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Welcome back everyone to Plumb Peeps. Ferf and

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I are so excited to be back together.

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We're kind of right now in the middle

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of summer, so hope everyone's enjoying their time.

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I think it's such a special time in

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the hospital. There's new residents. There's new fellows.

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So much

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excitement. So excited to bring you, though, a

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new case today and get back with things.

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Yeah. I love this time of year. New

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interns, new residents, new fellows. I feel like

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everyone has really great questions. And then the

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questions often let you

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teach about some core physiology or core topic,

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which is great. But they also then sometimes

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for topics that are a little more nebulous,

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make you really go back and say, what

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do I understand about this, and what don't

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I understand? And and so, actually, we're gonna

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talk today about a topic that is one

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that I think is pretty poorly understood, but

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also

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extremely,

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important and basically ubiquitous in any ICU where

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you're gonna be practicing. So we're gonna be

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talking about ICU acquired weakness today and hopefully

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drill through some of the uncertainty and get

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down to some of the misconceptions and some

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of the facts that we can understand about

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this to help take care of patients.

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Yeah. And we're very excited to welcome our

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special guests. We have one returning, and then

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we have a pump peeps first

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today. We're thrilled to welcome our first physiatrist.

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And for those of you who may be

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asking what a physiatrist is, that's a health

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care provider specializing in physical medicine and rehabilitation.

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But our first to the show and honored

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to welcome doctor Jim DeVaney,

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who's a physiatrist who just completed a neurocritical

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care fellowship at BIDMC.

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He's currently transitioning to a clinical associate position

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at the University Health Network, University of Toronto,

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where he'll be working as a PM and

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R consultant within the ICU.

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Jim, such a pleasure to have you on.

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Welcome to POMP peeps.

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Thank you, Christina. It's a pleasure to be

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here.

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Yeah, thanks, Jim. We're equally thrilled to welcome

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back doctor Kalila Paez. Kalila works at Beth

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Israel Deaconess. She's now a third year senior

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medical resident, interested in pulmonary and critical care

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and medical education.

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She's done some great episodes with us in

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the past, and, we're thrilled to have you

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back.

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Thanks for having me. It's always great to

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be back.

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Absolutely.

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And just as our standard disclaimer, as a

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reminder, this podcast is not meant to be

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used for specific medical advice. The views we

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expressed today may not reflect those of our

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respective employers.

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And the case we will present today is

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HIPAA compliant. Any details or patient identify,

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facts may have been changed to protect the

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privacy of our patient.

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Thanks, Verve. And, Klayla, welcome back. As as

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Dave mentioned,

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I feel like you're, yeah, almost a Plum

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Pipes veteran.

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I love doing some partnering with you of

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some recent Core I Am projects. So really

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love the collaboration,

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that we've had with you so far. Excited

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you're a senior resident now. I feel like

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the leader of the team, the know all.

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So excited for your year and your growth.

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And you actually brought this case to Dave

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and I to discuss. So thank you for

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this opportunity, and we're hoping that you can

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start out today by just describing, how the

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patient presented to you.

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Yeah, of course. It's it's great to be

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here. Thanks guys

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So let's start with the case. We have

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this 65 year old male patient He has

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a history of hypertension and type two diabetes

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And he's initially admitted to the icu because

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of severe sepsis

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secondary to a pneumonia.

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So he was

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mechanically ventilated. He was placed on vasopressor support,

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and he even got Cape Cod dose steroids.

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And then after about two weeks in the

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ICU, even though his septic shock had improved

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with IV antibiotics,

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he was still having this profound generalized weakness,

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particularly in his proximal proximal muscles.

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And we were having a hard time weaning

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him off of the ventilator, and it was

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already day 14.

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His vital signs were otherwise stable. He was

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breathing at a 100% on the vent.

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And his physical exam was most significant for

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this profound symmetric limb weakness,

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more so in his lower extremities.

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His deep tendon reflexes were intact. He had

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preserved cranial nerve function, and we didn't see

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any sensory deficits.

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So this patient came in for sepsis, has

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gotten better for a set from a sepsis

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point of view, and now his primary issue

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is more so weakness.

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So, Christina, when you're taking care of these

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patients, what are you usually thinking about? How

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are you usually approaching it?

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Great. Thanks, Kyle. And thank you so much

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for the question. And and you brought up

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some great things already that we should be

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thinking about. Just duration of hospital admission. So

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you mentioned two weeks. Other comorbidities you mentioned

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as well as coming in with sepsis and

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getting steroid dosing, as you said, kind of

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the Cape Cod protocol. So some things that

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we should be considering.

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But when you're thinking about, an approach to

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weakness in the ICU,

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I know there's many frameworks that you can

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think about, but one that I like is

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really going from brain to muscle. So neuroanatomical

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and system based framework for thinking about weakness

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in the ICU.

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And as I said, the idea is to

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work from central to peripheral, so brain to

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muscle, to systematically consider where along the motor

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pathway the problem could be because it could

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be so many different places. And I think

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one thing when when you start to have

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a a broad differential, you're gonna start just

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naming potential etiologies. And sometimes for myself, if

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I do that, I get a little bit

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disorganized

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and may miss something. So I really try

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to do systems based.

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So this could be starting with the brain

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and spinal cord, then moving to the anterior

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horn cells, the peripheral nerves, the neuromuscular junction,

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and finally, the muscle itself. So as I

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said, I think it breaks down things in

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a way that's organized and practical.

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So you're not just listing diagnosis, but really

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thinking about them on the level of dysfunction.

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And I'm sure we'll get to hear from

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you and and Jim and and Dave in

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a bit just on other ways to think

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about this and really important tests and diagnostics

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that we should consider.

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But to think about this more broadly going

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through the the system from a CNS standpoint,

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I think some etiologies

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that

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probably those listening today are already considering, right,

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is any trauma that may, the patient may

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have experienced,

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any recent hemorrhage or infarction that could have,

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could have occurred, as well as potential infection.

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And this is going to be broad, but

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such as encephalitis,

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potentially new abscess formation. This is where we

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can think about

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myelopathies

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as well.

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Subclinical

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seizures is also very important. And then a

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topic I'm sure will get you is just

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always having delirium as part of this etiology

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for the overall brain and CNS.

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So after I think about the CNS and

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think of those etiologies, I really then move

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to more of the anterior horn cells where

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this could be more motor neuron disease,

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poliomyelitis

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or West Nile virus could be considered in

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this.

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Moving from anterior horn cells into peripheral nerves,

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thinking about Guillain Barre syndrome,

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as well as several neuropathies. And this could

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be more from a vasculitic component,

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a perineoplastic

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component, or really critical illness polyneuropathy

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that you should be considering.

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Moving from peripheral nerves, I then go to

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neuromuscular

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junction. So, thinking about myasthenia gravis. I work

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with a lot of oncology ICU patients who

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may be on checkpoint inhibitors. So, sometimes you

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can get a myasthenia gravis like effect from

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checkpoint inhibitors to have on your differential.

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But also thinking about Lambert Eaton syndrome,

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botulism or any neuromuscular blocking drugs.

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And then from neuromuscular junction, as I said,

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going to muscle last. So, So, thinking about

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etiology such as inflammatory myopathies,

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such as polymyositis

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as well as dermatomyositis.

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Rhabdo definitely should be considered.

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More rare cases, rare cases we should still

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have on the differential could be some mitochondrial

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myopathies.

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More common cases to think about in someone

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who's been hospitalized for two weeks, you know,

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drug induced or toxic myopathies.

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And then we always have to think about

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critical illness myopathy.

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So, I know a lot of things are

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just said. But, again, I think if you

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could remember and take away from today, just

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go from brain to muscle and be system

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based. I think that could at least help

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you think of a, of good differentials.

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But based on the differential,

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right, lots of things to talk about today.

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But what kind of patterns do you associate

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these with, and what could we be looking

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for?

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Yeah. So I think weakness is such a

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a broad term, and then we're starting to

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try to hone down on it. And and

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you don't have to know and be an

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expert on all these things, but it really

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does help you to have a framework

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to think through it. It also helps you

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frame a good question for your consultants, which

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will include everybody from neurology to your physical

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therapist, to your physiatrist like Jim, who are

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gonna come in and give an evaluation. And

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if you can really have a a picture

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that's well described, that can help everybody. And

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so I I also take that same anatomic

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approach. And then Kyla already did a really

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great job of adding some of the things

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that we are gonna be asking asking about.

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So the first is, is this symmetric or

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asymmetric weakness, right, asymmetric weakness, I really start

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thinking about central nervous system problems, upper meridional

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problems because everything else should likely affect the

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nerves, the neuromuscular junctions, the muscles in a

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similar way. And so asymmetric really gets my

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warning signs coming up about whether or not

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I have some acute CNS process that might

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need to be an evaluation. So some patient

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tells me that all of a sudden can't

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move their arm, Obviously, it could be a

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peripheral nerve compression, but my first question is,

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do I need some head imaging for a

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central stroke going on?

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The next thing that I think about is

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the pattern of it. Is this sort of

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proximal versus distal? Now this I always find

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frustrating personally because everything has an atypical presentation.

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Right? So even the things that we think

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about as being really like a distal where

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it's a bit like Guillain Barre syndrome has

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00:09:52,304 --> 00:09:54,464
this sort of ascending distal weakness that comes

268
00:09:54,464 --> 00:09:56,460
up. You know, you'll have that atypical case

269
00:09:56,460 --> 00:09:58,300
that comes in where somebody just starts with

270
00:09:58,300 --> 00:09:59,519
a respiratory failure

271
00:09:59,899 --> 00:10:02,460
phenotype. And so I do like the patterns,

272
00:10:02,460 --> 00:10:04,379
but and I do gather that information. But

273
00:10:04,379 --> 00:10:05,899
obviously, you have to keep in mind that

274
00:10:05,899 --> 00:10:08,300
it can be atypical or common presentations of

275
00:10:08,300 --> 00:10:09,120
common diseases.

276
00:10:09,725 --> 00:10:11,884
But some things are like really textbook. So

277
00:10:11,884 --> 00:10:13,884
like, ascites is really are gonna be a

278
00:10:13,884 --> 00:10:17,084
weakness in the proximal muscles, the deltoids, biceps,

279
00:10:17,084 --> 00:10:18,384
triceps, the quadriceps,

280
00:10:18,684 --> 00:10:20,524
hamstrings, and the lower extremities. And so the

281
00:10:20,524 --> 00:10:22,605
worst thing is usually follow that typical pattern.

282
00:10:22,605 --> 00:10:24,304
So I wanna get a sense of that.

283
00:10:24,809 --> 00:10:27,870
Sensory loss, really, a lot of these conditions

284
00:10:28,090 --> 00:10:30,889
distal, to the anterior horn cells really shouldn't

285
00:10:30,889 --> 00:10:33,790
have sensory involvement unless you have remote neuropathy.

286
00:10:34,090 --> 00:10:36,889
So that always raises something in my head

287
00:10:36,889 --> 00:10:39,389
about, okay, I'm not really thinking about neuromuscular

288
00:10:39,690 --> 00:10:40,184
junction

289
00:10:40,504 --> 00:10:42,745
or the myocyte itself if I have combined

290
00:10:42,745 --> 00:10:45,465
sensory loss. It's gotta be the mixed nerves

291
00:10:45,465 --> 00:10:47,705
or above that are carrying this. And then

292
00:10:47,705 --> 00:10:49,465
I I care about reflexes as well is

293
00:10:49,465 --> 00:10:51,325
that a little bit of that same distinction.

294
00:10:51,544 --> 00:10:52,684
Anything that's a neuromuscular

295
00:10:53,149 --> 00:10:54,929
blockade or below neuromuscular

296
00:10:55,309 --> 00:10:57,870
muscle should have that preserved circuit even if

297
00:10:57,870 --> 00:11:00,110
any if something centrally is going on. And

298
00:11:00,110 --> 00:11:02,350
so if I have preserved reflexes, I'm really

299
00:11:02,350 --> 00:11:05,389
thinking more distal in that central nervous system

300
00:11:05,389 --> 00:11:08,264
down to myocyte distribution. And if it's got

301
00:11:08,264 --> 00:11:10,444
a change in reflexes, hypo, hyper,

302
00:11:10,824 --> 00:11:13,644
areflexic, then I'm thinking, more proximal to that.

