Critical Illness Myopathy/Neuropathy (ICU-Acquired Weakness)¶
VERSION: 1.1 CREATED: January 30, 2026 REVISED: January 30, 2026 STATUS: Approved
DIAGNOSIS: Critical Illness Myopathy/Neuropathy (ICU-Acquired Weakness)
ICD-10: G72.81 (Critical illness myopathy), G62.81 (Critical illness polyneuropathy), M62.81 (ICU-acquired weakness)
CPT CODES: 85025 (CBC with differential), 80053 (CMP (BMP + LFTs)), 83735 (Magnesium), 84100 (Phosphorus), 82330 (Calcium (ionized)), 82550 (Creatine kinase (CK)), 82947 (Blood glucose), 82803 (Arterial blood gas (ABG)), 83605 (Lactate), 84145 (Procalcitonin), 84443 (TSH), 81003 (Urinalysis with microscopy), 82085 (Aldolase), 83615 (LDH), 83874 (Myoglobin (serum)), 86255 (Anti-ganglioside antibodies (GM1, GD1a, GQ1b)), 86235 (Acetylcholine receptor antibodies), 82533 (Cortisol (random or AM)), 84439 (Free T4), 82306 (Vitamin D (25-OH)), 84134 (Prealbumin), 83036 (HbA1c), 83018 (Heavy metals (lead, arsenic, thallium)), 84120 (Porphyrins (urine ALA, PBG)), 20200 (Muscle biopsy), 64795 (Nerve biopsy (sural)), 95907-95913 (Nerve conduction studies (NCS)), 71046 (Chest X-ray), 93000 (ECG (12-lead)), 76604 (Ultrasound: diaphragm), 76881 (Ultrasound: muscle (quadriceps, biceps)), 72156 (MRI spine (whole) with and without contrast), 70553 (MRI brain with and without contrast), 94010 (Pulmonary function testing (formal spirometry)), 71260 (CT chest with contrast), 73718 (MRI muscle (thigh or upper arm)), 76000 (Fluoroscopic sniff test), 95907 (Phrenic nerve conduction study)
SYNONYMS: ICU-acquired weakness, ICUAW, critical illness myopathy, CIM, critical illness polyneuropathy, CIP, critical illness neuromyopathy, CINM, intensive care unit acquired paresis, acute quadriplegic myopathy, thick filament myopathy, critical care myopathy, critical care polyneuropathy, ventilator-associated weakness
SCOPE: Diagnosis, management, and rehabilitation of ICU-acquired weakness (ICUAW) including critical illness myopathy (CIM), critical illness polyneuropathy (CIP), and combined CIM/CIP (CINM). Covers risk factor identification and modification, electrodiagnostic differentiation (NCS/EMG including direct muscle stimulation), MRC sum score assessment, supportive management, early mobilization, ventilator liberation strategies, nutritional optimization, and long-term prognosis. Excludes pre-existing neuromuscular disorders (GBS, myasthenia gravis, ALS), spinal cord injury, and prolonged neuromuscular blockade effect without underlying neuromyopathy.
PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting
═══════════════════════════════════════════════════════════════ SECTION A: ACTION ITEMS ═══════════════════════════════════════════════════════════════
1. LABORATORY WORKUP¶
1A. Essential/Core Labs¶
| Test | Rationale | Target Finding | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|
| CBC with differential (CPT 85025) | Baseline; infection screen; leukocytosis suggests ongoing sepsis as risk factor for ICUAW | Normal; leukocytosis or bandemia suggest active infection | STAT | STAT | ROUTINE | STAT |
| CMP (BMP + LFTs) (CPT 80053) | Electrolytes (K, Mg, Ca, Phos affect muscle function); renal/hepatic function; glucose control assessment | Normal; hyperglycemia >180 mg/dL requires insulin adjustment; electrolyte correction | STAT | STAT | ROUTINE | STAT |
| Magnesium (CPT 83735) | Hypomagnesemia worsens weakness and impairs neuromuscular transmission | >2.0 mg/dL; replete if low | STAT | STAT | ROUTINE | STAT |
| Phosphorus (CPT 84100) | Hypophosphatemia causes profound muscle weakness including respiratory muscles; may mimic or worsen ICUAW | >2.5 mg/dL; replete aggressively if <1.5 mg/dL | STAT | STAT | ROUTINE | STAT |
| Calcium (ionized) (CPT 82330) | Hypocalcemia increases neuromuscular excitability; hypercalcemia causes weakness | Normal ionized Ca 4.5-5.3 mg/dL | STAT | STAT | ROUTINE | STAT |
| Creatine kinase (CK) (CPT 82550) | Elevated in CIM (often moderately 1000-5000 IU/L); very high levels suggest rhabdomyolysis; normal in CIP | Mildly to moderately elevated in CIM; normal in CIP; >10,000 suggests rhabdomyolysis | STAT | STAT | ROUTINE | STAT |
| Blood glucose (CPT 82947) | Hyperglycemia is a major modifiable risk factor for ICUAW; target 140-180 mg/dL per NICE-SUGAR | 140-180 mg/dL; avoid hypoglycemia <70 mg/dL | STAT | STAT | ROUTINE | STAT |
