Neuropathies severe enough to require admission to an intensive care unit (ICU) may present in two main ways (Table,!,). Firstly, limb and respiratory muscle weakness may develop rapidly over days in a sufficiently severe fashion to require intubation, ventilation, and management in an ICU ( Zifko,a,nd C.,h..e.n,.!..9.9.6). The main aim in management will initially be to stabilize the patient, but the cause of the weakness must be investigated while the patient is still in the ICU. Secondly, the patient may develop difficulty in weaning from the ventilator and variable limb weakness during management in the ICU after admission for other causes, i.e. severe systemic illness or trauma.
Table 1 Differential diagnosis in the ICU of the syndrome of rapidly developing weakness of limb and respiratory muscles
In both instances emergency evaluation is required, and the differential diagnosis should be approached by considering disorders of the spinal cord, peripheral nerves, neuromuscular junction, and muscle (Table 1). The investigations may involve magnetic resonance imaging to exclude neoplastic infectious or traumatic conditions involving the high cervical spinal cord, electrophysiological studies to investigate disorders of the peripheral nervous system, and measurements of creatine phosphokinase and possibly muscle biopsy to investigate for a primary myopathy. Accurate diagnosis is important because specific treatments may be instituted, such as immunosuppression for Guillain-Barre syndrome or myasthenia gravis. It is important in rendering a prognosis. Patients with amyotrophic lateral sclerosis will have a poor prognosis, but it is much better for patients with critical illness polyneuropathy if the sepsis and multiple organ failure can be brought under control.
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