CLASSIFICATION

1.Myopathy
            -ICU myopathy (acute necrotising myopathy, asthma myopathy
            floppy person syndrome)
-Disuse atrophy
            -Steroid myopathy
            -Pyomyositis
2.Neuromuscular junction abnormalities
            -Myasthenia like syndrome
            -Prolonged neuromuscular blockade
3.Neuropathy
            -ICU polyneuropathy
            -Acute motor neuropathy (Acute axonal variant of GBS)
            -Nutritional neuropathy (B1, B6, B12, Vitamin E)
4.Polyneuromyopathy
5.Others: Hopkins syndrome
 
MYOPATHY
 
Disuse atrophy
Increased catabolism, immobility & especially neuromuscular blockers contributory factors.
Common baseline condition upon which other processes (myopathy, neuropathy) are superimposed.
Muscle biopsy: uniform reduction in fibre size without patchy necrosis, Type IIB muscle atrophy
nonspecific.
 
ICU Myopathy
Spectrum:         ICU (cachectic) myopathy
                        Myopathy with selective loss of myosin filaments
Acute necrotising myopathy / Panfascicular muscle necrosis
Quadriparesis
Facial, ocular and respiratory muscles generally spared.
36% intubated asthmatic patients
76% patients with CK>200
 
Risk factors:
Conditions:       Sepsis
Respiratory disease
Multiorgan failure
Acidosis
Lung > liver > renal transplant
Steroids
Gentamycin
Inotropes (B2 agonists): ventolin, adrenaline
Neuromuscular blockers
 
LP if concerned re possibility of Guillain Barre Syndrome
EMG: polyphasic, low amplitude recruitment.
Biopsy: loss of thick myosin filaments, necrosis.            
(Panfascicular muscle necrosis: Sudden, generalized weakness of
muscles accompanied by markedly increased CK, sometimes myoglobinuria.)
 
MANAGEMENT
 
1.      Steroids: lowest dose possible for primary disease.
Rapid tapering
2.      Neuromuscular blockers: Intermittent bolus preferred over continuous as
lower total dosage.
Avoid vecuronium & pancuronium as unpredictable prolonged activity of
drug or its metabolite.
Atracurium preferred as nonorgan dependent metabolic pathway.
3.      B2 agonist: infuse at lowest dose possible.
    Regularly measure blood & lactate levels.
4.      Metabolic control: Treat fever
  Correct hypoalbuminemia, hyperglycemia, hypophosphatemia, hypokalemia,
hypermagnesemia, hypercapneic acidosis.