| Arterial blood gas (ABG) (CPT 82803) | Assess ventilation (PaCO2) and oxygenation; hypercapnia indicates respiratory muscle weakness contributing to ventilator dependence | Normal: pH 7.35-7.45, PaCO2 35-45; rising PaCO2 suggests respiratory muscle failure | STAT | STAT | - | STAT |
| Lactate (CPT 83605) | Elevated in sepsis and tissue hypoperfusion; ongoing sepsis perpetuates ICUAW | <2.0 mmol/L | STAT | STAT | - | STAT |
| Procalcitonin (CPT 84145) | Distinguish ongoing infection from inflammatory state; persistent sepsis worsens ICUAW prognosis | <0.5 ng/mL; elevated suggests active infection requiring treatment | STAT | STAT | - | STAT |
| TSH (CPT 84443) | Hypothyroid myopathy can mimic CIM; critical illness may cause sick euthyroid syndrome | Normal (interpret cautiously in ICU setting) | - | ROUTINE | ROUTINE | ROUTINE |
| Urinalysis with microscopy (CPT 81003) | UTI as source of ongoing sepsis; myoglobinuria if rhabdomyolysis | Negative; dark urine may indicate myoglobinuria | STAT | ROUTINE | ROUTINE | STAT |
1B. Extended Workup (Second-line)¶
| Test | Rationale | Target Finding | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|
| Aldolase (CPT 82085) | Muscle injury marker; may be elevated in CIM alongside CK; supports myopathic process | Elevated in CIM; normal in CIP | - | ROUTINE | ROUTINE | ROUTINE |
| LDH (CPT 83615) | Non-specific marker of tissue damage; elevated in myopathy and hemolysis | Elevated in CIM | - | ROUTINE | ROUTINE | ROUTINE |
| Myoglobin (serum) (CPT 83874) | Muscle breakdown marker; elevated in CIM and rhabdomyolysis; renal toxicity risk | <90 ng/mL; elevated suggests muscle damage | - | ROUTINE | - | URGENT |
| Urine myoglobin (CPT 83874) | Myoglobinuria from muscle breakdown; renal injury risk | Negative; positive indicates significant muscle damage | - | ROUTINE | - | URGENT |
| Anti-ganglioside antibodies (GM1, GD1a, GQ1b) (CPT 86255) | Exclude GBS if clinical presentation unclear; GBS can develop during ICU stay | Negative; positive suggests GBS rather than ICUAW | - | ROUTINE | ROUTINE | ROUTINE |
| Acetylcholine receptor antibodies (CPT 86235) | Exclude myasthenia gravis if weakness pattern suggests NMJ disorder | Negative; positive suggests MG | - | ROUTINE | ROUTINE | ROUTINE |
| Anti-MuSK antibodies (CPT 86235) | Exclude MuSK-positive myasthenia if AChR negative but MG suspected | Negative | - | ROUTINE | ROUTINE | - |
| Cortisol (random or AM) (CPT 82533) | Adrenal insufficiency from prolonged steroid use causing weakness; critical illness-related corticosteroid insufficiency | AM cortisol >10 mcg/dL generally adequate; <10 suggests insufficiency | - | ROUTINE | - | ROUTINE |
| Free T4 (CPT 84439) | Hypothyroid myopathy in differential; thyroid dysfunction assessment | Normal | - | ROUTINE | ROUTINE | ROUTINE |
| Vitamin D (25-OH) (CPT 82306) | Deficiency is common in ICU patients and contributes to muscle weakness and impaired recovery | >30 ng/mL; supplement if <20 ng/mL | - | ROUTINE | ROUTINE | ROUTINE |
| Prealbumin (CPT 84134) | Nutritional status marker; low levels indicate protein malnutrition affecting muscle recovery | >15 mg/dL; low suggests inadequate nutrition | - | ROUTINE | ROUTINE | ROUTINE |
| HbA1c (CPT 83036) | Chronic glycemic control assessment; poorly controlled diabetes increases ICUAW risk | <7% in general; assess baseline diabetes control | - | ROUTINE | ROUTINE | ROUTINE |
1C. Rare/Specialized (Refractory or Atypical)¶
| Test | Rationale | Target Finding | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|
| Paraneoplastic antibody panel (CPT 86255) | Paraneoplastic neuromyopathy in differential if cancer history or atypical features | Negative | - | EXT | EXT | EXT |
| Anti-VGCC antibodies | Lambert-Eaton myasthenic syndrome (LEMS) in differential; associated with small cell lung cancer | Negative; positive = LEMS | - | EXT | EXT | - |
| Myositis-specific antibodies (Jo-1, Mi-2, SRP, MDA5) | Inflammatory myopathy in differential if CK markedly elevated and atypical course | Negative | - | EXT | EXT | - |
| Heavy metals (lead, arsenic, thallium) (CPT 83018) | Toxic neuropathy mimic; occupational or environmental exposure | Normal | - | EXT | EXT | - |
| Porphyrins (urine ALA, PBG) (CPT 84120) | Acute intermittent porphyria mimic (motor neuropathy, autonomic dysfunction) | Normal | - | EXT | EXT | - |
