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Qualitative Ultrasound in Acute Critical Illness Muscle Wasting

Puthucheary, Zudin A. PhD1,2,3; Phadke, Rahul FRCPath4; Rawal, Jaikitry MRCS1; McPhail, Mark J. W. PhD5,6; Sidhu, Paul S. FRCR7; Rowlerson, Anthea PhD2; Moxham, John MD8; Harridge, Stephen PhD2; Hart, Nicholas PhD9; Montgomery, Hugh E. MD1

doi: 10.1097/CCM.0000000000001016
Clinical Investigations
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Objectives: A rapid and early loss of skeletal muscle mass underlies the physical disability common amongst survivors of critical illness. However, skeletal muscle function depends not only on its quantity but its quality, which may be adversely affected. We set out to characterise the changes in macroscopic muscle echogenicity and fascial characteristics that occur early in critical illness, and to relate these to microscopic histologically defined myofibre necrosis and fascial pathology.

Design and Setting: Prospective two center observational study.

Patients: Thirty subjects comprising a subgroup of patients recruited to the Musculoskeletal Ultrasound in Critical Illness: Longitudinal Evaluation (MUSCLE) study.

Measurements and Main Results: Comparisons were made between sequential Vastus Lateralis histological specimens and ultrasound assessment of Rectus Femoris echogenicity. Change in muscle echogenicity was greater in patients who developed muscle necrosis (n = 15) than in those who did not (8.2% [95% CI, –5.3 to 21.7] vs –15.0% [95% CI, –28.9 to –1.09]; p = 0.016). The area under receiver operator curve for ultrasound echogenicity’s prediction of myofiber necrosis was 0.74 (95% CI, 0.565 to 0.919; p = 0.024) increasing to 0.85 (95% CI, 0.703 to –0.995; p = 0.003) with the removal of those with potential iatrogenic muscle damage. Fasciitis was observed in 18 of 30 biopsies (60%).

Conclusions: Myofiber necrosis and fascial inflammation can be detected noninvasively using ultrasound in the critically ill. Fasciitis precedes and frequently accompanies muscle necrosis. These findings may have functional implications for survivors of critical illness.

1Institute of Health and Human Performance, University College London, London, United Kingdom.

2Centre of Human and Aerospace Physiological Sciences, Kings College London, London, United Kingdom.

3Division of Respiratory and Critical Care, University Medicine Cluster, National University Health System, Singapore, Singapore.

4University College London Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, United Kingdom.

5Hepatology and Gastroenterology, St Mary’s Hospital, Imperial College London, London, United Kingdom.

6Institute of Liver Studies, Kings College Hospital NHS Foundation Trust, London, United Kingdom.

7Kings College Hospital NHS Foundation Trust, London, United Kingdom.

8King’s College London School of Medicine, London, United Kingdom.

9Guy’s and St Thomas’ and King’s College London, NIHR Comprehensive Biomedical Research Centre, London, United Kingdom.

Drs. Puthucheary, Phadke, Sidhu, McPhail, Harridge, Hart, and Montgomery helped in concept and design. Dr. Puthucheary, Dr. Phadke, Mr. Rawal, Dr. McPhail, and Dr. Rowlerson helped in data collection. Drs. Puthucheary, Phadke, McPhail, Sidhu, Rowlerson, McPhail, Harridge, Hart, and Montgomery helped in analysis and interpretation. Dr. Puthucheary, Dr. Phadke, Mr. Rawal, Dr. McPhail, Dr. Sidhu, Dr. Rowlerson, Dr. McPhail, Dr. Harridge, Dr. Hart, and Dr. Montgomery helped in article drafting and revision.

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Dr. Puthucheary received support for article research (He is funded by the National Institute of Health Research [NIHR] [UK]. This research was supported by the NIHR University College London Hospitals Biomedical Research Centre [BRC], who also part-fund Dr. Montgomery. Additional funding was received from the European Society of Intensive Care Medicine, Guy’s and St Thomas’ and King’s College London NIHR Comprehensive Biomedical Research Centre and the Whittington Hospital NHS Trust). His institution received grant support from the National Institute of Health Research (UK). Dr. McPhail received support for article research from the Wellcome Trust. and acknowledges the BRC at Imperial College and Kings College London for infrastructure support. His institution received grant support from the Wellcome Trust UK. Dr. Sidhu lectured for Bracco SpA and Siemens AG (Lecture fees for Ultrasound topics). Dr. Harridge received support for article research from the NIHR, UK. His institution received grant support from the NIHR, UK. Dr. Montgomery has patents (no monies received. Patent unrelated to this study), has stock (no monies received. Stock unrelated to this study), and received support for article research from the UK National Institute for Health Research. His institution received grant support from the National Institute for Health Research (core study funding). The National Institute of Health Research, the European Society of Intensive Care Medicine, Guy’s & St Thomas’ and King’s College London NIHR Comprehensive BRC and the Whittington Hospital NHS Trust had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: Zudin_amilka_puthucheary@nuhs.edu.sg

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