Zusammenfassung
Die 'critical illness polyneuropathy' (CIP) und die Žcritical illness myopathyŽ sind
seit der Erstbeschreibung von Bolton et al. zunehmend beachtete Komplikationen bei
Intensivpatienten. CIP und CIM, alleine oder in Kombination, treten gewöhnlich bei
Patienten auf, die länger als eine Woche auf einer Intensivtherapiestation behandelt
werden. Typischerweise zeigen diese Patienten eine muskuläre Schwäche der Gliedmaßen
sowie eine erschwerte Entwöhnung vom Beatmungsgerät. Neurologische und elektrophysiologische
Untersuchungen sowie Muskelbiopsien bei Verdacht auf eine Myopathy können bei der
Identifikation und Charakterisierung von Polyneuropathien und Myopathien helfen.
Summary
Since the first description of Bolton et al., critical illness polyneuropathy (CIP)
and critical illness myopathy (CIM) are increasingly observed as a complication in
intensive care patients. CIP and CIM commonly occur in patients with an ICU length
of stay exceeding one week. Typically, these patients show weakness of the limbs and
difficulties in weaning from the respirator. Neurological and electrophysiological
examinations as well as muscle biopsies if myopathy is of concern may help to characterize
and identify polyneuropathy and myopathy.
Schlüsselwörter
Critical Illness Polyneuropathie - Critical Illness Myopathie - Weaning - muskuläre
Schwäche
Key words
critical illness polyneuropathy - critical illness myopathy - weaning failure - muscle
weakness
Kernaussagen
-
CIP und CIM stellen eine schwere und prognostisch relevante Komplikation bei Intensivpatienten
dar. Als wichtige Anzeichen gelten erschwerte Entwöhnung vom Beatmungsgerät sowie
eine schlaffe Parese der unteren Extremität. Oft sind die tiefen Sehnenreflexe abgeschwächt
oder fehlen ganz.
-
Die exakte Pathogenese der CIP bleibt unklar. Vermutet wird ein enger Zusammenhang
mit systemischen Auswirkungen von SIRS und Sepsis, sodass aufgrund einer zellulären
und humoralen Antwortreaktion auf die systemische inflammatorische Reaktion im gesamten
Organsimus eine Störung der Mikrozirkulation (Verminderung der Nährstoffutilisation)
hervorgerufen wird.
-
Ungeachtet vieler histopathologischer Charakteristika kann die CIM in die 3 Haupttypen
„Muskelatrophie”, „degenerativ-nekrotische Veränderung” und „selektiver Verlust des
dicken Filaments Myosin” unterteilt werden. Diese Typen treten oft gemeinsam auf.
-
SIRS, Sepsis und septischer Schock spielen in der Entwicklung der CIM eine wesentliche
Rolle. Diese Verbindung führte zur Hyopthese, dass mikrozirkulatorische Störungen
und Entzündungsreaktionen in den Untergang der Motorneuronenintegrität involviert
sein müssen.
-
In den letzten Jahren wurden weitere Faktoren wie die Langzeitapplikation von Glukokortikoiden
und Muskelrelaxanzien sowie eine hyperglykämische Stoffwechsellage in der Genese der
CIM identifiziert.
-
Auch mitochondrale Dysfunktionen unterschiedlicher Ursache stehen im Verdacht, die
Muskelerholung und -regeneration nachhaltig zu beeinträchtigen.
-
Die tatsächliche Inzidenz und Mortalität von CIP und CIM sind bis heute nicht bekannt.
Unterschiedlichste Patientenkollektive, uneinheitliche Diagnosekriterien bzw. Deklination
einerseits, aber auch Untersuchungszeitpunkt und Expertise des Untersuchers andererseits
beeinflussen die Diagnose entscheidend.
-
Nervenleitgeschwindigkeit und Nadel-Elektromyographie sind wertvolle und sensitive
Diagnoseinstrumente. Veränderungen des Aktionspotenzials können in der Frühphase jedoch
oft normal, im Verlauf auch rückläufig sein.
-
Histologisch aufgearbeitete Muskel- und Nervenbiopsien lassen eine erhebliche Diskrepanz
zwischen den elektrophysiologischen Befunden und der Histologie erkennen. Dies kann
unter anderem auf Zeitpunkt und Lokalisation der Biopsie zurückgeführt werden. Die
häufigste Veränderung in histologischen Muskelschnitten ist die Atrophie von Typ-II-Fasern,
was einen Beleg für den Innervationsverlust darstellt.
-
Viele Autoren sehen in der aggressiven Therapie von SIRS und Sepsis („Early-goal directed
Therapy”) den wichtigsten Bestandteil in der CIP- und CIM-Therapie. Eine intensivierte
Insulintherapie mit Blutglukosewerten zwischen 80-110mg/dl konnte die Inzidenz um
44 % reduzieren. Eine weitere Therapieoption in der Behandlung der CIP könnte die
intravenöse Gabe von Immunglobulinen darstellen.
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Dr. med. Markus Alb
Email: markus.alb@anaes.ma.uni-heidelberg.de
Dr. med. Stephanie Hirner
Email: stephanie.hirner@anaes.ma.uni-heidelberg.de
PD Dr. med. Thomas Luecke D.E.A.A.
Email: thomas.luecke@anaes.ma.uni-heidelberg.de