| Muscle biopsy (CPT 20200) | Definitive differentiation CIM vs CIP when electrodiagnostics are inconclusive; shows thick filament (myosin) loss in CIM; rarely needed in practice | CIM: selective loss of thick (myosin) filaments, type 2 fiber atrophy, necrosis; CIP: denervation changes, grouped atrophy | - | EXT | EXT | EXT |
| Nerve biopsy (sural) (CPT 64795) | Rarely indicated; axonal degeneration in CIP; only when diagnosis is uncertain and alternative treatable diagnoses are considered | CIP: axonal degeneration of sensory and motor fibers; no inflammation | - | EXT | EXT | - |
2. DIAGNOSTIC IMAGING & STUDIES¶
2A. Essential/First-line¶
| Study | Timing | Target Finding | Contraindications | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|
| Nerve conduction studies (NCS) (CPT 95907-95913) / EMG (CPT 95886) | When ICUAW suspected (typically after 1 week ICU stay with new weakness); ideally after sedation lightened to allow cooperation | CIP: reduced CMAP and SNAP amplitudes with normal conduction velocities (axonal pattern); CIM: reduced CMAP amplitudes with NORMAL SNAPs and myopathic MUP recruitment; Combined CINM: both axonal neuropathic and myopathic changes | Anticoagulation (relative for needle EMG); unable to cooperate for volitional EMG | - | URGENT | ROUTINE | URGENT |
| Direct muscle stimulation (DMS) | When CIM vs CIP differentiation needed in uncooperative or sedated patients; specialized technique | CIM: reduced ratio of nerve-stimulated CMAP to direct muscle-stimulated CMAP (nerve:muscle ratio <0.5); CIP: preserved ratio with reduced CMAPs on both | Requires specialized equipment; not widely available | - | EXT | - | URGENT |
| Chest X-ray (CPT 71046) | On recognition of ICUAW; baseline for ventilator weaning assessment | Atelectasis, pleural effusion, diaphragm elevation (weakness), aspiration | None significant | STAT | ROUTINE | - | STAT |
| ECG (12-lead) (CPT 93000) | Baseline; electrolyte abnormalities may cause arrhythmia; autonomic dysfunction assessment | Sinus rhythm; check for QTc prolongation, electrolyte-related changes | None | STAT | ROUTINE | - | STAT |
| Ultrasound: diaphragm (CPT 76604) | Assess diaphragm thickness and excursion; predicts ventilator weaning success; diaphragm atrophy develops within 48-72h of mechanical ventilation | Diaphragm thickness >2mm; thickening fraction >30% during inspiration; excursion >10mm; decreased values suggest diaphragm atrophy and prolonged weaning | None significant | - | ROUTINE | - | URGENT |
| Ultrasound: muscle (quadriceps, biceps) (CPT 76881) | Quantify muscle wasting; serial measurements track progression; cross-sectional area decreases significantly within first week of ICU | Reduced muscle thickness and cross-sectional area compared to admission baseline; echogenicity changes suggest myopathic process | None significant | - | ROUTINE | ROUTINE | ROUTINE |
2B. Extended¶
| Study | Timing | Target Finding | Contraindications | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|
| MRI spine (whole) with and without contrast (CPT 72156) | If spinal cord pathology suspected (upper motor neuron signs, sensory level) | Normal spinal cord; exclude compressive myelopathy, epidural abscess, infarction | Pacemaker, metallic implants; patient stability for transport | - | URGENT | ROUTINE | URGENT |
| MRI brain with and without contrast (CPT 70553) | If central cause of weakness suspected (stroke, brainstem lesion) | Normal; exclude stroke, demyelination, structural lesion | Same as MRI spine | - | URGENT | ROUTINE | URGENT |
| Repeat NCS/EMG (CPT 95907-95913) | At 2-4 weeks if initial study inconclusive or to assess prognosis and track recovery | Evolution of findings; persistent denervation predicts slower recovery; reinnervation signs suggest improvement | Same as initial NCS/EMG | - | ROUTINE | ROUTINE | ROUTINE |
| Pulmonary function testing (formal spirometry) (CPT 94010) | When patient can cooperate; assess respiratory muscle strength for weaning readiness; outpatient monitoring of recovery | FVC, MIP, MEP values; FVC >15 mL/kg supports weaning; serial improvement documents recovery | Patient cooperation required | - | ROUTINE | ROUTINE | ROUTINE |
| CT chest with contrast (CPT 71260) | If pulmonary pathology suspected (PE, empyema) complicating weaning failure | Pulmonary embolism; pleural effusion; lung pathology | Contrast allergy; renal impairment | - | ROUTINE | - | URGENT |
