–93.CrossRefGoogle Scholar
  3. 3.
    Latronico N, Bolton CF. Critical illness polyneuropathy and myopathy: a major cause of muscle weakness and paralysis. Lancet Neurol. 2011;10:931–41.CrossRefGoogle Scholar
  4. 4.
    Lacomis D, Giuliani MJ, Van Cott A, Kramer DJ. Acute myopathy of intensive care: clinical, electromyographic, and pathological aspects. Ann Neurol. 1996;40:645–54.CrossRefGoogle Scholar
  5. 5.
    Rouleau G, Karpati G, Carpenter S, et al. Glucocorticoid excess induces preferential depletion of myosin in denervated skeletal muscle fibers. Muscle Nerve. 1987;10:428–38.CrossRefGoogle Scholar
  6. 6.
    Di Giovanni S, Mirabella M, D’Amico A, et al. Apoptotic features accompany acute quadriplegic myopathy. Neurology. 2000;55:854–8.CrossRefGoogle Scholar
  7. 7.
    Di Giovanni S, Molon A, Broccolini A, et al. Constitutive activation of MAPK cascade in acute quadriplegic myopathy. Ann Neurol. 2004;55:195–206.CrossRefGoogle Scholar
  8. 8.
    Langhans C, Weber-Carstens S, Schmidt F, et al. Inflammation-induced acute phase response in skeletal muscle and critical illness myopathy. PLoS One. 2014;9:e92048.CrossRefGoogle Scholar
  9. 9.
    Capasso M, Di Muzio A, Pandolfi A, et al. Possible role for nitric oxide dysregulation in critical illness myopathy. Muscle Nerve. 2008;37:196–202.CrossRefGoogle Scholar
  10. 10.
    Mozaffar T, Haddad F, Zeng M, et al. Molecular and cellular defects of skeletal muscle in an animal model of acute quadriplegic myopathy. Muscle Nerve. 2007;35:55–65.CrossRefGoogle Scholar
  11. 11.
    Rossignol B, Gueret G, Pennec JP, et al. Effects of chronic sepsis on the voltage-gated sodium channel in isolated rat muscle fibers. Crit Care Med. 2007;35:351–7.CrossRefGoogle Scholar
  12. 12.
    De Jonghe B, Sharshar T, Lefaucheur JP, et al. Paresis acquired in the intensive care unit: a prospective multicenter study. JAMA. 2002;288:2859–67.CrossRefGoogle Scholar
  13. 13.
    Campellone JV, Lacomis D, Kramer DJ, et al. Acute myopathy after liver transplantation. Neurology. 1998;50:46–53.CrossRefGoogle Scholar
  14. 14.
    Bednarík J, Vondracek P, Dusek L, et al. Risk factors for critical illness polyneuromyopathy. J Neurol. 2005;252:343–51.CrossRefGoogle Scholar
  15. 15.
    Druschky A, Herkert M, Radespiel-Tröger M, et al. Critical illness polyneuropathy: clinical findings and cell culture assay of neurotoxicity assessed by a prospective study. Intensive Care Med. 2001;27:686–93.CrossRefGoogle Scholar
  16. 16.
    Amaya-Villar R, Garnacho-Montero J, García-Garmendía JL, et al. Steroid-induced myopathy in patients intubated due to exacerbation of chronic obstructive pulmonary disease. Intensive Care Med. 2005;31:157–61.CrossRefGoogle Scholar
  17. 17.
    Douglass JA, Tuxen DV, Horne M, et al. Myopathy in severe asthma. Am Rev Respir Dis. 1992;146:517–9.CrossRefGoogle Scholar
  18. 18.
    Shee CD. Risk factors for hydrocortisone myopathy in acute severe asthma. Respir Med. 1990;84:229–33.CrossRefGoogle Scholar
  19. 19.
    Panegyres PK, Squier M, Mills KR, Newsom-Davis J. Acute myopathy associated with large parenteral dose of corticosteroid in myasthenia gravis. J Neurol Neurosurg Psychiatry. 1993;56:702–4.CrossRefGoogle Scholar
  20. 20.
