title: Simplified electrophysiological evaluation of peripheral nerves in critically ill patients: the Italian multi-centre CRIMYNE study.
abstract: BACKGROUND
  Critical illness myopathy and/or neuropathy (CRIMYNE) is frequent in intensive care unit (ICU) patients. Although complete electrophysiological tests of peripheral nerves and muscles are essential to diagnose it, they are time-consuming, precluding extensive use in daily ICU practice. We evaluated whether a simplified electrophysiological investigation of only two nerves could be used as an alternative to complete electrophysiological tests.
  
  
  METHODS
  In this prospective, multi-centre study, 92 ICU patients were subjected to unilateral daily measurements of the action potential amplitude of the sural and peroneal nerves (compound muscle action potential [CMAP]). After the first ten days, complete electrophysiological investigations were carried out weekly until ICU discharge or death. At hospital discharge, complete neurological and electrophysiological investigations were performed.
  
  
  RESULTS
  Electrophysiological signs of CRIMYNE occurred in 28 patients (30.4%, 95% confidence interval [CI] 21.9% to 40.4%). A unilateral peroneal CMAP reduction of more than two standard deviations of normal value showed the best combination of sensitivity (100%) and specificity (67%) in diagnosing CRIMYNE. All patients developed the electrophysiological signs of CRIMYNE within 13 days of ICU admission. Median time from ICU admission to CRIMYNE was six days (95% CI five to nine days). In 10 patients, the amplitude of the nerve action potential dropped progressively over a median of 3.0 days, and in 18 patients it dropped abruptly within 24 hours. Multi-organ failure occurred in 21 patients (22.8%, 95% CI 15.4% to 32.4%) and was strongly associated with CRIMYNE (odds ratio 4.58, 95% CI 1.64 to 12.81). Six patients with CRIMYNE died: three in the ICU and three after ICU discharge. Hospital mortality was similar in patients with and without CRIMYNE (21.4% and 17.2%; p = 0.771). At ICU discharge, electrophysiological signs of CRIMYNE persisted in 18 (64.3%) of 28 patients. At hospital discharge, diagnoses in the 15 survivors were critical illness myopathy (CIM) in six cases, critical illness polyneuropathy (CIP) in four, combined CIP and CIM in three, and undetermined in two.
  
  
  CONCLUSIONS
  A peroneal CMAP reduction below two standard deviations of normal value accurately identifies patients with CRIMYNE. These should have full neurological and neurophysiological evaluations before discharge from the acute hospital.
authors.affiliation: Department of Anesthesiology-Intensive Care, University of Brescia, Spedali Civili, Brescia, Italy. latronic@med.unibs.it
authors.forename: Nicola
authors.initials: N
authors.lastname: Latronico
authors.forename: Guido
authors.initials: G
authors.lastname: Bertolini
authors.forename: Bruno
authors.initials: B
authors.lastname: Guarneri
authors.forename: Marco
authors.initials: M
authors.lastname: Botteri
authors.forename: Elena
authors.initials: E
authors.lastname: Peli
authors.forename: Serena
authors.initials: S
authors.lastname: Andreoletti
authors.forename: Paola
authors.initials: P
authors.lastname: Bera
authors.forename: Davide
authors.initials: D
authors.lastname: Luciani
authors.forename: Anna
authors.initials: A
authors.lastname: Nardella
authors.forename: Elena
authors.initials: E
authors.lastname: Vittorielli
authors.forename: Bruno
authors.initials: B
authors.lastname: Simini
authors.forename: Andrea
authors.initials: A
authors.lastname: Candiani
mesh_terms: D000200:Action Potentials; D016638:Critical Illness; D004594:Electrophysiology; D005500:Follow-Up Studies; D006801:Humans; D007362:Intensive Care Units; D053208:Kaplan-Meier Estimate; D009135:Muscular Diseases / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology; D010525:Peripheral Nerves / Q000502:physiology; D010523:Peripheral Nervous System Diseases / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology; D010543:Peroneal Nerve / Q000502:physiology*; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D013497:Sural Nerve / Q000502:physiology*