303
00:11:13,865 --> 00:11:15,464
So these are the types of info I

304
00:11:15,464 --> 00:11:17,225
get. I am gonna we're gonna post a

305
00:11:17,225 --> 00:11:18,985
graphic and an image to show some of

306
00:11:18,985 --> 00:11:20,504
this so you can see where all of

307
00:11:20,504 --> 00:11:21,245
these conditions

308
00:11:21,809 --> 00:11:24,370
lay out along that spectrum and we'll talk

309
00:11:24,370 --> 00:11:25,970
through each of them right now because that

310
00:11:25,970 --> 00:11:27,350
would be a pretty boring podcast.

311
00:11:27,730 --> 00:11:29,730
But that but Kalaia has already given us

312
00:11:29,730 --> 00:11:32,309
some interesting information that this is a patient

313
00:11:32,370 --> 00:11:35,029
who has this going on. It is symmetrical.

314
00:11:35,554 --> 00:11:37,554
It's in the limbs, more in the lower

315
00:11:37,554 --> 00:11:38,054
extremities.

316
00:11:38,595 --> 00:11:40,995
So we could think about some, more like

317
00:11:40,995 --> 00:11:44,194
ascending patterns. We have preserved cranial nerve functions,

318
00:11:44,194 --> 00:11:46,514
no sensory deficits, or we're thinking a little

319
00:11:46,514 --> 00:11:48,355
bit less of the central nervous system. We're

320
00:11:48,355 --> 00:11:50,759
really thinking a little bit more distal in

321
00:11:50,759 --> 00:11:54,040
the nerve sheaths, neuromuscular junction, the myocytes that,

322
00:11:54,200 --> 00:11:56,040
might play a role here. So we're gonna

323
00:11:56,040 --> 00:11:57,639
have to get a little bit more detail

324
00:11:57,639 --> 00:11:59,879
and a little bit more, studies for sure.

325
00:11:59,879 --> 00:12:02,040
So, Kalaiah, can you tell us what else

326
00:12:02,040 --> 00:12:03,639
was obtained, and what were some of the

327
00:12:03,639 --> 00:12:04,934
next steps in the work after

328
00:12:05,414 --> 00:12:07,815
this? Yeah. So the patient's labs were mostly

329
00:12:07,815 --> 00:12:08,315
unremarkable.

330
00:12:08,774 --> 00:12:10,855
He did have an elevated glucose in the

331
00:12:10,855 --> 00:12:13,575
three hundreds, a mildly elevated c k to

332
00:12:13,575 --> 00:12:15,975
four sixty five, but a normal CRP and

333
00:12:15,975 --> 00:12:16,875
a flat lactate.

334
00:12:17,440 --> 00:12:19,679
We got imaging of his brain, so brain

335
00:12:19,679 --> 00:12:22,399
MRI, CT head. Those didn't show any acute

336
00:12:22,399 --> 00:12:24,559
pathology. And then he did finally get an

337
00:12:24,559 --> 00:12:27,620
LP, which was also unremarkable. So normal protein,

338
00:12:27,759 --> 00:12:29,779
normal glucose, normal opening pressure.

339
00:12:30,215 --> 00:12:32,054
And then on exam, we still didn't note

340
00:12:32,054 --> 00:12:34,535
any deficits to his cranial nerves, and there

341
00:12:34,535 --> 00:12:36,615
was no fluctuation in his weakness. So it

342
00:12:36,615 --> 00:12:38,375
didn't get worse, like, with a bit of

343
00:12:38,375 --> 00:12:40,475
motion, like, better with repetitive movement.

344
00:12:41,254 --> 00:12:43,495
Thanks, Kyla. Yeah. I think this is really

345
00:12:43,495 --> 00:12:45,610
helpful and brings us to this next step

346
00:12:45,610 --> 00:12:47,769
for the workup for these patients. So we

347
00:12:47,769 --> 00:12:49,230
we talk about these broad differentials.

348
00:12:49,769 --> 00:12:52,250
And now as you're giving more info, we're

349
00:12:52,250 --> 00:12:54,809
seeing how this presentation is probably gonna fall

350
00:12:54,809 --> 00:12:58,350
into this broader spectrum of ICU acquired weakness.

351
00:12:58,490 --> 00:13:00,410
And we'll talk about the components of that

352
00:13:00,410 --> 00:13:02,815
in just a second, thinking about biopathy or

353
00:13:02,815 --> 00:13:03,315
neuropathy.

354
00:13:03,774 --> 00:13:05,615
But he has all the classic signs. Oh,

355
00:13:05,615 --> 00:13:08,014
he had severe sepsis. The timing kinda came

356
00:13:08,014 --> 00:13:11,375
on after that. He has generalized symmetric, proximal

357
00:13:11,375 --> 00:13:12,894
greater than just a week. This is what

358
00:13:12,894 --> 00:13:14,629
we see. He has reflexes,

359
00:13:15,170 --> 00:13:17,250
that are, you know, and that makes us

360
00:13:17,250 --> 00:13:19,809
think less of one where we're absent. Over

361
00:13:19,809 --> 00:13:22,149
time, you could get decrease in these reflexes.

362
00:13:22,769 --> 00:13:24,769
We don't see any cranial nerve lesions. That's

363
00:13:24,769 --> 00:13:26,690
really important. We don't think there's gonna be,

364
00:13:26,690 --> 00:13:28,290
like, a focal deficit, and we've had a

365
00:13:28,290 --> 00:13:30,174
really good workup of the central nervous system

366
00:13:30,174 --> 00:13:32,975
now. We're less concerned about infections. We've been

367
00:13:32,975 --> 00:13:35,454
at an LP. We'd be really thorough about

368
00:13:35,454 --> 00:13:38,254
this. The CK is mildly elevated. If it

369
00:13:38,254 --> 00:13:40,414
was in the 20 thousands, we might be

370
00:13:40,414 --> 00:13:42,334
thinking more about a rhabdo or more about,

371
00:13:42,334 --> 00:13:43,559
like, a severe inflammatory

372
00:13:44,419 --> 00:13:46,740
myositis picture, but it's certainly very common to

373
00:13:46,740 --> 00:13:49,220
see low level elevations like this. And then

374
00:13:49,220 --> 00:13:50,980
importantly, in ruling out some of the things

375
00:13:50,980 --> 00:13:53,779
that we don't wanna miss, electrolytes are pretty

376
00:13:53,779 --> 00:13:55,860
much normal, is what we've heard, the leftmost

377
00:13:55,860 --> 00:13:58,024
are normal. Glucose, a little bit elevated, and

378
00:13:58,024 --> 00:14:00,105
we'll talk about that. But that's just something

379
00:14:00,105 --> 00:14:01,325
we're gonna have to control.

380
00:14:01,705 --> 00:14:04,024
And then I think everybody in the ICU

381
00:14:04,024 --> 00:14:06,825
also wants to maintain awareness of these types

382
00:14:06,825 --> 00:14:09,164
of conditions that are really treatable and reversible.

383
00:14:09,480 --> 00:14:11,480
And so, like, Guillain Barre syndrome is one

384
00:14:11,480 --> 00:14:13,720
of these. After an infection, you can get

385
00:14:13,720 --> 00:14:15,019
this progressive weakness,

386
00:14:15,399 --> 00:14:18,360
but then ends up leading into areflexia and

387
00:14:18,360 --> 00:14:21,799
can respiratory failure. The LP being re normal

388
00:14:21,799 --> 00:14:24,120
with normal protein really makes us feel more

389
00:14:24,120 --> 00:14:26,865
reassured about that. The The timeline seems more

390
00:14:26,865 --> 00:14:29,024
like an ICU acquired weakness, but so it

391
00:14:29,024 --> 00:14:30,964
just moves much lower down our differential.

392
00:14:31,345 --> 00:14:32,945
And so we're probably not gonna worry about

393
00:14:32,945 --> 00:14:35,424
it. And then some of the other conditions

394
00:14:35,424 --> 00:14:37,424
that we always wanna be wary of and

395
00:14:37,424 --> 00:14:39,205
think about, like, in med school, like, myasthenia

396
00:14:39,345 --> 00:14:42,110
gravis, Lambert Eaton. You said cranial nerves are

397
00:14:42,110 --> 00:14:44,370
intact. There was no fluctuation of the weakness.

398
00:14:44,750 --> 00:14:47,309
There was no weakness preceding this presentation. So

399
00:14:47,309 --> 00:14:49,629
I feel a lot better about ruling these

400
00:14:49,629 --> 00:14:51,309
out. I don't even usually have to send

401
00:14:51,309 --> 00:14:53,549
the testing for these unless I see some,

402
00:14:53,549 --> 00:14:55,684
like, red flag symptoms. So I think this

403
00:14:55,684 --> 00:14:57,605
really helps us thinking about the ICU acquired

404
00:14:57,605 --> 00:14:59,605
weakness. And then, yeah, Jim, if you could

405
00:14:59,605 --> 00:15:01,764
move into summarizing some of these findings, how

406
00:15:01,764 --> 00:15:03,524
you think about it, that'd be great. Yeah,

407
00:15:03,524 --> 00:15:04,024
absolutely.

408
00:15:04,565 --> 00:15:05,065
So

409
00:15:05,524 --> 00:15:06,745
importantly, we

410
00:15:07,399 --> 00:15:10,039
took that very broad system based approach going

411
00:15:10,039 --> 00:15:12,279
proximal to distal and and really worked on

412
00:15:12,279 --> 00:15:14,360
that list. So as you're talking about now,

413
00:15:14,360 --> 00:15:17,080
the the CT MRI, everything being clean, it

414
00:15:17,080 --> 00:15:19,480
doesn't fully rule out anything central. Of course,

415
00:15:19,480 --> 00:15:21,899
there hasn't been a a EEG done. However,

416
00:15:22,039 --> 00:15:22,664
that's not

417
00:15:23,225 --> 00:15:25,464
something that generally just presents as only weakness

418
00:15:25,464 --> 00:15:27,544
or anything like that. And so, that helps

419
00:15:27,544 --> 00:15:28,985
me move away from just a a focal

420
00:15:28,985 --> 00:15:31,565
seizure, focal status, or something in that nature.

421
00:15:31,704 --> 00:15:33,544
The big thing with with this patient that

422
00:15:33,544 --> 00:15:36,044
we discussed and and how he presented

423
00:15:36,584 --> 00:15:39,120
is he presented with a a significant illness,

424
00:15:39,120 --> 00:15:41,059
no weakness. And so the important thing

425
00:15:41,440 --> 00:15:44,159
is ICU acquired weakness as an entity needs

426
00:15:44,159 --> 00:15:46,240
to have started after the onset of of

427
00:15:46,240 --> 00:15:48,079
critical illness. It can't have to be something

428
00:15:48,079 --> 00:15:50,559
that preceded it. Of course, somebody can be

429
00:15:50,559 --> 00:15:51,700
weak and then develop

430
00:15:52,034 --> 00:15:54,115
ICU acquired weakness, but they're two separate processes.

431
00:15:54,115 --> 00:15:56,674
And so the timeline for for this patient

432
00:15:56,674 --> 00:15:57,174
really

433
00:15:57,554 --> 00:16:00,454
helps help us focus on on this diagnosis.

434
00:16:01,154 --> 00:16:01,654
And

435
00:16:02,274 --> 00:16:04,454
as we've discussed as well, generalized weakness

436
00:16:04,834 --> 00:16:07,679
is is is is showing something more systemic.

437
00:16:07,679 --> 00:16:09,600
It's not showing that there is a vocal

438
00:16:09,600 --> 00:16:11,919
compression in the spinal cord. It's not making

439
00:16:11,919 --> 00:16:14,159
you think that there's something in one certain

440
00:16:14,159 --> 00:16:15,860
location to to go after.