2C. Rare/Specialized¶
| Study | Timing | Target Finding | Contraindications | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|
| MRI muscle (thigh or upper arm) (CPT 73718) | When inflammatory myopathy in differential; assesses muscle edema and fatty infiltration | CIM: diffuse muscle edema on STIR; inflammatory myopathy: focal/multifocal edema and enhancement | MRI-incompatible implants | - | EXT | EXT | - |
| Fluoroscopic sniff test (CPT 76000) | Diaphragm paralysis evaluation when ultrasound is equivocal; paradoxical diaphragm motion | Normal bilateral diaphragm excursion; paradoxical motion indicates paralysis | Radiation exposure; patient must be transported | - | EXT | EXT | - |
| Phrenic nerve conduction study (CPT 95907) | Assess phrenic nerve function directly; CIP may involve phrenic nerves causing diaphragm weakness | Reduced phrenic CMAP amplitude suggests CIP involving phrenic nerve; normal suggests preserved phrenic function | Same as standard NCS | - | EXT | - | EXT |
3. TREATMENT¶
3A. Acute/Emergent¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Insulin (regular) infusion | IV | Glycemic control to reduce ICUAW risk and severity; hyperglycemia is major modifiable risk factor | Variable rate :: IV :: continuous :: Insulin infusion per ICU protocol; target glucose 140-180 mg/dL (NICE-SUGAR target); avoid hypoglycemia <70 mg/dL; transition to subcutaneous when tolerating enteral nutrition | Hypoglycemia risk; requires frequent glucose monitoring | Glucose q1-2h during infusion; q4-6h when stable; watch for hypokalemia | - | ROUTINE | - | STAT |
| DVT prophylaxis: Enoxaparin | SC | Immobilized ICU patients at high risk for VTE; ICUAW patients are bedbound | 40 mg :: SC :: daily :: 40 mg SC daily; adjust for renal function (CrCl <30: 30 mg SC daily or use UFH) | Active bleeding; platelets <50K; CrCl <30 (use heparin instead) | Platelets q3 days; anti-Xa if renal impairment; signs of bleeding | - | ROUTINE | - | ROUTINE |
| DVT prophylaxis: Heparin SC (renal alternative) | SC | VTE prophylaxis when enoxaparin contraindicated due to renal impairment | 5000 units :: SC :: q8h :: 5000 units SC q8h; use when CrCl <30 mL/min | Active bleeding; HIT history | Platelets q3 days for HIT surveillance | - | ROUTINE | - | ROUTINE |
| Pneumatic compression devices | - | VTE prophylaxis adjunct for all immobilized ICUAW patients; use in addition to pharmacologic prophylaxis | Apply bilaterally on admission :: - :: continuous :: Apply bilaterally; continue until patient is ambulatory; use as monotherapy only if pharmacologic anticoagulation contraindicated | Acute DVT in affected limb; severe peripheral vascular disease | Skin integrity daily; device function | STAT | STAT | - | STAT |
| Stress ulcer prophylaxis: Famotidine | IV | GI prophylaxis for mechanically ventilated patients with ICUAW | 20 mg :: IV :: BID :: 20 mg IV q12h; transition to PO when tolerating enteral feeds | Severe renal impairment (dose adjust) | None significant | - | ROUTINE | - | ROUTINE |
| Stress ulcer prophylaxis: Pantoprazole | IV | GI prophylaxis alternative; use if high bleed risk (coagulopathy, prior GI bleed) | 40 mg :: IV :: daily :: 40 mg IV daily; transition to PO when tolerating enteral feeds | None significant | C. difficile risk with prolonged use | - | ROUTINE | - | ROUTINE |
3B. Symptomatic Treatments¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Gabapentin | PO | Neuropathic pain from CIP (burning, tingling, allodynia); common in recovery phase | 300 mg :: PO :: qHS :: Start 300 mg PO qHS; titrate by 300 mg/day q1-3 days; target 900-1800 mg/day divided TID; max 3600 mg/day; dose adjust for renal function | Severe renal impairment (dose adjust per CrCl); oversedation risk | Sedation, dizziness, peripheral edema; renal function for dose adjustment | - | ROUTINE | ROUTINE | ROUTINE |
| Pregabalin | PO | Neuropathic pain alternative to gabapentin; may be better tolerated | 75 mg :: PO :: BID :: Start 75 mg PO BID; increase to 150 mg BID after 3-7 days; max 300 mg BID (600 mg/day); dose adjust for renal function | Renal impairment (dose adjust); angioedema history | Sedation, weight gain, peripheral edema; renal function | - | ROUTINE | ROUTINE | ROUTINE |
