Critical Care of Neuromuscular Disorders

Diana Greene-Chandos, MD, FNCS; Michel Torbey, MD, MPH, FCCM, FAHA, FNCS, FAAN p. 1753-1775 December 2018, Vol.24, No.6 doi: 10.1212/CON.0000000000000682
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PURPOSE OF REVIEW: Weakness is a common reason patients are seen in neurologic consultation. This article reviews the differential diagnosis of neuromuscular disorders in the intensive care unit (ICU), discusses the intensive care needs and evaluation of respiratory failure in patients with neuromuscular disorders, and provides a practical guide for management.

RECENT FINDINGS: Although primary neuromuscular disorders used to be the most common cause for weakness from peripheral nervous system disease in the ICU, a shift toward ICU-acquired weakness is observed in today’s clinical practice. Therefore, determining the cause of weakness is important and may have significant prognostic implications. Guillain-Barré syndrome and myasthenia gravis remain the most common primary neuromuscular disorders in the ICU. In patients with myasthenia gravis, it is important to be vigilant with the airway and institute noninvasive ventilation early in the course of the disease to attempt to avoid the need for intubation. On the other hand, patients with Guillain-Barré syndrome should be intubated without delay if the airway is at risk to avoid further complications. In patients with ICU-acquired weakness, failure to wean from the ventilator is usually the challenge. Early mobility, glucose control, minimizing sedation, and avoiding neuromuscular blocking agents remain the only therapeutic regimen available for ICU-acquired weakness.

SUMMARY: Critical care management of neuromuscular disorders requires a multidisciplinary approach engaging members of the ICU and consultative teams. Developing an airway management protocol could have implications on outcome and length of stay for patients with neuromuscular disorders in the ICU. Tending to the appropriate nuances of each patient who is critically ill with a neuromuscular disorder through evidence-based medicine can also have implications on length of stay and outcome.

Address correspondence to Dr Michel Torbey, University of New Mexico, Department of Neurology, 2211 Lomas Blvd NE, Albuquerque, NM 87106, mtorbey@salud.unm.edu.

RELATIONSHIP DISCLOSURE: Dr Greene-Chandos has received personal compensation as a speaker for the Ecuador Neurocritical Care Society Annual Meeting and the Neurocritical Care Society Annual Meeting and has received research/grant support from Biogen, the Neuroemergency Treatment Trials Grant from the National Institutes of Health, and the Stroke Network Grant from the National Institute of Neurological Disorders and Stroke. Dr Greene-Chandos has worked as a consultant for court cases. Dr Torbey has received personal compensation as the past president of the Neurocritical Care Society and has received grant support from the National Institute of Neurological Disorders and Stroke.

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Drs Greene-Chandos and Torbey report no disclosures.

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© 2018 American Academy of Neurology