441
00:16:16,320 --> 00:16:19,360
Overall, the picture that we've we've shown and

442
00:16:19,360 --> 00:16:19,860
demonstrated

443
00:16:20,394 --> 00:16:23,115
has this person that is at high risk

444
00:16:23,115 --> 00:16:25,355
of acquiring ICU acquired weakness for reasons that

445
00:16:25,355 --> 00:16:28,154
we'll talk about later and presenting as if

446
00:16:28,154 --> 00:16:29,615
he has it. Importantly,

447
00:16:30,075 --> 00:16:31,674
and we'll talk about this later as well,

448
00:16:31,674 --> 00:16:34,330
ICU acquired weakness, it sounds like a unifying

449
00:16:34,330 --> 00:16:36,649
diagnosis. However, it's an umbrella term. It disc

450
00:16:36,730 --> 00:16:37,629
it describes

451
00:16:38,009 --> 00:16:41,389
different entities, specifically critical illness, myopathy, critical illness,

452
00:16:41,450 --> 00:16:41,950
neuropathy,

453
00:16:42,410 --> 00:16:44,649
and then the combination where both are present

454
00:16:44,649 --> 00:16:47,165
at the same time, critical illness, neuromyopathy,

455
00:16:47,865 --> 00:16:49,404
which all have different pathophysiologies

456
00:16:49,785 --> 00:16:52,764
within and all present in a similar fashion.

457
00:16:53,225 --> 00:16:55,384
Yeah. Absolutely. I think this is one of

458
00:16:55,384 --> 00:16:58,105
the issues and with ICU bioweaponics, as you

459
00:16:58,105 --> 00:17:00,419
said, is it really is this umbrella term.

460
00:17:00,579 --> 00:17:01,320
And importantly,

461
00:17:01,779 --> 00:17:04,019
why are we talking about this? And it's

462
00:17:04,019 --> 00:17:07,380
because we know that ICU acquired weakness, a

463
00:17:07,380 --> 00:17:09,380
patient just like this compared to a patient

464
00:17:09,380 --> 00:17:11,640
who had the same illness but doesn't demonstrate

465
00:17:11,779 --> 00:17:12,434
these findings,

466
00:17:12,914 --> 00:17:16,115
really has large impact on their outcomes. And

467
00:17:16,115 --> 00:17:17,555
these are with short term and long term.

468
00:17:17,555 --> 00:17:18,775
I get very clear,

469
00:17:19,154 --> 00:17:21,555
that patients who have ICU acquired weakness compared

470
00:17:21,555 --> 00:17:23,875
to those who don't have longer stays in

471
00:17:23,875 --> 00:17:25,815
the hospital, longer time on the ventilators,

472
00:17:26,400 --> 00:17:28,180
increased likelihood of being reintubated,

473
00:17:28,880 --> 00:17:30,980
increased ICU and hospital mortality

474
00:17:31,279 --> 00:17:33,759
as probably a consequence of these, will other

475
00:17:33,759 --> 00:17:34,740
short term consequences.

476
00:17:35,440 --> 00:17:37,680
We also know that if you leave the

477
00:17:37,680 --> 00:17:40,320
hospital and have with still some level of

478
00:17:40,320 --> 00:17:43,025
ICU acquired weakness, like, depending on, what functional

479
00:17:43,025 --> 00:17:45,184
level you achieve, you're more likely to go

480
00:17:45,184 --> 00:17:47,505
to rehab, than home. You have long stays

481
00:17:47,505 --> 00:17:49,744
at rehab, and that's associated with its own

482
00:17:49,744 --> 00:17:51,525
side effects, and you actually have an increased,

483
00:17:51,825 --> 00:17:53,759
chance of coming back to the hospital. And

484
00:17:53,759 --> 00:17:55,839
then decreased functioning in a year in this

485
00:17:55,839 --> 00:17:58,160
world where we're really focused on post ICU

486
00:17:58,160 --> 00:18:00,480
syndrome. You guys can listen to our episode

487
00:18:00,480 --> 00:18:02,320
that we did with Dale Needham and Wes

488
00:18:02,320 --> 00:18:04,559
Ely about this. This is a huge component

489
00:18:04,559 --> 00:18:06,559
of that. Patients year out who just can't

490
00:18:06,559 --> 00:18:08,160
do what they used to after an acute

491
00:18:08,160 --> 00:18:10,734
illness. So we care about finding this quite

492
00:18:10,734 --> 00:18:11,315
a bit.

493
00:18:11,775 --> 00:18:14,515
Jim, you sort of mentioned that the pathophysiology

494
00:18:14,894 --> 00:18:17,855
is not unifying, right, because there's multiple different

495
00:18:17,855 --> 00:18:20,575
etiologies that can be lumped into ICU acquired

496
00:18:20,575 --> 00:18:22,335
weakness. Could you tell us a little bit

497
00:18:22,335 --> 00:18:23,154
more about

498
00:18:23,590 --> 00:18:25,509
some of the factors that do go into

499
00:18:25,509 --> 00:18:28,950
developing this? Yeah. Absolutely. And I think just

500
00:18:28,950 --> 00:18:31,029
before moving onto that, I think it's such

501
00:18:31,029 --> 00:18:31,769
an important

502
00:18:32,630 --> 00:18:34,950
connection to make with ICU acquired weakness and

503
00:18:34,950 --> 00:18:37,585
post intensive care syndrome and just there's not

504
00:18:37,585 --> 00:18:40,865
something that says exactly ICU acquired weakness becomes

505
00:18:40,865 --> 00:18:42,964
post intensive care syndrome, but you can definitely

506
00:18:43,345 --> 00:18:45,585
infer somebody who's weak and continues to be

507
00:18:45,585 --> 00:18:48,144
weak for a year following, intensive care stay.

508
00:18:48,384 --> 00:18:51,204
That significantly impacts their life and and can,

509
00:18:51,744 --> 00:18:54,119
of course, impact all the other demands of

510
00:18:54,119 --> 00:18:56,619
PICS. So jumping into critical illness

511
00:18:57,000 --> 00:18:57,500
myopathy,

512
00:18:57,960 --> 00:18:59,639
as you can tell from the name myop

513
00:18:59,799 --> 00:19:01,019
myopathy myopathy

514
00:19:01,319 --> 00:19:03,720
has a issue within the muscle itself. And

515
00:19:03,720 --> 00:19:06,539
so the the pathology is is primarily,

516
00:19:07,079 --> 00:19:09,244
in this case, related to muscle.

517
00:19:09,945 --> 00:19:11,865
So with this, there's there's a selective loss

518
00:19:11,865 --> 00:19:14,025
of myosin at the thick filaments. It's unclear

519
00:19:14,025 --> 00:19:16,684
exactly why the thick filaments are preferentially

520
00:19:17,065 --> 00:19:18,744
acted. However, it might have something to do

521
00:19:18,744 --> 00:19:21,419
with the bioenergetic failure as the myosin is

522
00:19:21,419 --> 00:19:21,659
what,

523
00:19:22,220 --> 00:19:24,779
connects with the ATP to to help the

524
00:19:24,779 --> 00:19:27,500
contraction happen. Within that, the the type two

525
00:19:27,500 --> 00:19:28,960
muscle fibers are most frequently

526
00:19:29,659 --> 00:19:31,899
associate or are most frequently affected. So these

527
00:19:31,899 --> 00:19:34,274
are the fast twitch powerful fibers. So you

528
00:19:34,274 --> 00:19:37,075
can you can imagine the significant weakness associated

529
00:19:37,075 --> 00:19:38,934
with that as opposed to a slower filament

530
00:19:39,075 --> 00:19:40,454
that that would be less

531
00:19:40,994 --> 00:19:42,454
visible on on exam.

532
00:19:42,755 --> 00:19:44,835
Additionally, with some of the damage to the

533
00:19:44,835 --> 00:19:46,934
muscle, there's there's impairment of

534
00:19:47,250 --> 00:19:50,369
electrical impulses with inactivation of sodium channels, which

535
00:19:50,369 --> 00:19:51,269
can happen with,

536
00:19:51,730 --> 00:19:54,369
with acid based changes as well as other

537
00:19:54,369 --> 00:19:56,390
other changes within the muscle itself

538
00:19:56,690 --> 00:19:58,470
resulting in a decrease excitability.

539
00:19:59,265 --> 00:20:01,205
All of this is also coupled with bioenergetic

540
00:20:01,424 --> 00:20:03,424
collapse as I talked about with binding to

541
00:20:03,424 --> 00:20:04,484
ADP on myosin.

542
00:20:04,945 --> 00:20:07,744
Mitochondria is is less functional in the state

543
00:20:07,744 --> 00:20:10,065
of of critical illness, especially within sepsis and

544
00:20:10,065 --> 00:20:11,585
other things that we'll talk about in just

545
00:20:11,585 --> 00:20:13,609
a minute. And, of course, the this all

546
00:20:13,609 --> 00:20:15,929
results in an impaired functional outcome. Now moving

547
00:20:15,929 --> 00:20:17,869
to critical illness, neuropathy.

548
00:20:18,329 --> 00:20:18,829
Now

549
00:20:19,529 --> 00:20:22,269
this is an a nerve issue, typically.

550
00:20:22,730 --> 00:20:24,970
And so there there's injury to the nerve

551
00:20:24,970 --> 00:20:26,509
itself, usually the axons.

552
00:20:26,865 --> 00:20:29,365
One proposed reason is by microvascular

553
00:20:29,664 --> 00:20:32,384
dysfunction, and so there's decreased perfusion to the

554
00:20:32,384 --> 00:20:33,845
nerve axon itself.

555
00:20:34,545 --> 00:20:36,644
So that can result in ischemia,

556
00:20:37,105 --> 00:20:37,924
ultra permeability,

557
00:20:38,625 --> 00:20:39,924
changing of the

558
00:20:40,630 --> 00:20:42,329
the lining or or the

559
00:20:42,869 --> 00:20:45,769
the myelin sheaths that help to propagate

560
00:20:46,150 --> 00:20:47,609
the trichlet impulses quicker.

561
00:20:47,990 --> 00:20:50,329
And then with that, you can have degeneration

562
00:20:50,470 --> 00:20:52,089
of the axons. And so

563
00:20:52,904 --> 00:20:55,545
this is really helpful in differentiating the the

564
00:20:55,545 --> 00:20:57,545
physical exam findings that you see with these

565
00:20:57,545 --> 00:20:58,045
patients,

566
00:20:58,424 --> 00:21:00,605
and how there can be some some variability

567
00:21:00,664 --> 00:21:01,325
in presentation.

568
00:21:02,025 --> 00:21:03,005
However, importantly,

569
00:21:03,384 --> 00:21:04,365
this is a continuum

570
00:21:04,664 --> 00:21:06,744
that they can happen together as critical illness

571
00:21:06,744 --> 00:21:09,599
myopathy, critical illness neuropathy. They can become something

572
00:21:09,599 --> 00:21:11,299
called critical illness neuromyopathy

573
00:21:11,680 --> 00:21:12,500
or polyradiculoneuropathy.

574
00:21:14,160 --> 00:21:16,559
And so these are things that, are important

575
00:21:16,559 --> 00:21:18,960
to to to differentiate, to try to look

576
00:21:18,960 --> 00:21:21,380
for in the patients that you see. Importantly,

577
00:21:21,759 --> 00:21:23,859
as you're having somebody with a more neuropathic

578
00:21:24,000 --> 00:21:24,500
picture,

579
00:21:24,855 --> 00:21:26,535
if the the nerves themselves are damaged, you

580
00:21:26,535 --> 00:21:28,134
can have more of a distal pattern. As

581
00:21:28,134 --> 00:21:30,234
you can imagine, damage to the nerve

582
00:21:30,535 --> 00:21:31,035
than

583
00:21:31,575 --> 00:21:34,315
along that that track as with a radiculopathy

584
00:21:34,615 --> 00:21:36,214
or some of that something of that nature.