| Duloxetine | PO | Neuropathic pain and concurrent depression; dual benefit in ICUAW recovery | 30 mg :: PO :: daily :: Start 30 mg PO daily x 1 week, then increase to 60 mg daily; max 120 mg/day | Severe hepatic impairment; concurrent MAOIs; uncontrolled narrow-angle glaucoma | LFTs; blood pressure; serotonin syndrome signs; mood | - | ROUTINE | ROUTINE | - |
| Acetaminophen | PO/IV | Musculoskeletal pain and general discomfort from immobility | 650 mg :: PO :: q6h :: 650-1000 mg PO/IV q6h; max 4 g/day (2 g/day if hepatic impairment) | Severe liver disease; hepatic impairment (reduce max dose) | LFTs if prolonged use | STAT | ROUTINE | ROUTINE | STAT |
| Melatonin | PO | ICU delirium prevention and sleep-wake cycle restoration; disrupted sleep worsens ICUAW | 3 mg :: PO :: qHS :: 3-5 mg PO qHS; administer at consistent time to promote circadian rhythm | None significant | Sleep quality; delirium assessment | - | ROUTINE | - | ROUTINE |
| Docusate sodium | PO | Constipation from immobility and opioid use | 100 mg :: PO :: BID :: 100 mg PO BID | GI obstruction | Bowel function daily | - | ROUTINE | ROUTINE | ROUTINE |
| Senna | PO | Constipation when docusate alone is insufficient | 8.6 mg :: PO :: qHS :: 8.6-17.2 mg PO qHS; may increase to BID | GI obstruction; acute abdomen | Bowel function | - | ROUTINE | ROUTINE | - |
| Polyethylene glycol (MiraLAX) | PO | Constipation refractory to docusate and senna | 17 g :: PO :: daily :: 17 g PO daily dissolved in 8 oz water | GI obstruction | Bowel function; electrolytes with prolonged use | - | ROUTINE | ROUTINE | - |
| Sertraline | PO | Depression and anxiety during prolonged ICU stay and recovery; common comorbidity in ICUAW | 25 mg :: PO :: daily :: Start 25-50 mg PO daily; titrate by 25-50 mg q1-2 weeks; max 200 mg/day | Concurrent MAOIs; QT prolongation risk | Mood assessment; suicidality monitoring (first 4 weeks); serotonin syndrome signs | - | ROUTINE | ROUTINE | - |
| Trazodone | PO | Insomnia during ICU recovery when melatonin insufficient | 25 mg :: PO :: qHS :: Start 25-50 mg PO qHS; max 100 mg qHS for insomnia | Severe hepatic impairment; concurrent MAOIs | Sedation; orthostatic hypotension; priapism (rare) | - | ROUTINE | ROUTINE | - |
| Cholecalciferol (Vitamin D3) | PO | Vitamin D deficiency is prevalent in ICU patients and contributes to muscle weakness | 2000 IU :: PO :: daily :: 2000 IU PO daily for maintenance; 50,000 IU PO weekly x 8 weeks if deficient (<20 ng/mL), then 2000 IU daily | Hypercalcemia; granulomatous disease | 25-OH vitamin D level at 8-12 weeks; calcium | - | ROUTINE | ROUTINE | ROUTINE |
3C. Second-line/Refractory¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Amitriptyline | PO | Neuropathic pain refractory to gabapentin/pregabalin; also helps insomnia | 10 mg :: PO :: qHS :: Start 10-25 mg PO qHS; titrate by 10-25 mg q1-2 weeks; max 150 mg/day | Arrhythmia; recent MI; urinary retention; angle-closure glaucoma; elderly (anticholinergic burden) | ECG at baseline and if dose >100 mg; anticholinergic side effects; QTc | - | ROUTINE | ROUTINE | - |
| Lidocaine patch 5% | TOP | Localized neuropathic pain; adjunctive to systemic agents | 1 patch :: TOP :: daily :: Apply up to 3 patches to painful area for 12h on/12h off | Allergy to amide anesthetics; broken skin at application site | Skin irritation at application site | - | ROUTINE | ROUTINE | - |
| Methylphenidate | PO | Severe fatigue and cognitive impairment during ICUAW recovery when non-pharmacologic measures insufficient | 5 mg :: PO :: BID :: Start 5 mg PO BID (morning and noon); max 20 mg BID; avoid afternoon dosing to prevent insomnia | Severe anxiety; cardiac arrhythmia; uncontrolled hypertension; concurrent MAOIs | Blood pressure; heart rate; appetite; sleep; mood; abuse potential | - | EXT | ROUTINE | - |
| Modafinil | PO | Persistent fatigue during ICUAW recovery; alternative to methylphenidate | 100 mg :: PO :: daily :: Start 100 mg PO daily in AM; max 200 mg daily | Severe hepatic impairment; cardiac arrhythmia | Blood pressure; hepatic function; mood; sleep | - | EXT | ROUTINE | - |
3D. Disease-Modifying or Chronic Therapies¶
No disease-specific pharmacologic therapy has been proven effective for CIM or CIP. Management is supportive and preventive. The following interventions target modifiable risk factors and rehabilitation.