    Deconinck N, Van Parijs V, Beckers-Bleukx G, Van den Bergh P. Critical illness myopathy unrelated to corticosteroids or neuromuscular blocking agents. Neuromuscul Disord. 1998;8:186–92.CrossRefGoogle Scholar
  21. 21.
    Showalter CJ, Engel AG. Acute quadriplegic myopathy: analysis of myosin isoforms and evidence for calpain-mediated proteolysis. Muscle Nerve. 1997;20:316–22.CrossRefGoogle Scholar
  22. 22.
    Hermans G, Van den Berghe G. Clinical review: intensive care unit acquired weakness. Crit Care. 2015;19:274.CrossRefGoogle Scholar
  23. 23.
    Hough CL, Steinberg KP, Taylor Thompson B, et al. Intensive care unit-acquired neuromyopathy and corticosteroids in survivors of persistent ARDS. Intensive Care Med. 2009;35:63–8.CrossRefGoogle Scholar
  24. 24.
    Latronico N, Bertolini G, Guarneri B, et al. Simplified electrophysiological evaluation of peripheral nerves in critically ill patients: the Italian multi-Centre CRIMYNE study. Crit Care. 2007;11:R11.CrossRefGoogle Scholar
  25. 25.
    Lacomis D. Electrophysiology of neuromuscular disorders in critical illness. Muscle Nerve. 2013;47:452–63.CrossRefGoogle Scholar
  26. 26.
    Crone C. Tetraparetic critically ill patients show electrophysiological signs of myopathy. Muscle Nerve. 2017;56:433–40.CrossRefGoogle Scholar
  27. 27.
    Ojha A, Zivkovic SA, Lacomis D. Electrodiagnostic studies in the intensive care unit: a comparison study 2 decades later. Muscle Nerve. 2018;57:772–6.CrossRefGoogle Scholar
  28. 28.
    Kramer CL, Boon AJ, Harper CM, Goodman BP. Compound muscle action potential duration in critical illness neuromyopathy. Muscle Nerve. 2018;57:395–400.CrossRefGoogle Scholar
  29. 29.
    Hermans G, Wilmer A, Meersseman W, et al. Impact of intensive insulin therapy on neuromuscular complications and ventilator dependency in the medical intensive care unit. Am J Respir Crit Care Med. 2007;175:480–9.CrossRefGoogle Scholar
  30. 30.
    Hermans G, De Jonghe B, Bruyninckx F, Van den Berghe G. Interventions for preventing critical illness polyneuropathy and critical illness myopathy. Cochrane Database Syst Rev. 2009;(1):CD006832.Google Scholar
  31. 31.
    Fletcher SN, Kennedy DD, Ghosh IR, et al. Persistent neuromuscular and neurophysiologic abnormalities in long-term survivors of prolonged critical illness. Crit Care Med. 2003;31:1012–6.CrossRefGoogle Scholar
  32. 32.
    Van den Berghe G, Schoonheydt K, Becx P, et al. Insulin therapy protects the central and peripheral nervous system of intensive care patients. Neurology. 2005;64:1348–53.CrossRefGoogle Scholar
  33. 33.
    Falciglia M, Freyberg RW, Almenoff PL, et al. Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis. Crit Care Med. 2009;37:3001–9.CrossRefGoogle Scholar
  34. 34.
    Li Y, Bai Z, Li M, et al. U-shaped relationship between early blood glucose and mortality in critically ill children. BMC Pediatr. 2015;15:88.CrossRefGoogle Scholar
  35. 35.
    Qaseem A, Humphrey LL, Chou R, et al. Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2011;154:260–7.CrossRefGoogle Scholar
  36. 36.
    van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359–67.CrossRefGoogle Scholar
  37. 37.
    Likosky DS, Nugent WC, Clough RA, et al. Comparison of three measurements of cardiac surgery mortality for the Northern New England Cardiovascular Disease Study Group. Ann Thorac Surg. 2006;81:1393–5.CrossRefGoogle Scholar
  38. 38.