585
00:21:36,454 --> 00:21:39,210
The more distal things are more frequently affected

586
00:21:39,210 --> 00:21:40,430
and longer to recover.

587
00:21:41,130 --> 00:21:44,190
Things to discuss, as we've alluded to earlier,

588
00:21:44,490 --> 00:21:45,309
for pathophysiology

589
00:21:45,930 --> 00:21:48,670
reasons why this happens, there are both modifiable

590
00:21:48,809 --> 00:21:52,065
and non modifiable risk factors starting with hyper

591
00:21:52,065 --> 00:21:52,804
or hypoglycemia,

592
00:21:54,065 --> 00:21:56,384
which we've seen in our patient. High high

593
00:21:56,384 --> 00:21:59,025
sugars are are injurious. They can result in

594
00:21:59,025 --> 00:22:01,825
reactive oxygen, species formation and then and then

595
00:22:01,825 --> 00:22:03,750
damage for so many different reasons.

596
00:22:04,309 --> 00:22:06,869
So it's important to have a good control

597
00:22:06,869 --> 00:22:07,529
of sugar.

598
00:22:07,910 --> 00:22:10,170
However, as we've seen or as

599
00:22:10,549 --> 00:22:11,930
multiple studies have shown,

600
00:22:12,390 --> 00:22:15,269
overaggressive control of both sugar can also be

601
00:22:15,269 --> 00:22:17,805
incredibly damaging as well. And so having that

602
00:22:17,884 --> 00:22:20,205
that general one forty to one eighty goal

603
00:22:20,205 --> 00:22:23,265
of of blood sugar is important. Parenteral nutrition

604
00:22:23,485 --> 00:22:25,325
can be a risk factor. You wanna start

605
00:22:25,325 --> 00:22:26,625
with early nutrition,

606
00:22:27,164 --> 00:22:27,664
enterally,

607
00:22:27,965 --> 00:22:28,705
as possible.

608
00:22:29,085 --> 00:22:30,605
And one of the biggest things for our

609
00:22:30,605 --> 00:22:31,904
patients, especially somebody

610
00:22:32,329 --> 00:22:32,910
like ours, is

611
00:22:33,450 --> 00:22:33,950
immobility.

612
00:22:34,890 --> 00:22:37,470
And so whether it's prolonged ventilation,

613
00:22:37,930 --> 00:22:39,470
if you if somebody comes in

614
00:22:39,769 --> 00:22:42,750
with sepsis, ARDS, and they also have

615
00:22:43,210 --> 00:22:45,470
drugs on board such as neuromuscular blockers,

616
00:22:45,865 --> 00:22:48,605
Immobility can result in something called mechanical silencing,

617
00:22:49,065 --> 00:22:51,804
which basically leads to disuse atrophy.

618
00:22:52,105 --> 00:22:55,304
Other drugs such as vasoactive drugs necessary, especially

619
00:22:55,304 --> 00:22:57,784
for somebody who's in in septic shock or

620
00:22:57,784 --> 00:22:59,085
some some other process,

621
00:22:59,519 --> 00:23:01,440
can also result in, of course,

622
00:23:01,920 --> 00:23:02,420
microvascular,

623
00:23:03,119 --> 00:23:05,359
issues with perfusion to to things such as

624
00:23:05,359 --> 00:23:08,340
muscle and nerve. As we've briefly touched on,

625
00:23:08,400 --> 00:23:08,900
additives,

626
00:23:09,359 --> 00:23:11,680
can also result in delirium and also more,

627
00:23:11,920 --> 00:23:12,420
immobility

628
00:23:12,904 --> 00:23:13,804
as we go

629
00:23:14,105 --> 00:23:16,204
forward. The things that are non not non

630
00:23:16,585 --> 00:23:17,085
modifiable

631
00:23:17,464 --> 00:23:21,224
but worth paying attention to are the severity

632
00:23:21,224 --> 00:23:21,804
of disease,

633
00:23:22,264 --> 00:23:25,384
patients with sepsis and SIRS, and specifically multiple

634
00:23:25,384 --> 00:23:27,865
organ failure as reasons for why people are

635
00:23:27,865 --> 00:23:30,460
higher risk for ICU acquired weakness.

636
00:23:31,000 --> 00:23:31,659
And then

637
00:23:32,440 --> 00:23:35,740
additionally, finally, female sex, older age, and importantly,

638
00:23:35,960 --> 00:23:39,000
premorbid functional state are all important things to

639
00:23:39,000 --> 00:23:41,480
consider. If somebody comes in with lower reserve,

640
00:23:41,480 --> 00:23:42,379
they're much more

641
00:23:42,815 --> 00:23:46,095
risk of having continued injury and continued disability.

642
00:23:46,095 --> 00:23:46,994
They have less,

643
00:23:47,375 --> 00:23:49,634
to pull from should something like this happen.

644
00:23:51,055 --> 00:23:51,375
Yeah. The

645
00:23:52,174 --> 00:23:54,355
thanks for walking through that. It's a interesting

646
00:23:54,589 --> 00:23:56,750
spectrum to think about of the myopathy versus

647
00:23:56,750 --> 00:23:58,589
the neuropathy. I know we'll dive into it

648
00:23:58,589 --> 00:24:00,190
a little bit more. But just a word

649
00:24:00,190 --> 00:24:02,430
on the risk factors, it's always tough with

650
00:24:02,430 --> 00:24:04,589
the non modifiable versus modifiable. Can one of

651
00:24:04,589 --> 00:24:06,670
the non modifiable is where the severity of

652
00:24:06,670 --> 00:24:09,414
disease, sepsis, how sick are you? And then

653
00:24:09,414 --> 00:24:11,575
one of the modifiable is a laser active

654
00:24:11,575 --> 00:24:12,075
drugs,

655
00:24:12,455 --> 00:24:14,394
steroids, neuromuscular blockade,

656
00:24:14,695 --> 00:24:19,195
additives. And these sometimes can feel in practice,

657
00:24:19,815 --> 00:24:22,029
sort of non modifiable, You're like, this vision

658
00:24:22,029 --> 00:24:23,630
is really sick. I need to use three

659
00:24:23,630 --> 00:24:26,190
pressers to keep their map up. And so

660
00:24:26,190 --> 00:24:28,509
how modifiable is that? But I do think

661
00:24:28,509 --> 00:24:30,990
that just raises the strong attention for us

662
00:24:30,990 --> 00:24:32,210
to have very intentional

663
00:24:32,670 --> 00:24:35,674
and best practices use when we're using things,

664
00:24:36,054 --> 00:24:37,194
like adding a presser,

665
00:24:37,575 --> 00:24:39,434
using neuromuscular blockade,

666
00:24:39,734 --> 00:24:42,775
adding steroids, sedatives for sure. Right? It's like,

667
00:24:42,775 --> 00:24:44,694
does this person really need to be on

668
00:24:44,694 --> 00:24:45,194
neuromuscular?

669
00:24:45,494 --> 00:24:47,335
Do they really need to be RAS negative

670
00:24:47,335 --> 00:24:49,740
five? Or is it something that makes it

671
00:24:49,740 --> 00:24:53,339
easier for us, but is not necessary by

672
00:24:53,339 --> 00:24:55,579
their condition? So I do think and we'll

673
00:24:55,579 --> 00:24:56,960
get into prevention and treatment.

674
00:24:57,419 --> 00:24:59,099
A lot of this is just being really

675
00:24:59,099 --> 00:25:01,099
mindful and really thoughtful about how we use

676
00:25:01,099 --> 00:25:03,434
these things, which is not easy because we're

677
00:25:03,434 --> 00:25:05,755
we're also trying to treat this critically ill

678
00:25:05,755 --> 00:25:07,515
patient. And so it takes a lot of

679
00:25:07,515 --> 00:25:09,294
awareness as we're going through it.

680
00:25:11,275 --> 00:25:13,434
So anyway. Totally, Bert. Thanks so much for

681
00:25:13,434 --> 00:25:15,835
for bringing that up. And and, Jim, some

682
00:25:15,835 --> 00:25:16,335
great,

683
00:25:16,700 --> 00:25:18,559
great walk through of some pathophysiology

684
00:25:19,099 --> 00:25:20,619
and I think for that was such a

685
00:25:20,619 --> 00:25:22,559
great point on the on the risk factors.

686
00:25:22,779 --> 00:25:24,619
Right? Coming coming back and bringing it back

687
00:25:24,619 --> 00:25:26,779
to our patients' cases, Kyla mentioned, right, we

688
00:25:26,779 --> 00:25:29,259
had a 65 year old gentleman admitted for

689
00:25:29,259 --> 00:25:31,875
two weeks in the ICU with with severe

690
00:25:31,875 --> 00:25:32,375
sepsis,

691
00:25:32,914 --> 00:25:33,815
received corticosteroids.

692
00:25:34,355 --> 00:25:36,914
So exactly is, like, what's what's modifiable and

693
00:25:36,914 --> 00:25:39,174
what was it during his two week stay?

694
00:25:39,474 --> 00:25:40,835
Jim, so I would love for you to

695
00:25:40,835 --> 00:25:43,234
extend on on two broad topics, which I

696
00:25:43,234 --> 00:25:45,394
think learners would probably really wanna hear more

697
00:25:45,394 --> 00:25:47,679
about, and myself as well. So you mentioned

698
00:25:47,679 --> 00:25:51,599
that ICU associated weakness encompasses both critical illness

699
00:25:51,599 --> 00:25:54,019
myopathy as well as critical illness polyneuropathy.

700
00:25:54,720 --> 00:25:55,940
You talked about the pathophysiology

701
00:25:56,640 --> 00:25:59,359
and the difference between them. But clinically, how

702
00:25:59,359 --> 00:26:01,664
can we distinguish between them, and how does

703
00:26:01,664 --> 00:26:04,164
that affect your overall management of the patient?

704
00:26:04,384 --> 00:26:06,945
Absolutely. And also just a quick point on

705
00:26:06,945 --> 00:26:09,745
on you talking about what is modifiable and

706
00:26:09,745 --> 00:26:11,985
what isn't modifiable as far as the KIDCON

707
00:26:11,985 --> 00:26:14,519
dose steroids too. There's been some discussion of

708
00:26:14,839 --> 00:26:16,220
is steroids actually

709
00:26:16,599 --> 00:26:18,599
a a real risk factor in these cases

710
00:26:18,599 --> 00:26:21,480
for ICU acquired weakness. Are these people just

711
00:26:21,480 --> 00:26:23,720
sicker? Do they need steroids? And is this

712
00:26:23,720 --> 00:26:26,039
just a a demonstration of of where they

713
00:26:26,039 --> 00:26:27,420
are? And so

714
00:26:27,865 --> 00:26:30,585
going into that additionally, so talking about how

715
00:26:30,585 --> 00:26:32,664
we differentiate these people, I think the important

716
00:26:32,664 --> 00:26:34,345
thing is then getting into the why. Right?