| Treatment | Route | Indication | Dosing | Pre-Treatment Requirements | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|---|
| Early mobilization protocol | - | Prevention and treatment of ICUAW; reduces duration of mechanical ventilation and ICU length of stay | Structured protocol :: - :: daily :: Phase 1 (passive ROM) within 24-48h of ICU admission; Phase 2 (active-assisted exercises) when patient alert; Phase 3 (sitting, standing, ambulation) when hemodynamically stable; minimum 20-30 min sessions BID | Hemodynamic stability (MAP >65, no active vasopressor uptitration); adequate oxygenation (FiO2 <0.6, PEEP <10); no active arrhythmia; no active hemorrhage | Active hemorrhage; unstable fractures; severe hemodynamic instability requiring high-dose vasopressors; acute MI; unsecured airway | Heart rate, blood pressure, SpO2 during sessions; RASS sedation score; MRC sum score weekly | - | STAT | ROUTINE | STAT |
| Corticosteroid minimization | IV/PO | Minimize corticosteroid exposure as major risk factor for CIM; taper to lowest effective dose as rapidly as clinically feasible | Individualized taper :: IV/PO :: daily :: Reassess corticosteroid indication daily; taper to lowest effective dose; discontinue if not clearly indicated; avoid concurrent use with NMBAs when possible | Document clear indication for continued steroids; review alternatives | Do not abruptly discontinue if patient has been on >7 days (adrenal suppression risk) | Glucose (steroid-induced hyperglycemia); blood pressure; adrenal function if tapering after prolonged course | - | ROUTINE | - | STAT |
| Neuromuscular blocking agent (NMBA) minimization | IV | Minimize NMBA exposure as risk factor for ICUAW; use train-of-four monitoring to avoid deep paralysis | Individualized :: IV :: continuous :: If NMBA required (e.g., ARDS, refractory ICP), use lowest effective dose guided by train-of-four (TOF) monitoring; target 1-2/4 twitches; daily sedation/paralysis vacation if feasible; discontinue NMBA as soon as clinically possible | Document clear indication (severe ARDS, refractory ICP, open abdomen) | Concurrent high-dose corticosteroids (greatly increases CIM risk); avoid unless absolutely necessary | Train-of-four q4h; daily attempt to discontinue; document indication daily | - | - | - | STAT |
| Enteral nutrition (high-protein) | PO/EN | Protein supplementation to support muscle preservation and recovery; protein catabolism is accelerated in ICUAW | 1.2-2.0 g/kg/day protein :: EN :: daily :: Target protein 1.2-2.0 g/kg/day (adjusted body weight if obese); initiate enteral nutrition within 24-48h of ICU admission; caloric target 25-30 kcal/kg/day; avoid overfeeding | Functional GI tract; hemodynamic stability (MAP >60 on stable or decreasing vasopressors) | GI obstruction; uncontrolled shock (delay until resuscitated); bowel ischemia | Prealbumin weekly; nitrogen balance; feeding tolerance (residuals); glucose | - | STAT | ROUTINE | STAT |
| Tight glycemic control protocol | IV/SC | Target glucose 140-180 mg/dL to reduce ICUAW incidence; hyperglycemia independently increases CIM/CIP risk | Insulin per protocol :: IV/SC :: continuous :: IV insulin infusion in ICU targeting 140-180 mg/dL; transition to basal-bolus SC insulin when tolerating nutrition; avoid tight control <110 (increased mortality per NICE-SUGAR) | Active hypoglycemia | Adrenal insufficiency (may require stress-dose steroids before aggressive glucose control) | Glucose q1-2h on infusion; q4-6h on SC insulin; HbA1c at discharge | - | ROUTINE | ROUTINE | STAT |
| Sedation minimization protocol | IV | Daily sedation interruption and light sedation targets reduce ICUAW risk and facilitate early mobilization | RASS target -1 to 0 :: IV :: continuous :: Daily spontaneous awakening trial (SAT); target RASS -1 to 0; use analgesia-first approach (pain, delirium, then sedation); prefer dexmedetomidine or propofol over benzodiazepines (benzodiazepines increase delirium and ICUAW risk) | Pain adequately controlled; no active seizures; no procedures requiring deep sedation | Active seizures; procedures requiring deep sedation; severe agitation endangering patient safety (titrate to lowest necessary level) | RASS q4h; CAM-ICU for delirium BID; pain assessment | - | - | - | STAT |
