Kritik Hastalık Polinöromiyopatisi
Özet
Yoğun bakım ünitesinde (YBÜ) edinilmiş güçsüzlük, “kritik hastalıktan başka makul bir etiyoloji bulunmayan kritik hastalarda klinik olarak tespit edilen güçsüzlük” olarak tanımlanır, en sık görülen nöromüsküler bozukluktur ve YBÜ hastalarının klinik seyrini ve sonuçlarını etkiler. Kritik hastalık polinöropatisi (KHP) ve kritik hastalık miyopatisi (KHM) sıklıkla aynı anda ortaya çıkar veya birbirinden ayırt edilemez. KHP ve KHM kombinasyonu kritik hastalık polinöromiyopatisi (KHPM) olarak adlandırılır. Kritik bir hastalığın başlangıcından sonra ortaya çıkan, ekstremiteleri ve solunum kaslarını etkileyen bilateral ve flask parezi olarak ortaya çıkar. Kas zayıflığı, yeniden entübasyon oranının artmasına ve ventilatör ilişkili pnömoni, trakeostomi ihtiyacı, uzun yoğun bakım yatış süreleri gibi komplikasyonlarla birlikte uzun süreli ventilasyon ve weaning fazına yol açarak morbidite ve mortalitenin artmasına neden olur. Tanıda klinik, periferik sinirlerin ve kasların elektrofizyolojik incelemeleri ve seçilmiş vakalarda da kas biyopsisi kullanılmaktadır.
Yoğun bakım ünitesinde henüz kanıtlanmış faydası olan spesifik tedavisi bulunmadığından, sepsis tedavisini agresif bir şekilde yapmak ve yoğun bakım ünitesinde risk faktörlerine maruziyeti en aza indirecek stratejiler uygulamak hayati önem taşımaktadır. Hafif sedasyon, günlük sedasyon tatilleri ve erken mobilizasyon yoğun bakım ünitesinde edinilmiş güçsüzlüğü önlemek için en etkili stratejilerdir. Bu olgu sunumunda, COVİD-19 enfeksiyonu sonrası yoğun bakım ünitemizde takip ve tedavi edilen KHPM olgusu tanı ve tedavi yöntemleri literatür eşliğinde tartışılmıştır.
Intensive care unit acquired weakness, defined as “clinically detected weakness in critically ill patients with no plausible etiology other than critical illness”, is the most common neuromuscular disorder and affects the clinical course and outcomes of ICU patients. Critical illness polyneuropathy and critical illness myopathy often occur simultaneously or are indistinguishable. The combination of CIP and CIM is called critical illness polyneuromyopathy (CIPM). It manifests as bilateral and flaccid paresis affecting the extremities and respiratory muscles, occurring after the onset of a critical illness. Muscle weakness leads to an increased rate of reintubation and prolonged ventilation and weaning phase with complications such as respiratory-associated pneumonia, possibly the need for tracheostomy, prolonged treatment times in the intensive care unit, leading to increased morbidity and mortality. Clinical diagnosis, electrophysiological examinations of peripheral nerves and muscles and, in selected cases, muscle biopsy can eventually be used to determine the specific pathologic diagnosis.
Since there is no specific treatment with proven benefit in the ICU, it is vital to treat sepsis aggressively and implement strategies to minimize exposure to risk factors in the ICU. Light sedation, daily sedation holidays and early mobilization are the most effective strategies to prevent acquired weakness in the ICU. In this case report, the diagnosis and treatment methods of a case of CHPM who was followed and treated in our intensive care unit after COVID-19 infection were discussed in the light of the literature.
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