717
00:26:34,345 --> 00:26:37,464
And so critical illness myopathy versus myopathy. The

718
00:26:37,464 --> 00:26:39,224
the the issue, as we were talking about

719
00:26:39,224 --> 00:26:40,984
before, being in the muscle or in the

720
00:26:40,984 --> 00:26:43,809
nerve or in the the joint critical illness,

721
00:26:43,809 --> 00:26:44,869
neuropathy or

722
00:26:45,170 --> 00:26:46,710
radicular neuropathy and myopathy,

723
00:26:47,170 --> 00:26:49,730
some combination there. And and so as we

724
00:26:49,730 --> 00:26:51,809
talk about something, an an injury within the

725
00:26:51,809 --> 00:26:54,789
muscle, you talk about pure weakness, no sensory

726
00:26:54,849 --> 00:26:56,815
loss. And that's going to be one of

727
00:26:56,815 --> 00:26:59,454
the biggest differentiating factors between the two. But

728
00:26:59,454 --> 00:27:01,154
this one also happens more

729
00:27:01,454 --> 00:27:03,934
rapidly, and you can have some muscle loss

730
00:27:03,934 --> 00:27:06,015
within the first forty eight hours of ICU

731
00:27:06,015 --> 00:27:08,034
stay. You can have up to 2% of

732
00:27:08,174 --> 00:27:10,829
lean muscle mass loss per day, for the

733
00:27:10,829 --> 00:27:12,509
first two weeks in ISU stay. So you

734
00:27:12,509 --> 00:27:14,910
really see a profound loss of muscle and

735
00:27:14,910 --> 00:27:17,309
you that's visible. Something that you can physically

736
00:27:17,309 --> 00:27:17,789
see,

737
00:27:18,109 --> 00:27:20,289
which can help point you in those directions

738
00:27:20,349 --> 00:27:22,669
as well. With our patient, there's a slight

739
00:27:22,669 --> 00:27:24,664
elevation in CK. Of course, not to a

740
00:27:24,664 --> 00:27:26,585
RAB level, but it also suggests that there's

741
00:27:26,585 --> 00:27:29,304
some ruble of muscle damage being happening as

742
00:27:29,304 --> 00:27:31,785
well. For the for the neuropathy, of course,

743
00:27:31,785 --> 00:27:34,184
you're gonna see, damage to the entire nerve,

744
00:27:34,184 --> 00:27:36,025
not just a a motor nerve, and so

745
00:27:36,025 --> 00:27:38,279
you're gonna have sensory impact. As I started

746
00:27:38,279 --> 00:27:39,960
to allude to in the last part, you

747
00:27:39,960 --> 00:27:41,660
can also differentiate

748
00:27:42,200 --> 00:27:44,200
where the the injury is based on the

749
00:27:44,200 --> 00:27:46,440
location of presentation. So if there's more distal

750
00:27:46,440 --> 00:27:49,000
predominant weakness, which is not common at all

751
00:27:49,000 --> 00:27:50,779
in in critical illness myopathy,

752
00:27:51,240 --> 00:27:53,914
but would potentially be more common in something

753
00:27:53,914 --> 00:27:56,555
of the critical illness neuropathy picture because of

754
00:27:56,555 --> 00:27:58,394
the length of the axon itself, the the

755
00:27:58,394 --> 00:28:00,394
more time in which or more space in

756
00:28:00,394 --> 00:28:02,734
which this nerve has to to be injured.

757
00:28:02,955 --> 00:28:04,875
And so those are some of the the

758
00:28:04,875 --> 00:28:05,375
big

759
00:28:05,859 --> 00:28:07,880
important differentiating factors

760
00:28:08,259 --> 00:28:09,000
in general.

761
00:28:10,019 --> 00:28:12,039
And then for the critical illness polyneuropathy

762
00:28:12,659 --> 00:28:15,299
and myopathy, the the combination ended up being

763
00:28:15,299 --> 00:28:16,679
very murky as as

764
00:28:17,059 --> 00:28:18,899
Dave was talking about earlier in in this

765
00:28:18,899 --> 00:28:21,174
where where you can have a typical presentation

766
00:28:21,174 --> 00:28:23,335
and then somebody who comes in with a

767
00:28:23,335 --> 00:28:24,795
presentation that looks like

768
00:28:25,335 --> 00:28:26,154
it's it's

769
00:28:26,615 --> 00:28:28,215
very different than than what you're taught in

770
00:28:28,215 --> 00:28:29,654
the book. And so that's how I think

771
00:28:29,654 --> 00:28:30,555
of the neuromyopathy

772
00:28:31,015 --> 00:28:31,515
picture.

773
00:28:33,089 --> 00:28:35,169
It's great. Thanks, Jim. We're trying to really

774
00:28:35,169 --> 00:28:37,490
put on specific labels to something that is

775
00:28:37,490 --> 00:28:39,669
often a hybrid, often difficult to distinguish.

776
00:28:39,970 --> 00:28:41,190
I think this is important

777
00:28:41,490 --> 00:28:44,630
both for treatment, but also for, like, ongoing

778
00:28:44,690 --> 00:28:47,414
research to understand what the condition is and

779
00:28:47,414 --> 00:28:48,394
to name it appropriately,

780
00:28:48,775 --> 00:28:50,234
even though out of practicality

781
00:28:51,095 --> 00:28:53,015
and convenience, we often will use an all

782
00:28:53,015 --> 00:28:56,375
encapturing term. So for this, as we've mentioned,

783
00:28:56,375 --> 00:28:58,934
we've ruled out major things we sometimes think

784
00:28:58,934 --> 00:28:59,914
about in the ICU,

785
00:29:00,220 --> 00:29:03,500
new ischemic strokes, new hemorrhages. As you mentioned,

786
00:29:03,500 --> 00:29:05,019
we didn't have an EEG yet, but let's

787
00:29:05,019 --> 00:29:06,380
assume we got one or we didn't have

788
00:29:06,380 --> 00:29:08,539
seizures, and weakness would be very atypical for

789
00:29:08,539 --> 00:29:10,720
that. Ruled out encephalitis and meningitis.

790
00:29:11,740 --> 00:29:13,994
Also, for the sake of argument here, let's

791
00:29:13,994 --> 00:29:15,274
assume this is not an

792
00:29:16,474 --> 00:29:17,054
a myasthenia

793
00:29:17,355 --> 00:29:19,054
gravis, Lambert, and organophosphate

794
00:29:19,434 --> 00:29:21,595
poisoning case where someone is missed or and

795
00:29:21,595 --> 00:29:23,355
in some cases, you'll have the testing for

796
00:29:23,355 --> 00:29:24,654
that, but didn't seem typical.

797
00:29:25,079 --> 00:29:27,339
If we want a sort of diagnostic purist

798
00:29:27,400 --> 00:29:28,539
as opposed to diagnostic

799
00:29:28,919 --> 00:29:31,720
nihilist for this one, Kaila, what would we

800
00:29:31,720 --> 00:29:34,039
do? How what tools could we use, clinch

801
00:29:34,039 --> 00:29:36,839
the diagnosis, and feel pretty comfortable calling this,

802
00:29:37,079 --> 00:29:39,339
this umbrella term of ICU required weakness?

803
00:29:40,255 --> 00:29:42,414
Yeah. So there are a couple of tools

804
00:29:42,414 --> 00:29:44,815
that are commonly used. The most commonly used

805
00:29:44,815 --> 00:29:47,534
one to make a diagnosis of ICU acquired

806
00:29:47,534 --> 00:29:50,575
weakness is this score called the medical research

807
00:29:50,575 --> 00:29:52,515
council score or the MRCSS.

808
00:29:53,329 --> 00:29:55,250
And basically, what that is is that we

809
00:29:55,250 --> 00:29:57,890
as physicians will, like, grade 12 different muscle

810
00:29:57,890 --> 00:30:00,549
groups and then tally up that total score.

811
00:30:00,930 --> 00:30:02,930
If the total score is less than 48,

812
00:30:02,930 --> 00:30:05,650
then we think about someone having ICU acquired

813
00:30:05,650 --> 00:30:07,884
weakness. And if it's less than 36, we

814
00:30:07,884 --> 00:30:09,744
think of it as, like, a severe disease.

815
00:30:10,285 --> 00:30:12,205
There are a couple of other scores like

816
00:30:12,205 --> 00:30:14,945
the critical care physical assessment tool

817
00:30:15,325 --> 00:30:17,825
or the functional status score for the ICU.

818
00:30:18,365 --> 00:30:20,490
These are also just ways to, like, assess

819
00:30:20,490 --> 00:30:23,369
someone's, like, functional mobility and, like, cadence and

820
00:30:23,369 --> 00:30:23,869
ambulation,

821
00:30:24,569 --> 00:30:26,509
but they're less used than the MRCSS.

822
00:30:27,450 --> 00:30:29,390
And then we have something called a handheld

823
00:30:29,529 --> 00:30:31,929
dynamometer, which is supposed to be like a

824
00:30:31,929 --> 00:30:34,329
screening tool. And, basically, what that is is

825
00:30:34,329 --> 00:30:35,789
that we will, like, assess

826
00:30:36,184 --> 00:30:38,585
the maximum exertional strength that someone like, someone's

827
00:30:38,585 --> 00:30:39,325
grip strength.

828
00:30:39,625 --> 00:30:41,224
And then if it's, like, less than 11

829
00:30:41,224 --> 00:30:43,704
kilograms in men or less than seven kilograms

830
00:30:43,704 --> 00:30:45,704
in female, that's, like, a very good screening

831
00:30:45,704 --> 00:30:48,044
tool for someone having ICU acquired weakness.

832
00:30:48,664 --> 00:30:50,345
I think the caveat with all of these

833
00:30:50,345 --> 00:30:52,599
is that the patient should be awake and

834
00:30:52,599 --> 00:30:54,839
able to cooperate with an exam. And we

835
00:30:54,839 --> 00:30:57,240
know that oftentimes our patients in the ICU

836
00:30:57,240 --> 00:30:59,400
are sedated or delirious, and we've talked about

837
00:30:59,400 --> 00:31:00,220
that a lot.

838
00:31:00,599 --> 00:31:02,140
So we have a couple of different

839
00:31:02,519 --> 00:31:04,539
things we can do outside of these scores.

840
00:31:05,115 --> 00:31:07,194
So we talked about imaging, like maybe a

841
00:31:07,194 --> 00:31:08,095
muscle ultrasound.

842
00:31:08,875 --> 00:31:10,394
These are good because we can do it

843
00:31:10,394 --> 00:31:11,775
at the bedside repeatedly.

844
00:31:12,394 --> 00:31:14,394
The problem with it is that it sometimes

845
00:31:14,394 --> 00:31:14,894
underestimates

846
00:31:15,434 --> 00:31:17,434
muscle loss in a patient, and especially if

847
00:31:17,434 --> 00:31:19,115
they're really edematous. I think it's a little

848
00:31:19,115 --> 00:31:20,734
bit harder to get good windows.

849
00:31:21,250 --> 00:31:23,569
We can do other imaging like CTs or

850
00:31:23,569 --> 00:31:24,069
MRIs,

851
00:31:24,369 --> 00:31:25,669
but these are expensive.

852
00:31:26,130 --> 00:31:28,609
And oftentimes, it's like a logistical challenge to

853
00:31:28,609 --> 00:31:30,049
get them all the way down to the

854
00:31:30,049 --> 00:31:30,869
CT scanner.

855
00:31:32,049 --> 00:31:35,410
The two gold standards for defining ICU acquired

856
00:31:35,410 --> 00:31:37,335
weakness are the electrophysiologic

857
00:31:37,955 --> 00:31:39,894
evaluations and the muscle biopsies.

858
00:31:40,515 --> 00:31:41,495
So the electrophysiologic

859
00:31:42,195 --> 00:31:42,695
evaluations

860
00:31:43,154 --> 00:31:46,195
consist of nerve studies, nerve conduction studies, and

861
00:31:46,195 --> 00:31:46,695
EMGs.

862
00:31:47,475 --> 00:31:49,394
And these are great because per the patient

863
00:31:49,394 --> 00:31:51,750
doesn't have to cooperate with them. But the

864
00:31:51,750 --> 00:31:53,769
problem is that they're time consuming.

865
00:31:54,309 --> 00:31:55,750
There is, like, a little bit of pain

866
00:31:55,750 --> 00:31:57,190
that may be involved, a little bit of

867
00:31:57,190 --> 00:31:57,690
invasiveness.

868
00:31:58,390 --> 00:32:00,470
And, usually, like, the technicians have to be

869
00:32:00,470 --> 00:32:02,230
trained and we need, like, trained physicians to

870
00:32:02,230 --> 00:32:03,769
be able to interpret these studies.

871
00:32:04,424 --> 00:32:05,785
And then the last one, like the other

872
00:32:05,785 --> 00:32:08,025
part of the gold standard is a muscle

873
00:32:08,025 --> 00:32:08,525
biopsy.

874
00:32:08,985 --> 00:32:10,505
And this is really great because we can

875
00:32:10,505 --> 00:32:13,705
actually tell the difference between medical illness myopathy

876
00:32:13,705 --> 00:32:14,445
and polyneuropathy

877
00:32:14,745 --> 00:32:16,650
and whether it's a combination of both.