    Koch S, Wollersheim T, Bierbrauer J, et al. Long-term recovery in critical illness myopathy is complete, contrary to polyneuropathy. Muscle Nerve. 2014;50:431–6.CrossRefGoogle Scholar
  39. 39.
    Intiso D, Amoruso L, Zarrelli M, et al. Long-term functional outcome and health status of patients with critical illness polyneuromyopathy. Acta Neurol Scand. 2011;123:211–9.CrossRefGoogle Scholar
  40. 40.
    Guarneri B, Bertolini G, Latronico N. Long-term outcome in patients with critical illness myopathy or neuropathy: the Italian multicentre CRIMYNE study. J Neurol Neurosurg Psychiatry. 2008;79:838–41.CrossRefGoogle Scholar
  41. 41.
    Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369:1306–16.CrossRefGoogle Scholar
  42. 42.
    Jackson JC, Pandharipande PP, Girard TD, et al. Depression, post-traumatic stress disorder, and functional disability in the BRAIN-ICU study: a longitudinal cohort study. Lancet Respir Med. 2014;5:369–79.CrossRefGoogle Scholar
  43. 43.
    Maley JH, Brewster I, Mayoral I, et al. Resilience in survivors of critical illness in the context of the survivors’ experience and self-reported neuropsychological and physical function. Ann Am Thorac Soc. 2016;13:1351–60.CrossRefGoogle Scholar
  44. 44.
    Bolton CF, Gilbert JJ, Hahn AF, Sibbald WJ. Polyneuropathy in critically ill patients. J Neurol Neurosurg Psychiatry. 1984;47:1223–31.CrossRefGoogle Scholar
  45. 45.
    Fischler D. Prolonged respiratory insufficiency due to acute motor neuropathy: a new syndrome? Neurology. 1983;33:s240.CrossRefGoogle Scholar
  46. 46.
    Sander HW, Golden M, Danon MJ. Quadriplegic areflexic ICU illness: selective thick filament loss and normal nerve histology. Muscle Nerve. 2002;26:499–505.CrossRefGoogle Scholar
  47. 47.
    Bolton CF. Neuromuscular manifestations of critical illness. Muscle Nerve. 2005;32:140–63.CrossRefGoogle Scholar
  48. 48.
    Yuki N, Hartung HP. Guillain-Barré syndrome. N Engl J Med. 2012;366:2294–304.CrossRefGoogle Scholar
  49. 49.
    Sejvar JJ, Baughman AL, Wise M, Morgan OW. Population incidence of Guillain-Barré syndrome: a systematic review and meta-analysis. Neuroepidemiology. 2011;36:123–33.CrossRefGoogle Scholar
  50. 50.
    Ropper AH. The Guillain-Barré syndrome. N Engl J Med. 1992;326:1130–6.CrossRefGoogle Scholar
  51. 51.
    Hadden RD, Cornblath DR, Hughes RA, et al. Electrophysiological classification of Guillain-Barré syndrome: clinical associations and outcome. Plasma exchange/Sandoglobulin Guillain-Barré Syndrome Trial Group. Ann Neurol. 1998;44:780–8.CrossRefGoogle Scholar
  52. 52.
    Patwa HS, Chaudhry V, Katzberg H, et al. Evidence-based guideline: intravenous immunoglobulin in the treatment of neuromuscular disorders: report of the therapeutics and technology assessment Subcommittee of the American Academy of Neurology. Neurology. 2012;78:1009–15.CrossRefGoogle Scholar
  53. 53.
    Buchwald B, Ahangari R, Weishaupt A, Toyka KV. Intravenous immunoglobulins neutralize blocking antibodies in Guillain-Barré syndrome. Ann Neurol. 2002;51:673–80.CrossRefGoogle Scholar
  54. 54.
    Kress JP, Hall JB. ICU-acquired weakness and recovery from critical illness. N Engl J Med. 2014;370:1626.CrossRefGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  1. 1.Department of NeurologyUniversity of FloridaGainesvilleUSA

Personalised recommendations