Critical evaluation of muscle mass loss as a prognostic marker of morbidity in critically ill patients and methods for its determination
Vera Joskova, Anna Patkova, Eduard Havel, Simona Najpaverova, Daniela Uramova, Miroslav Kovarik, Zdenek Zadak, Miloslav Hronek
Department of Biological and Medical Sciences, Faculty of Pharmacy in Hradec Kralove, Charles University, Czech Republic
Objective: Loss of muscle mass in critically ill patients is associated with serious consequences, such as prolonged mechanical ventilation, intensive care unit confinement, and higher mortality. Thus, monitoring muscle mass, and especially its decline, should provide a useful indicator of morbidity and mortality. Performing evaluations according only to body mass index is imperfect, therefore the aim of this article was to evaluate appropriate methods for muscle mass loss determination in ICU patients.
Methods: For this review, the literature searches were conducted through Embase and Medline, PubMed and Google Scholar databases up to February 2018 for the following Medical Subject Headings terms muscle atrophy, protein catabolism, ICU-aquaired weakness, muscle muss loss, myolysis, critical illness, stress metabolism, computed tomography, magnetic resonance imaging, dual-energy X-ray absorptiometry, neutron activation analysis, anthropometric examination, determination of endogenous metabolites of the skeletal muscles, bioimpedance spectroscopy, ultrasound.
Result: It appears that ultrasound, which is widely available in hospitals, is the most advantageous method. Muscle ultrasound is non-invasive, relatively inexpensive, and is a bedside method that is free of ionizing radiation. Furthermore, muscle ultrasound also seems to be valid in patients with severe fluid retention, which is a typical complication with other conventional methods.
Conclusion: Early detection of critical illness neuromyo-pathy could be beneficial for improving the standards of intensive care, and thus reducing the risk of mortality in these patients.
Every day there are many people around the world who suffer from multiple injuries, burns or serious diseases leading to the hospitalization in the intensive care units. These life-threatening conditions are associated with the muscle mass loss being one of the mortality risk factors. According to the published literature, in critically ill patients wastage of muscle mass is up to 9% daily with harmful consequences such as inability to breathe spontaneously. Therefore, care should include not only medication, but also appropriate nutrition and rehabilitation. The aim of this paper was to evaluate available methods for monitoring muscle mass. Ultrasound seems to be the most advantageous. It is readily available diagnostic equipment in hospitals, which is noninvasive, relatively inexpensive and free of ionizing radiation. Early detection and evaluation of muscle wasting could be beneficial for improving the standards of intensive care and thus reducing the risk of mortality in these patients.
Dr. Yeowleng Tan
Consultant, Singapore General Hospital
point-of-care ultrasound is a useful and radiation-free modality to evaluate muscle wasting in critically ill individuals. The authors have made excellent comments with regards to technical considerations of using ultrasound for clinical measurements, i.e, same location on the body parts, reasonable sonographic skills in transducer angulation to ensure muscle echo texture measurements and consistent ultrasound settings. I will like to use this opportunity to further elaborate on three clinical perspectives.
Firstly, while serial studies to evaluate muscle wasting are needed, there is a lack of standardized worldwide protocol on the frequency of these serial studies. Studies have so far described serial measurements in their methodology but few have commented on a standardized scanning frequency.(1,2)
Secondly, precise pre-determined location and data norms on each specific muscle measured needs to be developed.(3) A recent study by Carlos et al describes anatomical landmarks for measuring the quadriceps femoris but data norms on commonly measured muscles remained lacking. More studies are needed with aims of developing guidelines for location measurements and normative data for interpretation purposes.
The third point revolves around the use of serial ultrasound measurements to monitor improvement in muscle mass in critically ill patients after a course of early rehabilitation. There is, at present, lack of clinical studies to measure improvements in muscle mass after various introduction of rehabilitation such as physical therapy or the use of neuromuscular electrical stimulation. There are, however, ongoing trials to validate these and the extent of the role of ultrasound remains to be seen.(4)
In summary, ultrasound is a promising tool to evaluate muscle mass in critically ill patients. More work is needed to develop clinical protocols and data norms for ultrasound muscle measurements, reduce variations in measurement, and to document changes in measurements after rehabilitative interventions. I congratulate Vera et al and team for this insightful paper.
1) Nobuto Nakanishi, Jun OtoRie , Tsutsumi, Marina Iuchi, Mutsuo Onodera, Masaji Nishimura. Upper and lower limb muscle atrophy in critically ill patients: an observational ultrasonography study;Intensive Care Medicine; February 2018, Volume 44, Issue 2, pp 263–264
2) Vijay Hadda, Gopi C Khilnani, Rohit Kumar, Ashesh Dhunguna, Saurabh Mittal, Maroof Ahmad Khan, Karan Madan, Anant Mohan, Randeep Guleria.Indian Journal of Critical Care Medicine. 2017 Volume 2 Issue 7;448-452
3) Marina Mourtzakis, Selina Parry, Bronwen Connolly, Zudin Puthucheary. Skeletal Muscle Ultrasound in Critical Care: A Tool in Need of Translation.Ann Am Thorac Soc. 2017 Oct; 14(10): 1495–1503.
4) Marc R Nickels, Leanne M Aitken, James Walsham, Adrian G Barnett, Steven M McPhail. Critical Care Cycling Study (CYCLIST) trial protocol: a randomised controlled trial of usual care plus additional in-bed cycling sessions versus usual care in the critically ill. BMJ Oct 2018, Volume 7, Issue 10.
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