878
00:32:17,130 --> 00:32:19,690
But, of course, it's invasive, and, we have

879
00:32:19,690 --> 00:32:21,369
all of the risks of a procedure like

880
00:32:21,369 --> 00:32:22,830
infection, bleeding, etcetera.

881
00:32:23,450 --> 00:32:26,009
Yeah. This part diagnostic person is so interesting.

882
00:32:26,009 --> 00:32:27,690
As you said, there's some really great tools

883
00:32:27,690 --> 00:32:29,764
if your patient is awake and cooperative. And

884
00:32:29,764 --> 00:32:32,005
so that that happens. If that patient has

885
00:32:32,005 --> 00:32:34,164
gotten better, they can participate, they can do

886
00:32:34,164 --> 00:32:36,424
some ventilator mechanics, they can use the dynamometer,

887
00:32:36,804 --> 00:32:39,065
I probably mispronounced that, but anemometer,

888
00:32:39,444 --> 00:32:41,224
right, to give us some hand drum strength.

889
00:32:41,444 --> 00:32:43,099
But a lot of our patients are not

890
00:32:43,099 --> 00:32:44,940
in that case going all the way to

891
00:32:44,940 --> 00:32:48,139
muscle biopsy then sometimes feels like a lot

892
00:32:48,139 --> 00:32:48,639
right

893
00:32:48,940 --> 00:32:50,079
I have personally

894
00:32:50,460 --> 00:32:53,179
had EMG come in the ICU and I've

895
00:32:53,179 --> 00:32:54,799
actually found it pretty helpful

896
00:32:55,534 --> 00:32:57,294
The patients I've had it the most is,

897
00:32:57,294 --> 00:32:59,875
like, when the history is a little murky

898
00:32:59,934 --> 00:33:01,855
of, like, how they've been doing at home.

899
00:33:01,855 --> 00:33:04,734
Obviously, we have a large frailty population in

900
00:33:04,734 --> 00:33:06,974
the ICU. And so sometimes there's just, like,

901
00:33:06,974 --> 00:33:09,134
well, they haven't been doing so well. Maybe

902
00:33:09,134 --> 00:33:11,210
they have been weaker at home. And then

903
00:33:11,210 --> 00:33:13,450
you're wondering, like, was there this precondition? As

904
00:33:13,450 --> 00:33:15,849
Jim said, ICU acquired weakness can layer on

905
00:33:15,849 --> 00:33:18,089
top, but it really shouldn't have proceeded if

906
00:33:18,089 --> 00:33:19,930
there were the weakness shouldn't have proceeded the

907
00:33:19,930 --> 00:33:22,570
critical illness. And so I have had that

908
00:33:22,570 --> 00:33:25,034
EMG done just help say, like, look, there's

909
00:33:25,034 --> 00:33:26,095
not some isolated

910
00:33:26,794 --> 00:33:29,914
muscle problem. There's not isolated neuromuscular problem. Like,

911
00:33:29,914 --> 00:33:32,174
this looks like we have now this combined

912
00:33:32,474 --> 00:33:32,974
polyneuropathy,

913
00:33:33,355 --> 00:33:35,355
myopathy. This is just gonna take time. And

914
00:33:35,355 --> 00:33:37,755
that's influence vision again. Right? Giving me a

915
00:33:37,755 --> 00:33:40,569
better sense of how I can what course

916
00:33:40,569 --> 00:33:42,809
I can anticipate. Does this patient want a

917
00:33:42,809 --> 00:33:44,809
prolonged rehab course? Do they want a trach?

918
00:33:44,809 --> 00:33:46,650
Things like that, where we have a little

919
00:33:46,650 --> 00:33:48,809
bit more diagnostic clarity. And and then it

920
00:33:48,809 --> 00:33:51,464
could say, look, this pure muscle, then maybe

921
00:33:51,464 --> 00:33:53,664
I would do a muscle biopsy. The only

922
00:33:53,664 --> 00:33:56,544
caveat I'll also add, I I am much

923
00:33:56,544 --> 00:33:59,025
more in the diagnostic purest camp. Like, I

924
00:33:59,025 --> 00:34:01,105
love to really know what's going on, but

925
00:34:01,105 --> 00:34:02,565
I've gone through the whole pathway,

926
00:34:02,944 --> 00:34:05,765
got an ENG, gotten muscle biopsy, and still

927
00:34:05,904 --> 00:34:07,769
people are like, well, I don't know. Maybe

928
00:34:07,769 --> 00:34:08,590
it's all diabetes.

929
00:34:08,890 --> 00:34:10,890
Maybe it's a little critical illness, or it's

930
00:34:10,890 --> 00:34:12,570
not always like you get a crystal clear

931
00:34:12,570 --> 00:34:14,650
answer. So you have to decide with your

932
00:34:14,650 --> 00:34:17,130
patient and their family how much that's worth

933
00:34:17,130 --> 00:34:19,690
it to you. Jim, anything to add about

934
00:34:19,690 --> 00:34:20,989
that diagnostic process?

935
00:34:21,454 --> 00:34:23,375
Yeah. I think and thank you. This is

936
00:34:23,375 --> 00:34:25,635
this is such a, I think, important

937
00:34:25,934 --> 00:34:27,954
part of the conversation. I think

938
00:34:28,815 --> 00:34:30,655
as we've talked about before, as far as

939
00:34:30,655 --> 00:34:31,155
prognostication,

940
00:34:31,614 --> 00:34:34,014
the the diagnostic purist in me really, really

941
00:34:34,014 --> 00:34:36,034
wants something like this. I think EMG

942
00:34:36,549 --> 00:34:38,789
is something that is incredibly helpful in these

943
00:34:38,789 --> 00:34:40,250
cases. The issue, however,

944
00:34:41,989 --> 00:34:44,150
is EMG, they all whenever you ask for

945
00:34:44,150 --> 00:34:46,150
it, they also push back because there's electrical

946
00:34:46,150 --> 00:34:48,150
interference with all the ventilators and everything else.

947
00:34:48,150 --> 00:34:49,909
And so it makes the test that much

948
00:34:49,909 --> 00:34:52,454
more murky. And so as far as, you

949
00:34:52,454 --> 00:34:54,454
know, in a perfect world, we have a

950
00:34:54,454 --> 00:34:56,795
lack of electrical interference. We can get this

951
00:34:56,934 --> 00:34:59,734
handheld thing because the EMG, machines are are

952
00:34:59,734 --> 00:35:02,315
massive, tough to bring into to already crowded

953
00:35:02,534 --> 00:35:04,900
rooms. But as far as talking about what

954
00:35:04,900 --> 00:35:07,059
the patient can expect and having those really

955
00:35:07,059 --> 00:35:07,559
important

956
00:35:07,860 --> 00:35:10,660
family conversations, patient conversations, what do you want,

957
00:35:10,660 --> 00:35:12,500
what what can we tell you this is

958
00:35:12,500 --> 00:35:14,980
gonna look like? We've talked about the different

959
00:35:15,219 --> 00:35:17,239
differences of myopathy versus neuropathy.

960
00:35:17,614 --> 00:35:20,255
One important difference that that I forgot to

961
00:35:20,255 --> 00:35:22,974
include is is the myopathy tends to have

962
00:35:22,974 --> 00:35:23,795
a better prognosis.

963
00:35:24,094 --> 00:35:25,795
You you have a much better

964
00:35:26,734 --> 00:35:29,454
ability to rebuild muscle than that of nerve,

965
00:35:29,454 --> 00:35:32,449
especially because nerve, it it takes time, much

966
00:35:32,449 --> 00:35:35,089
more time. There's willary and degeneration. There's time,

967
00:35:35,409 --> 00:35:37,010
equivalent to the distance that it needs to

968
00:35:37,010 --> 00:35:39,010
travel to to recover, and then is it

969
00:35:39,010 --> 00:35:41,010
actually going to recover. And so being able

970
00:35:41,010 --> 00:35:41,750
to differentiate

971
00:35:42,289 --> 00:35:43,750
via something like an ENG

972
00:35:44,130 --> 00:35:46,194
more so than a muscle biopsy because that

973
00:35:46,194 --> 00:35:47,954
tells you there's myopathy, but it doesn't tell

974
00:35:47,954 --> 00:35:51,174
you the lack of neuropathy. And so, importantly,

975
00:35:51,394 --> 00:35:53,714
the EMG, you can actually differentiate. Is this

976
00:35:53,714 --> 00:35:55,734
a myopathic pattern or is this a neuropathic

977
00:35:55,875 --> 00:35:57,795
pattern or is this both? So if you're

978
00:35:57,795 --> 00:35:59,315
able to do that, you can have really

979
00:35:59,315 --> 00:36:00,090
informed conversations

980
00:36:00,650 --> 00:36:02,730
patient or the family going forward about what

981
00:36:02,730 --> 00:36:04,110
to expect as well.

982
00:36:04,489 --> 00:36:06,410
Thanks so much, Jim. And I as you're

983
00:36:06,410 --> 00:36:08,570
saying this, and I'd love I have another

984
00:36:08,570 --> 00:36:10,010
question for you as well that I love

985
00:36:10,010 --> 00:36:11,769
your expertise on it because I think even

986
00:36:11,769 --> 00:36:14,329
just between institutions, there's gonna be variation in

987
00:36:14,329 --> 00:36:16,385
what type of tests are available. I know

988
00:36:16,385 --> 00:36:18,545
it's it's quite difficult to get EMG, in

989
00:36:18,545 --> 00:36:19,585
many of our ICU.

990
00:36:19,905 --> 00:36:22,625
It's not impossible, but it it does take

991
00:36:22,625 --> 00:36:25,744
some, mystical planning. But I'm wondering for those

992
00:36:25,744 --> 00:36:26,244
institutions

993
00:36:26,545 --> 00:36:28,625
or or places where EMG is not gonna

994
00:36:28,625 --> 00:36:31,184
be ready readily available and the patient's not

995
00:36:31,184 --> 00:36:33,590
alert and can't cooperate with, like, the screening

996
00:36:33,590 --> 00:36:35,670
tools that Khalilah mentioned and some of the

997
00:36:35,670 --> 00:36:36,410
other things.

998
00:36:36,710 --> 00:36:38,309
Where are you left at with that if

999
00:36:38,309 --> 00:36:40,650
that's not an option for for some patients?

1000
00:36:40,869 --> 00:36:43,510
As far as trying to differentiate between ICU,

1001
00:36:43,510 --> 00:36:45,369
the critical illness, biopothy, neuropathy

1002
00:36:45,989 --> 00:36:46,489
Yes.

1003
00:36:47,264 --> 00:36:49,025
Then you really get into a murky space.

1004
00:36:49,025 --> 00:36:49,605
I think

1005
00:36:49,905 --> 00:36:52,304
it's still in its infancy, but as far

1006
00:36:52,304 --> 00:36:53,364
as looking at

1007
00:36:54,065 --> 00:36:56,625
muscle ultrasound, there there are different grading scales

1008
00:36:56,625 --> 00:36:58,304
that can be helpful. But as we've already

1009
00:36:58,304 --> 00:37:00,050
talked about, there's there's a lot of differences

1010
00:37:00,269 --> 00:37:03,550
as far as new interator reliability and somebody

1011
00:37:03,550 --> 00:37:04,910
who's a dentist because they've been able to

1012
00:37:04,910 --> 00:37:07,150
be actually getting fluids and any other number

1013
00:37:07,150 --> 00:37:09,469
of reasons that can be an issue. You

1014
00:37:09,469 --> 00:37:10,849
can clearly see,

1015
00:37:11,150 --> 00:37:13,094
and if you track over, do an ultrasound

1016
00:37:13,094 --> 00:37:14,454
once a week on a patient, you can

1017
00:37:14,454 --> 00:37:16,155
see that there's a change in the architecture.

