Abstract
BackgroundDegeneration of intraepidermal nerve fibers (IENF) is a hallmark of small fiber neuropathy of different etiology, whose clinical picture is dominated by neuropathic pain. It is unknown if critical illness can affect IENF.MethodsWe enrolled 14 adult neurocritical care patients with prolonged intensive care unit (ICU) stay and artificial ventilation (≥ 3 days), and no previous history or risk factors for neuromuscular disease. All patients underwent neurological examination including evaluation of consciousness, sensory functions, muscle strength, nerve conduction study and needle electromyography, autonomic dysfunction using the finger wrinkling test, and skin biopsy for quantification of IENF and sweat gland innervation density during ICU stay and at follow-up visit. Development of infection, sepsis and multiple organ failure was recorded throughout the ICU stay.ResultsOf the 14 patients recruited, 13 (93%) had infections, sepsis or multiple organ failure. All had severe and non-length dependent loss of IENF. Sweat gland innervation was reduced in all except one patient. Of the 7 patients available for follow-up visit, three complained of diffuse sensory loss and burning pain, and another three showed clinical dysautonomia.ConclusionsSmall fiber pathology can develop in the acute phase of critical illness and may explain chronic sensory impairment and pain in neurocritical care survivors. Its impact on long term disability warrants further studies involving also non-neurologic critical care patients.
Highlights
Survivors of critical illness may suffer from prolonged disability [1]
246 patients were excluded because the intensive care unit (ICU) stay was less than 3 days (158 patients), or patients had diabetes (41 patients), malignancy (19 patients), alcohol abuse (7 patients), renal insufficiency (4 patients), liver cirrhosis (4 patients), pre-existing neuromuscular disorders (3 patients), hepatitis C infection (2 patients), patients were in terminal condition (7 patients) or skin biopsy was not feasible (1 patients)
We report the first-ever observation that critical illness can be associated with a non-length dependent degeneration of somatic and autonomic small nerve fibers
Summary
Survivors of critical illness may suffer from prolonged disability [1]. Several causes contribute to this so-called “postintensive care syndrome”, which is defined as new or worsening impairment in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization [2]. Stocking and glove sensory loss, feeling of cool extremities, numbness, tingling, and neuropathic pain symptoms including hyperalgesia and burning have been described at long-term follow-up of ICU survivors [5,6]. Degeneration of intraepidermal nerve fibers (IENF) is a hallmark of small fiber neuropathy of different etiology, whose clinical picture is dominated by neuropathic pain. It is unknown if critical illness can affect IENF. All patients underwent neurological examination including evaluation of consciousness, sensory functions, muscle strength, nerve conduction study and needle electromyography, autonomic dysfunction using the finger wrinkling test, and skin biopsy for quantification of IENF and sweat gland innervation density during ICU stay and at follow-up visit. Its impact on long term disability warrants further studies involving non-neurologic critical care patients
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