4. OTHER RECOMMENDATIONS¶
4A. Referrals & Consults¶
| Recommendation | ED | HOSP | OPD | ICU |
|---|---|---|---|---|
| Neurology consultation for diagnosis confirmation and electrodiagnostic planning (NCS/EMG) to differentiate CIM, CIP, and alternative diagnoses | - | STAT | ROUTINE | STAT |
| Physical therapy for early mobilization protocol initiation, passive/active ROM exercises, progressive strengthening, and functional mobility training | - | STAT | ROUTINE | STAT |
| Occupational therapy for upper extremity strengthening, ADL retraining, adaptive equipment assessment, and fine motor recovery | - | URGENT | ROUTINE | URGENT |
| Speech-language pathology for swallowing evaluation given risk of pharyngeal weakness and aspiration in ICUAW patients | - | URGENT | ROUTINE | URGENT |
| Respiratory therapy for ventilator weaning protocols, tracheostomy care, pulmonary rehabilitation, and secretion management | - | STAT | - | STAT |
| Rehabilitation medicine (physiatry) for comprehensive rehabilitation planning and disposition (inpatient rehab vs skilled nursing facility) | - | ROUTINE | ROUTINE | ROUTINE |
| Nutrition/Dietitian for enteral nutrition optimization, protein target (1.2-2.0 g/kg/day), caloric assessment, and micronutrient supplementation | - | URGENT | ROUTINE | URGENT |
| Pulmonology for ventilator management optimization, weaning strategies, and tracheostomy decision if prolonged ventilation anticipated | - | ROUTINE | - | URGENT |
| Pain management for refractory neuropathic pain not responding to first-line gabapentinoids | - | ROUTINE | ROUTINE | ROUTINE |
| Social work for discharge planning, family support, insurance authorization for rehabilitation, and community resources | - | ROUTINE | ROUTINE | - |
| Psychology/Psychiatry for ICU-acquired PTSD, depression, anxiety, and cognitive dysfunction screening and treatment | - | ROUTINE | ROUTINE | ROUTINE |
| Palliative care for goals-of-care discussion if severe ICUAW with poor prognosis, prolonged ventilator dependence, or significant comorbidities | - | ROUTINE | - | ROUTINE |
4B. Patient Instructions¶
| Recommendation | ED | HOSP | OPD |
|---|---|---|---|
| Recovery from ICU-acquired weakness typically takes weeks to months; CIM generally recovers faster than CIP (inform patient and family to set expectations) | - | ROUTINE | ROUTINE |
| Participate actively in all physical and occupational therapy sessions as tolerated to maximize recovery potential | - | ROUTINE | ROUTINE |
| Report new or worsening weakness, numbness, tingling, or breathing difficulty to medical team immediately (may indicate complication or alternative diagnosis) | - | ROUTINE | ROUTINE |
| Continue home exercise program as prescribed by physical therapy between formal sessions to maintain gains | - | ROUTINE | ROUTINE |
| Fall precautions: use assistive devices (walker, cane) as recommended; remove tripping hazards at home; do not attempt stairs without supervision until cleared | - | ROUTINE | ROUTINE |
| Do not drive until strength and coordination have recovered sufficiently and cleared by neurologist or physiatrist | - | ROUTINE | ROUTINE |
| Follow-up with neurology in 4-8 weeks after discharge for strength assessment and possible repeat NCS/EMG to track recovery | - | ROUTINE | ROUTINE |
| Adequate nutrition with high-protein diet (1.2-2.0 g/kg/day protein) supports muscle recovery | - | ROUTINE | ROUTINE |
| Mental health is important during recovery; report symptoms of depression, anxiety, or PTSD to healthcare provider (common after prolonged ICU stay) | - | ROUTINE | ROUTINE |
4C. Lifestyle & Prevention¶
| Recommendation | ED | HOSP | OPD |
|---|---|---|---|
| Early mobilization within 24-48 hours of ICU admission when hemodynamically stable to prevent and mitigate ICUAW | - | STAT | - |
| High-protein nutrition (1.2-2.0 g/kg/day) to support muscle preservation and recovery during critical illness | - | ROUTINE | ROUTINE |
| Smoking cessation to optimize pulmonary function and tissue oxygenation for nerve and muscle recovery | - | ROUTINE | ROUTINE |
| Glycemic control (target glucose 140-180 mg/dL in ICU; HbA1c <7% outpatient) to reduce ongoing neuromyopathy risk | - | ROUTINE | ROUTINE |