1018
00:37:16,215 --> 00:37:18,375
That's something that's pretty clear there. But as

1019
00:37:18,375 --> 00:37:20,534
far as ruling out a nerve injury, that's

1020
00:37:20,534 --> 00:37:23,414
really, really hard. And so so it gets

1021
00:37:23,414 --> 00:37:26,140
it gets difficult on that. Ideally, that's potentially

1022
00:37:26,140 --> 00:37:28,219
something that then can get further elucidated down

1023
00:37:28,219 --> 00:37:30,000
the road when you're out of the ICU

1024
00:37:30,219 --> 00:37:31,900
or or you've gotten a trach in a

1025
00:37:31,900 --> 00:37:33,579
bag and you're more on the rehab side.

1026
00:37:33,820 --> 00:37:36,640
So the conversations can continue. It doesn't ideally,

1027
00:37:36,860 --> 00:37:39,045
of course, in as intensive as we want

1028
00:37:39,045 --> 00:37:39,625
to have

1029
00:37:40,164 --> 00:37:41,925
everything light laid out. This is where we

1030
00:37:41,925 --> 00:37:43,625
go from here. This is what's gonna happen.

1031
00:37:43,764 --> 00:37:46,324
But this this, as we've all alluded to

1032
00:37:46,324 --> 00:37:48,105
quite a few times, becomes quite murky.

1033
00:37:48,405 --> 00:37:50,644
Yeah. Thanks so much for that. And, Khalilah,

1034
00:37:50,644 --> 00:37:52,289
I'm hoping we can come back to the

1035
00:38:04,744 --> 00:38:07,224
cooperate with our exam. He scored a 32

1036
00:38:07,224 --> 00:38:08,204
on the MRCSS,

1037
00:38:08,505 --> 00:38:11,005
so that is severe IC required weakness.

1038
00:38:11,385 --> 00:38:13,485
And then he did the handheld dynamometer

1039
00:38:13,785 --> 00:38:15,804
dime I'm gonna say it wrong too.

1040
00:38:16,105 --> 00:38:16,605
Dynamometer.

1041
00:38:17,380 --> 00:38:19,139
And he also had a poor grip strength.

1042
00:38:19,139 --> 00:38:21,800
So, overall, we think severe ICU acquired weakness.

1043
00:38:23,380 --> 00:38:24,900
Yes. I think it was confirmed that we

1044
00:38:24,900 --> 00:38:27,780
we fall squarely into the umbrella term. Big

1045
00:38:27,780 --> 00:38:29,445
question is now what can we do about

1046
00:38:29,445 --> 00:38:32,005
it? Patient already has it. And so what

1047
00:38:32,005 --> 00:38:34,085
are the types of interventions or things that

1048
00:38:34,085 --> 00:38:36,244
we can do to help them cover? And

1049
00:38:36,244 --> 00:38:37,065
then obviously,

1050
00:38:37,525 --> 00:38:39,125
obviously, we also wanna keep in the back

1051
00:38:39,125 --> 00:38:40,644
of our mind things we can learn from

1052
00:38:40,644 --> 00:38:42,760
this patient to the next one to maybe

1053
00:38:42,760 --> 00:38:44,679
see if we can try to prevent this.

1054
00:38:44,679 --> 00:38:47,500
So, Jim, any thing treatments or best practices

1055
00:38:47,559 --> 00:38:49,099
we can do for patients like this?

1056
00:38:49,480 --> 00:38:51,880
Yeah. Absolutely. And so as you've alluded to,

1057
00:38:51,880 --> 00:38:53,925
this person already has this process. And so

1058
00:38:53,925 --> 00:38:56,244
as with anything, the the best treatment is

1059
00:38:56,244 --> 00:38:58,405
prevention. And so an ounce of prevention is

1060
00:38:58,405 --> 00:38:59,945
is greater than a pound of cure.

1061
00:39:00,405 --> 00:39:02,405
However, as I think the important thing is

1062
00:39:02,405 --> 00:39:04,085
realizing that this is this is a process

1063
00:39:04,085 --> 00:39:05,844
that can continue to happen. And so by

1064
00:39:05,844 --> 00:39:07,305
doing something now, you're also

1065
00:39:07,719 --> 00:39:09,800
stepping in and and preventing worsening of it.

1066
00:39:09,800 --> 00:39:11,800
And so, in general, I like to think

1067
00:39:11,800 --> 00:39:14,599
about two different kind of acronyms for thinking

1068
00:39:14,599 --> 00:39:16,599
about it. One, the the factors that are

1069
00:39:16,599 --> 00:39:18,920
associated with this increased weakness and try and

1070
00:39:18,920 --> 00:39:20,840
simplify it for myself because we talked about

1071
00:39:20,840 --> 00:39:22,875
things in-depth and there's quite a lot. So

1072
00:39:23,034 --> 00:39:24,715
if you're thinking somebody has or is at

1073
00:39:24,715 --> 00:39:26,554
risk of issue acquired weakness, things that you

1074
00:39:26,554 --> 00:39:29,114
wanna think about are sepsis and inflammation as

1075
00:39:29,114 --> 00:39:31,054
risk factors, immol immobilization

1076
00:39:31,355 --> 00:39:32,014
and inactivity

1077
00:39:32,554 --> 00:39:35,135
and resource imbalance, whether that be hyperglycemia, hyperglycemia,

1078
00:39:35,355 --> 00:39:37,295
mitochondrial dysfunction, ATP depletion,

1079
00:39:37,599 --> 00:39:39,699
any other electrolyte abnormality, hypermagnesemia

1080
00:39:40,239 --> 00:39:41,839
being a cause of weakness and things like

1081
00:39:41,839 --> 00:39:44,800
that. And then exogenous things for the e.

1082
00:39:44,800 --> 00:39:46,819
What are we doing to this person that

1083
00:39:47,119 --> 00:39:49,039
we can potentially try and pull them? You

1084
00:39:49,039 --> 00:39:51,219
know, limit neuromuscular blockers, limit corticosteroids.

1085
00:39:51,974 --> 00:39:54,295
And then thinking about maybe the vulnerability that

1086
00:39:54,295 --> 00:39:56,535
you've already talked about. How what was this

1087
00:39:56,535 --> 00:39:59,175
person doing before, and how can we best

1088
00:39:59,175 --> 00:40:00,715
tee them up? And

1089
00:40:01,015 --> 00:40:02,934
then thinking about our patient and what we

1090
00:40:02,934 --> 00:40:05,494
do, you wanna treat the infection. We we

1091
00:40:05,494 --> 00:40:08,239
gave coupon dose steroids. We gave antibiotics. We

1092
00:40:08,239 --> 00:40:10,000
gave everything that needed to be done to

1093
00:40:10,000 --> 00:40:11,380
treat the underlying process.

1094
00:40:11,839 --> 00:40:14,159
Another thing, I'm glad that we we talked

1095
00:40:14,159 --> 00:40:15,859
about kind of Wesley Lee,

1096
00:40:16,320 --> 00:40:18,639
and and colleagues as far as the AF

1097
00:40:18,639 --> 00:40:20,894
bundle. This is something that has been

1098
00:40:21,295 --> 00:40:23,635
really impactful for a number

1099
00:40:26,094 --> 00:40:28,034
of a number of different processes,

1100
00:40:28,335 --> 00:40:30,974
critical illness, and and looking at different outcomes,

1101
00:40:30,974 --> 00:40:31,954
not just weakness.

1102
00:40:32,255 --> 00:40:34,335
But this is something that for those who

1103
00:40:34,335 --> 00:40:35,949
are are not familiar,

1104
00:40:36,329 --> 00:40:38,730
the ADF bundle is is a collection of

1105
00:40:38,730 --> 00:40:41,449
six different interventions that can be and should

1106
00:40:41,449 --> 00:40:43,150
be done for every patient every day.

1107
00:40:44,089 --> 00:40:46,750
Broad strokes talking about choice of sedation,

1108
00:40:47,465 --> 00:40:48,684
daily SAT, SBT,

1109
00:40:49,704 --> 00:40:52,824
assessing and managing pain, delirium treatment, and then

1110
00:40:52,824 --> 00:40:53,324
importantly,

1111
00:40:53,704 --> 00:40:56,344
early mobility. And so I think on my

1112
00:40:56,344 --> 00:40:58,505
own little soapbox, I think early mobility is

1113
00:40:58,505 --> 00:41:00,730
also a little of a a shortcoming

1114
00:41:01,030 --> 00:41:03,190
going forward too. You get early mobility that

1115
00:41:03,190 --> 00:41:05,510
just talks about walking. We can also start

1116
00:41:05,510 --> 00:41:07,109
talking about what we can do with the

1117
00:41:07,109 --> 00:41:08,329
patient in the bed,

1118
00:41:08,630 --> 00:41:10,389
yells, and things of that nature. So trying

1119
00:41:10,389 --> 00:41:12,089
to get people involved and engaged

1120
00:41:12,550 --> 00:41:13,849
to have helped their function

1121
00:41:14,295 --> 00:41:15,594
either improve or

1122
00:41:16,135 --> 00:41:17,194
or stall the

1123
00:41:17,734 --> 00:41:20,534
the the downtrend in function. And then, of

1124
00:41:20,534 --> 00:41:22,694
course, talking to families, which is something that's

1125
00:41:22,694 --> 00:41:24,855
very important. And we already talked about as

1126
00:41:24,855 --> 00:41:26,550
far as controlling glucose, pretty,

1127
00:41:26,949 --> 00:41:28,949
pretty important. And then team based care. We

1128
00:41:28,949 --> 00:41:30,469
wanna make sure that everybody who needs to

1129
00:41:30,469 --> 00:41:31,449
be involved is involved,

1130
00:41:31,989 --> 00:41:34,630
whether it be therapists or or different consulting

1131
00:41:34,630 --> 00:41:36,710
services and and things of that nature. So

1132
00:41:36,710 --> 00:41:38,170
just really being very vigilant

1133
00:41:38,710 --> 00:41:40,329
and and trying to to

1134
00:41:40,789 --> 00:41:43,655
prevent any worsening and and to recognize the

1135
00:41:43,655 --> 00:41:44,715
the warning signs.

1136
00:41:45,335 --> 00:41:48,074
One thing? Yeah. One last thing that's that's,

1137
00:41:48,934 --> 00:41:51,914
based on different meta meta analysis and reviews,

1138
00:41:52,934 --> 00:41:55,335
can potentially be helpful, but is not yet

1139
00:41:55,780 --> 00:41:57,860
And it's actually in the the recommendations for

1140
00:41:57,860 --> 00:42:00,420
anybody in the ICU that can feasibly do

1141
00:42:00,420 --> 00:42:02,280
it is neuro NMES or dermochecular

1142
00:42:02,980 --> 00:42:03,880
electric stimulation.

1143
00:42:04,500 --> 00:42:06,180
This is helpful for, as we talked about,

1144
00:42:06,180 --> 00:42:07,619
all the patients who we have who are

1145
00:42:07,619 --> 00:42:10,855
intubated, sedated, unable to participate in things. NMES

1146
00:42:10,914 --> 00:42:14,375
places electrodes on the muscles and causes contraction.

1147
00:42:14,514 --> 00:42:17,315
So there's there's improvement as far as lack

1148
00:42:17,315 --> 00:42:18,454
of mechanical silencing,

1149
00:42:18,914 --> 00:42:21,414
engagement of these muscles that can potentially prevent

1150
00:42:21,474 --> 00:42:22,694
this this myopathy

1151
00:42:22,994 --> 00:42:25,300
or at least atrophy and weakness

1152
00:42:25,679 --> 00:42:26,579
part. However,

1153
00:42:27,199 --> 00:42:29,440
other things associated with critical illness end up

1154
00:42:29,440 --> 00:42:32,480
being things that really limit the efficacy of

1155
00:42:32,480 --> 00:42:34,659
this because if you're septic, acidotic,

1156
00:42:35,280 --> 00:42:37,940
the the stimulation needed for contraction is also

1157
00:42:38,285 --> 00:42:40,684
higher. And so, in general, it's it's something

1158
00:42:40,684 --> 00:42:42,844
that potentially could be helpful if if your

1159
00:42:42,844 --> 00:42:45,405
hospital is is proficient and able to do

1160
00:42:45,405 --> 00:42:45,905
it.

