Interact CardioVasc Thorac Surg 2007;6:419-420. doi:10.1510/icvts.2006.149575
© 2007 European Association of Cardio-Thoracic Surgery
Case report - Cardiac general |
Critical illness polyneuropathy. Regression following cardiac operation
Giuseppe Gattia,*,
Paolo Grassib,
Luciano Silvestric and
Bartolo Zingonea
a Department of Cardiovascular Medicine, Division of Cardiac Surgery, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Trieste, Ospedale di Cattinara, strada di Fiume, 447 – 34100 Trieste, Italy
b Divisions of Anesthesia and Intensive Care, Ospedali Riuniti di Trieste, Trieste, Italy
c Division of Anesthesia and Intensive Care, Ospedale di Gorizia, Gorizia, Italy
Received 30 November 2006;
received in revised form 21 February 2007;
accepted 21 February 2007
*Corresponding author. Tel.: +39 040 3994856; fax: +39 040 3994995.
E-mail address: giusep.gatti{at}tiscali.it (G. Gatti).
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Abstract
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Critical illness polyneuropathy is an acute neuromuscular disorder of severely ill patients that may also occur in complicated postoperative heart surgery course. This case report should make this disease known also as a preoperative condition that may regress following a successful cardiac operation.
Key Words: Peripheral nerves; Neurological injury; Preoperative care
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1. Introduction
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Critical illness polyneuropathy is an acute neuromuscular disorder of severely ill patients characterized by distal axonal degeneration of motor fibers causing flaccid tetraparesis, decreased or absent deep tendon reflexes, and muscle wasting of the limbs. Sensory fibers and cranial nerves are generally preserved. Bolton et al. in 1984 first reported this syndrome as a new neurological entity [1]. Complex pathogenetic mechanisms have been hypothesized involving metabolic, inflammatory, and bioenergetic alterations supporting microvascular changes in peripheral nerves, though its etiology remains unclear [2].
Clinical studies have elucidated critical illness polyneuropathy as a cause of ventilator dependency during prolonged intensive care unit stay after cardiac operations [3–5]. The purpose of this paper is to illustrate critical illness polyneuropathy as a preoperative condition as well, and show how it is potentially reversible following effective surgical treatment of the underlying cardiac condition.
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2. Case report
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A 66-year-old woman with recent myocardial infarction, severe mitral regurgitation, and severe biventricular dysfunction was evaluated for surgery in the light of a coexisting critical illness polyneuropathy.
She had experienced, two months earlier, three episodes of cardiac arrest requiring prolonged cardiopulmonary resuscitation in the emergency room, on admission for worsening heart failure. During the following days she developed a septic state due to bronchopneumonia from P. aeruginosa and soon manifested an apparently vegetative state combined with flaccid tetraparesis, absent deep tendon reflexes, and muscle wasting of the limbs, and became totally dependent on mechanical ventilation. At the time of surgical consultation, the diagnosis of critical illness polyneuropathy had been established after excluding structural abnormalities and the Guillain-Barré syndrome by magnetic resonance imaging and spinal tap, respectively. Electrophysiological testing demonstrated widely distributed denervation with fibrillation potentials and sharp positive waves in the presence of decreased compound muscle action potential amplitudes, i.e. electrophysiological findings typical for critical illness polyneuropathy (Table 1). Administration of aminoglycosides and corticosteroids required during her hospital stay increased the likelihood that this patient could develop critical illness polyneuropathy [6]. As the cardiac condition prevented any possible progress, the patient was accepted for surgery. The APACHE III prognostic system score was 104 (range 0–299) at this time [7]. Following intraaortic balloon pumping initiated during coronary angiography, she underwent treatment of severe mitral regurgitation with IMR ETlogix annuloplasty ring (Edwards Lifesciences, Irvine, CA) and double saphenous vein coronary bypass grafting. Hemodynamics and neurological status slowly but steadily improved following surgery: she was weaned from counterpulsation on postoperative day 4, conscious since day 5, and able to perform spontaneous movements of the limbs and to breath autonomously from day 11 and 17, respectively. Finally, she was discharged home, being able to walk independently, after 40 days from operation. Neurological status remained unchanged with respect to the condition at discharge, and the patient was in NYHA functional class II at one year of follow-up. Echocardiographic assessment showed trivial mitral regurgitation and confirmed severe biventricular dysfunction.
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3. Discussion
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Critical illness polyneuropathy may be part of the final common pathway of the systemic inflammatory response syndrome, sepsis, and multiple organ failure, with cytokines such as the tumor necrosis factor- playing a pivotal role on the activation of the body defense system. However, a number of other conditions, such as the underlying disease, diabetes, malnutrition, immobility, dialysis, and the use of neuromuscular blocking agents, corticosteroids, or aminoglycosides, have been also postulated [2, 5, 6].
In recent years critical illness polyneuropathy has been reported with increasing frequency as a cause of acute paralysis in a critical care setting. In a number of cases the diagnosis may be missed due to the presence of several confounding factors such as drug effects, underlying disorders, and coexisting abnormalities of the nervous system. Considered neurological disorders include Guillain-Barré syndrome, myasthenia gravis, spinal cord lesion, stroke of the basilar artery, porphyry, motor neuron or muscle (metabolic or inflammatory) diseases, botulism, and hypophosphatemia. All of these should be positively excluded before establishing the diagnosis of critical illness polyneuropathy. A high index of suspicion strengthened by meticulous neurological and electrophysiological testing may eventually prompt the correct diagnosis.
Many patients who have been diagnosed with critical illness polyneuropathy are reported to complain of profound muscle weakness or persisting milder disabilities after hospital discharge. Functional recovery is generally good, however, with patients regaining the ability to breath spontaneously and to walk independently in as many as 70% of the cases [8].
This report intends to emphasize both the opportunity to timely diagnose critical illness polyneuropathy and to consider appropriate surgical operations as a means to improve upon patient's course and prognosis.
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References
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Abstract
1. Introduction