Abstract
Objectives: To evaluate the accuracy of the peroneal nerve test (PENT) in the diagnosis of critical illness polyneuropathy (CIP) and myopathy (CIM) in the intensive care unit (ICU). We hypothesised that abnormal reduction of peroneal compound muscle action potential (CMAP) amplitude predicts CIP/CIM diagnosed using a complete nerve conduction study and electromyography (NCS-EMG) as a reference diagnostic standard.Design: prospective observational study.Setting: Nine Italian ICUs.Patients: One-hundred and twenty-one adult (≥18 years) neurologic (106) and non-neurologic (15) critically ill patients with an ICU stay of at least 3 days.Interventions: None.Measurements and main results: Patients underwent PENT and NCS-EMG testing on the same day conducted by two independent clinicians who were blind to the results of the other test. Cases were considered as true negative if both NCS-EMG and PENT measurements were normal. Cases were considered as true positive if the PENT result was abnormal and NCS-EMG showed symmetric abnormal findings, independently from the specific diagnosis by NCS-EMG (CIP, CIM, or combined CIP and CIM). All data were centrally reviewed and diagnoses were evaluated for consistency with predefined electrophysiological diagnostic criteria for CIP/CIM.During the study period, 342 patients were evaluated, 124 (36.3%) were enrolled and 121 individuals with no protocol violation were studied. Sensitivity and specificity of PENT were 100% (95% CI 96.1-100.0) and 85.2% (95% CI 66.3-95.8). Of 23 patients with normal results, all presented normal values on both tests with no false negative results. Of 97 patients with abnormal results, 93 had abnormal values on both tests (true positive), whereas four with abnormal findings with PENT had only single peroneal nerve neuropathy at complete NCS-EMG (false positive).Conclusions: PENT has 100% sensitivity and high specificity, and can be used to diagnose CIP/CIM in the ICU.
Highlights
Critical illness polyneuropathy (CIP) affects 30% to 50% of the most severely critically ill patients and is the most frequent acute polyneuropathy in the intensive care unit (ICU)[1]
CIP is often associated with an acute, primary myopathy called critical illness myopathy (CIM), and both conditions occur in patients with multiple organ dysfunctions and failure (MOF)
In a previous study called CRIMYNE10, we found that a simplified electrophysiological investigation, the peroneal nerve electrophysiological test (PENT), had high sensitivity (100%) and moderate specificity (67%) in identifying patients with a diagnosis of CIP or CIM using complete nerve conduction studies (NCS) as the reference diagnostic standard
Summary
Critical illness polyneuropathy (CIP) affects 30% to 50% of the most severely critically ill patients and is the most frequent acute polyneuropathy in the intensive care unit (ICU)[1]. CIP is often associated with an acute, primary myopathy called critical illness myopathy (CIM), and both conditions occur in patients with multiple organ dysfunctions and failure (MOF). CIP and CIM represent the failure of the neuromuscular system in patients with MOF1. CIP classically presents as a sensory-motor axonal polyneuropathy causing difficulty in weaning patients from a ventilator, flaccid limbs, and a possible reduction in deep tendon reflexes. Amplitude reduction of both the compound muscle action potential (CMAP) and the sensory nerve action potential (SNAP) is the predominant electrophysiological finding in CIM and CIP; latency and nerve conduction velocity remain normal or are only slightly decreased. The clinical features are often the same as for CIP, but sensation, if testable, is normal
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