1161
00:42:46,204 --> 00:42:47,724
Great. Thank you so much, Jim. And I

1162
00:42:47,724 --> 00:42:50,285
know, as you mentioned, so important prevention is

1163
00:42:50,285 --> 00:42:51,570
key. But if

1164
00:42:52,050 --> 00:42:54,050
if you have this, right, there are many

1165
00:42:54,050 --> 00:42:56,210
steps that you can do to try to

1166
00:42:56,210 --> 00:42:57,269
prevent or minimize

1167
00:42:57,570 --> 00:42:59,650
the outcomes from it. So I know I

1168
00:42:59,650 --> 00:43:01,250
get I have the opportunity to work with,

1169
00:43:01,489 --> 00:43:04,710
with del Netam, and early mobility is definitely,

1170
00:43:05,090 --> 00:43:06,675
something that we try to we try to

1171
00:43:06,675 --> 00:43:08,195
do. And I know sometimes when we're rounding

1172
00:43:08,195 --> 00:43:10,195
in the ICU, like, we're we're coming to

1173
00:43:10,195 --> 00:43:11,394
the end and everyone's like, well, what would

1174
00:43:11,394 --> 00:43:13,315
Dell do? What would Dell say for this

1175
00:43:13,315 --> 00:43:15,394
patient? Because if Dell says that we gotta

1176
00:43:15,394 --> 00:43:15,974
do it.

1177
00:43:16,275 --> 00:43:18,594
But definitely so many great things and so

1178
00:43:18,594 --> 00:43:20,460
many colleagues to get to work with to

1179
00:43:20,460 --> 00:43:23,039
help patients with ICU acquired weakness.

1180
00:43:23,579 --> 00:43:25,340
And, Kalei, I think we're coming to an

1181
00:43:25,340 --> 00:43:26,859
end on our case. I would love if

1182
00:43:26,859 --> 00:43:28,699
you could give us an update in how

1183
00:43:28,699 --> 00:43:31,359
the the patient was managed and overall outcome.

1184
00:43:32,139 --> 00:43:35,474
Yeah. Of course. So he underwent aggressive physical

1185
00:43:35,474 --> 00:43:35,974
therapy.

1186
00:43:36,355 --> 00:43:38,514
That's to prevent any muscle any further muscle

1187
00:43:38,514 --> 00:43:41,155
atrophy, improve his strength. We did a better

1188
00:43:41,155 --> 00:43:43,635
job with controlling his sugars with his insulin

1189
00:43:43,635 --> 00:43:45,714
sliding scale, and we were able to start

1190
00:43:45,714 --> 00:43:47,815
him on enteral nutrition very quickly.

1191
00:43:48,590 --> 00:43:50,590
Fortunately, he had already completed his dose of

1192
00:43:50,590 --> 00:43:52,030
steroids, so that kind of out of the

1193
00:43:52,030 --> 00:43:54,510
way. And, ultimately, he was transferred to an

1194
00:43:54,510 --> 00:43:56,909
LTAC. And then after being there for several

1195
00:43:56,909 --> 00:43:59,789
weeks, he was actually able to improve enough

1196
00:43:59,789 --> 00:44:01,545
that he was being off of the vent

1197
00:44:03,704 --> 00:44:04,204
successfully.

1198
00:44:04,505 --> 00:44:05,864
Well, that's so great to hear. And I

1199
00:44:05,864 --> 00:44:08,025
know definitely I think all of us that

1200
00:44:08,025 --> 00:44:09,704
take care of patients in the ICU, a

1201
00:44:09,704 --> 00:44:11,545
lot of the courses can be quite long

1202
00:44:11,545 --> 00:44:12,284
and extend

1203
00:44:12,664 --> 00:44:15,304
outside the ICU to the floors as as

1204
00:44:15,304 --> 00:44:17,880
well as to rehab facilities. So definitely a

1205
00:44:17,880 --> 00:44:19,400
long process and a lot of people that

1206
00:44:19,400 --> 00:44:21,320
help along the way. But I'm glad that

1207
00:44:21,320 --> 00:44:23,260
he had a a successful outcome.

1208
00:44:24,039 --> 00:44:25,960
Well, I know that Dave and I really

1209
00:44:25,960 --> 00:44:28,359
want to thank you both for joining today.

1210
00:44:28,359 --> 00:44:29,719
This has been a great case and a

1211
00:44:29,719 --> 00:44:31,019
great topic to introduce.

1212
00:44:31,514 --> 00:44:33,755
So thank you so much, Jim and Kyla,

1213
00:44:33,755 --> 00:44:36,074
for being with us here today. Jim, just

1214
00:44:36,074 --> 00:44:37,994
wanted to see if you had any parting

1215
00:44:37,994 --> 00:44:40,234
words for today or anything that you wanted

1216
00:44:40,234 --> 00:44:40,894
to add.

1217
00:44:42,074 --> 00:44:44,570
Yeah. So I think first off, I wanna

1218
00:44:44,570 --> 00:44:46,650
thank you all for for allowing me to

1219
00:44:46,650 --> 00:44:48,170
be here. It's really been a pleasure and

1220
00:44:48,170 --> 00:44:49,610
a really just just a lot of fun

1221
00:44:49,610 --> 00:44:51,769
to talk about something that that is is

1222
00:44:51,769 --> 00:44:53,369
really important to me. This is something that

1223
00:44:53,369 --> 00:44:54,650
I plan on spending a lot of my

1224
00:44:54,650 --> 00:44:57,554
career looking further into. And so the having

1225
00:44:57,554 --> 00:44:59,394
the the ability to to be here and

1226
00:44:59,394 --> 00:45:00,994
talk with you guys has been a lot

1227
00:45:00,994 --> 00:45:02,054
of fun. I think

1228
00:45:02,514 --> 00:45:04,755
as as far as a takeaway goes, I'd

1229
00:45:04,755 --> 00:45:05,574
I'd say

1230
00:45:05,954 --> 00:45:06,614
be vigilant.

1231
00:45:07,155 --> 00:45:09,309
Know that this is something that not just

1232
00:45:09,309 --> 00:45:11,789
can happen, but does happen frequently. And to

1233
00:45:11,789 --> 00:45:13,789
to know the the warning signs and and

1234
00:45:13,789 --> 00:45:15,949
how to to intervene. Kala thanks, Jim. It's

1235
00:45:15,949 --> 00:45:18,030
great. Kala, did you have any takeaway points

1236
00:45:18,030 --> 00:45:19,710
or anything that you wanted to to add

1237
00:45:19,710 --> 00:45:20,530
for this case?

1238
00:45:21,389 --> 00:45:23,175
Yeah. I'd I'd say a takeaway point for

1239
00:45:23,175 --> 00:45:25,494
me is what you were mentioning about how

1240
00:45:25,494 --> 00:45:25,994
sometimes

1241
00:45:26,295 --> 00:45:27,815
not at like, even the things that we're

1242
00:45:27,815 --> 00:45:30,375
doing don't feel like modifiable risk factors. So

1243
00:45:30,375 --> 00:45:32,295
really just keeping a very close eye on

1244
00:45:32,295 --> 00:45:33,974
what we're giving the patients and what we

1245
00:45:33,974 --> 00:45:35,309
can pull back when we need

1246
00:45:36,110 --> 00:45:38,989
to. Yeah. 100%. I think that is attention

1247
00:45:38,989 --> 00:45:40,910
to detail of these things, and I have

1248
00:45:40,910 --> 00:45:42,670
also had the pleasure of rounding with Dale,

1249
00:45:42,670 --> 00:45:44,829
Christina. And I think he is a prime

1250
00:45:44,829 --> 00:45:45,969
example of

1251
00:45:46,670 --> 00:45:49,070
things are modifiable even though we are getting

1252
00:45:49,070 --> 00:45:51,385
entrenched and think they're not and and beyond

1253
00:45:51,385 --> 00:45:53,545
just him, but everywhere. I think the best

1254
00:45:53,545 --> 00:45:55,464
case scenario for this story is the use

1255
00:45:55,464 --> 00:45:57,464
of midazolam with benzos, which we know are

1256
00:45:57,464 --> 00:45:59,484
associated with worse and delirium and outcomes.

1257
00:45:59,784 --> 00:46:03,085
And really, this was super common practice basically

1258
00:46:03,144 --> 00:46:03,644
everywhere.

1259
00:46:04,105 --> 00:46:06,490
And now very, very rarely are you gonna

1260
00:46:06,490 --> 00:46:09,070
see people on sustained drips at high doses

1261
00:46:09,210 --> 00:46:11,530
unless there's, like, absolutely no other option. So

1262
00:46:11,530 --> 00:46:13,070
it does it just takes time.

1263
00:46:13,530 --> 00:46:15,210
I think my takeaway is gonna be something

1264
00:46:15,210 --> 00:46:17,769
Jim was talking about with the spectrum, critical

1265
00:46:17,769 --> 00:46:18,510
is myopathy

1266
00:46:18,970 --> 00:46:19,690
to poly

1267
00:46:20,135 --> 00:46:22,614
to neuropathy and then the mix. In my

1268
00:46:22,614 --> 00:46:24,234
own entrenched frameworks,

1269
00:46:24,694 --> 00:46:26,795
I, like, usually think of ICU acquired weaknesses

1270
00:46:26,855 --> 00:46:28,934
muscle alone because I'm really thinking about that

1271
00:46:28,934 --> 00:46:29,994
early myopathy.

1272
00:46:30,375 --> 00:46:31,974
But I it's important for me to always

1273
00:46:31,974 --> 00:46:33,894
remember that you can get these sensory deficits

1274
00:46:33,894 --> 00:46:35,650
that come on later on, and then you

1275
00:46:35,650 --> 00:46:37,250
can get this more sort of mixed picture.

1276
00:46:37,250 --> 00:46:38,849
And I know that, and I've seen visions

1277
00:46:38,849 --> 00:46:40,690
of that, but it takes time to build

1278
00:46:40,690 --> 00:46:43,409
into my illness script for ICU acquired weakness.

1279
00:46:43,409 --> 00:46:45,829
So that's one I'll add to it. Christina?

1280
00:46:47,170 --> 00:46:48,690
Awesome. Yeah. I think I'm going back to

1281
00:46:48,690 --> 00:46:51,224
one of Jim's first things that he discussed

1282
00:46:51,224 --> 00:46:53,864
when thinking about IC acquired weakness, really more

1283
00:46:53,864 --> 00:46:55,484
of this umbrella term.

1284
00:46:55,864 --> 00:46:57,385
And then I think a a nice point

1285
00:46:57,385 --> 00:46:59,464
that you that was mentioned was this must

1286
00:46:59,464 --> 00:47:02,025
not precede critical illness, and how we think

1287
00:47:02,025 --> 00:47:03,704
about that. So that's one of the one

1288
00:47:03,704 --> 00:47:05,565
of the many takeaways from today.

1289
00:47:06,489 --> 00:47:08,170
That's great. Well, thank you guys again for

1290
00:47:08,170 --> 00:47:09,530
coming on the show. Thank you all for

1291
00:47:09,530 --> 00:47:11,450
tuning in and listening. Stay out there. Be

1292
00:47:11,450 --> 00:47:14,489
vigilant, about these factors and and and screening

1293
00:47:14,489 --> 00:47:16,650
for ICU require weakness. And tune in in

1294
00:47:16,650 --> 00:47:18,650
two weeks for our next episode. This episode

1295
00:47:18,650 --> 00:47:21,505
was written, produced, edited by myself, Christina Montemayo.

1296
00:47:21,644 --> 00:47:23,805
Kalaio Paez came up with the idea, and

1297
00:47:23,805 --> 00:47:26,204
Jim is our expert consultant here. And the

1298
00:47:26,204 --> 00:47:28,204
music is original music by Art Rogers. And

1299
00:47:28,204 --> 00:47:29,344
we'll see you next time.