title: Muscle mass, strength and functional outcomes in critically ill patients after cardiothoracic surgery: does neuromuscular electrical stimulation help? The Catastim 2 randomized controlled trial.
abstract: BACKGROUND
  The effects of neuromuscular electrical stimulation (NMES) in critically ill patients after cardiothoracic surgery are unknown. The objectives were to investigate whether NMES prevents loss of muscle layer thickness (MLT) and strength and to observe the time variation of MLT and strength from preoperative day to hospital discharge.
  
  
  METHODS
  In this randomized controlled trial, 54 critically ill patients were randomized into four strata based on the SAPS II score. Patients were blinded to the intervention. In the intervention group, quadriceps muscles were electrically stimulated bilaterally from the first postoperative day until ICU discharge for a maximum of 14 days. In the control group, the electrodes were applied, but no electricity was delivered. The primary outcomes were MLT measured by ultrasonography and muscle strength evaluated with the Medical Research Council (MRC) scale. The secondary functional outcomes were average mobility level, FIM score, Timed Up and Go Test and SF-12 health survey. Additional variables of interest were grip strength and the relation between fluid balance and MLT. Linear mixed models were used to assess the effect of NMES on MLT, MRC score and grip strength.
  
  
  RESULTS
  NMES had no significant effect on MLT. Patients in the NMES group regained muscle strength 4.5 times faster than patients in the control group. During the first three postoperative days, there was a positive correlation between change in MLT and cumulative fluid balance (r = 0.43, P = 0.01). At hospital discharge, all patients regained preoperative levels of muscle strength, but not of MLT. Patients did not regain their preoperative levels of average mobility (P = 0.04) and FIM score (P = 0.02) at hospital discharge, independent of group allocation.
  
  
  CONCLUSIONS
  NMES had no effect on MLT, but was associated with a higher rate in regaining muscle strength during the ICU stay. Regression of intramuscular edema during the ICU stay interfered with measurement of changes in MLT. At hospital discharge patients had regained preoperative levels of muscle strength, but still showed residual functional disability and decreased MLT compared to pre-ICU levels in both groups.
  
  
  BACKGROUND
  Clinicaltrials.gov identifier NCT02391103. Registered on 7 March 2015.
authors.affiliation: Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care and Pain Control, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria. arabella.fischer@meduniwien.ac.at.
authors.forename: Arabella
authors.initials: A
authors.lastname: Fischer
authors.affiliation: Kantonsspital Sankt Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland. matthias.spiegl@kssg.ch.
authors.forename: Matthias
authors.initials: M
authors.lastname: Spiegl
authors.affiliation: Krankenhaus der Barmherzigen Schwestern Ried, Schlossberg 1, 4910, Ried im Innkreis, Austria. klausaltmann@posteo.de.
authors.forename: Klaus
authors.initials: K
authors.lastname: Altmann
authors.affiliation: University Hospital Landeskrankenhaus Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria. winkler.andreas@hotmail.com.
authors.forename: Andreas
authors.initials: A
authors.lastname: Winkler
authors.affiliation: Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria. anna.salamon@gmx.at.
authors.forename: Anna
authors.initials: A
authors.lastname: Salamon
authors.affiliation: Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria. michael.themessl-huber@meduniwien.ac.at.
authors.forename: Michael
authors.initials: M
authors.lastname: Themessl-Huber
authors.affiliation: Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care and Pain Control, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria. mohamed.mouhieddine@meduniwien.ac.at.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Mouhieddine
authors.affiliation: Institute for Physical Medicine and Rehabilitation, Kaiser-Franz-Josef-Spital Wien, Kundratstrasse 3, 1100, Vienna, Austria. strasser_eva@yahoo.de.
authors.forename: Eva Maria
authors.initials: EM
authors.lastname: Strasser
authors.affiliation: Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care and Pain Control, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria. arno.schiferer@meduniwien.ac.at.
authors.forename: Arno
authors.initials: A
authors.lastname: Schiferer
authors.affiliation: Institute for Physical Medicine and Rehabilitation, Donauspital Wien, Langobardenstraße 122, 1220, Vienna, Austria. tatjana.paternostro-sluga@wienkav.at.
authors.forename: Tatjana
authors.initials: T
authors.lastname: Paternostro-Sluga
authors.affiliation: Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care and Pain Control, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria. michael.hiesmayr@meduniwien.ac.at.
authors.forename: Michael
authors.initials: M
authors.lastname: Hiesmayr
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D016638:Critical Illness / Q000628:therapy*; D004558:Electric Stimulation / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D053580:Muscle Strength / Q000502:physiology*; D063868:Patient Outcome Assessment
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