| Avoid unnecessary corticosteroids and neuromuscular blocking agents to reduce ICUAW risk in current and future ICU admissions | - | ROUTINE | ROUTINE |
| Graduated exercise program starting with low-intensity activities and progressing as tolerated to rebuild strength and endurance | - | ROUTINE | ROUTINE |
| Frequent repositioning every 2 hours during immobility to prevent pressure ulcers and contractures | - | STAT | - |
| Adequate sleep hygiene with consistent sleep-wake cycles to promote neurological recovery and reduce delirium | - | ROUTINE | ROUTINE |
| Vitamin D supplementation if deficient to support muscle function and bone health during recovery | - | ROUTINE | ROUTINE |
| Alcohol avoidance as alcohol worsens neuropathy and impairs muscle recovery | - | ROUTINE | ROUTINE |
═══════════════════════════════════════════════════════════════ SECTION B: REFERENCE (Expand as Needed) ═══════════════════════════════════════════════════════════════
5. DIFFERENTIAL DIAGNOSIS¶
| Alternative Diagnosis | Key Distinguishing Features | Tests to Differentiate |
|---|---|---|
| Guillain-Barré syndrome (GBS) | Ascending paralysis, areflexia, can develop during ICU stay; antecedent infection; albuminocytologic dissociation on LP; may be monophasic; usually not associated with prolonged steroid/NMBA exposure | CSF analysis (elevated protein, normal WBC); NCS/EMG (demyelinating pattern in AIDP); anti-ganglioside antibodies; clinical timeline |
| Myasthenia gravis exacerbation | Fatigable weakness, ptosis, diplopia, bulbar symptoms; fluctuating course; intact reflexes (usually); responds to cholinesterase inhibitors | AChR and MuSK antibodies; repetitive nerve stimulation (decremental); ice pack test; edrophonium test |
| Prolonged neuromuscular blockade effect | History of NMBA use; resolves within hours to days of NMBA discontinuation; train-of-four monitoring shows persistent block; no sensory involvement | Train-of-four monitoring (incomplete recovery of twitches); clinical resolution after NMBA clearance (typically <48h); NCS/EMG normal after drug clearance |
| Spinal cord injury/compression | Sensory level; upper motor neuron signs below level (hyperreflexia, Babinski); bladder dysfunction; back pain | MRI spine (cord compression, hemorrhage, infarction); clinical exam with sensory level |
| Central pontine myelinolysis (osmotic demyelination) | History of rapid sodium correction; quadriparesis with pseudobulbar features; locked-in syndrome; MRI brain lesion | MRI brain (pontine or extrapontine demyelination on T2/FLAIR); serum sodium correction history |
| Rhabdomyolysis | Very elevated CK (typically >10,000 IU/L); dark urine; acute kidney injury; history of crush injury, statins, or seizures | CK markedly elevated; urine myoglobin; renal function; clinical context |
| Acute necrotizing myopathy | Very elevated CK; myopathic EMG; may occur with statin use in ICU; requires muscle biopsy for definitive diagnosis | CK markedly elevated; NCS/EMG (myopathic); muscle biopsy (necrosis without inflammation); anti-HMGCR or anti-SRP antibodies |
| Lambert-Eaton myasthenic syndrome (LEMS) | Proximal weakness improving with repeated effort; autonomic dysfunction; associated with small cell lung cancer; incremental response on RNS | Anti-VGCC antibodies; repetitive nerve stimulation (incremental at high-rate); CT chest for malignancy |
| Disuse atrophy | Weakness proportional to immobility duration; normal NCS/EMG; no sensory changes; normal CK | NCS/EMG normal; clinical context; muscle ultrasound (atrophy without echogenicity changes) |
| Hypothyroid myopathy | Proximal weakness; elevated CK; delayed relaxation of reflexes; other hypothyroid features (edema, cold intolerance) | TSH elevated; free T4 low; CK elevated; NCS/EMG (myopathic) |
| Acute inflammatory myopathy (polymyositis/dermatomyositis) | Proximal weakness; elevated CK (often >5000); skin changes in dermatomyositis; may respond to immunosuppression | CK markedly elevated; myositis-specific antibodies; MRI muscle (edema); muscle biopsy (inflammatory infiltrate) |
| Steroid myopathy (chronic) | Proximal weakness; normal CK; history of chronic corticosteroid use; no sensory involvement; gradual onset | Normal CK; NCS/EMG (myopathic MUPs); clinical improvement with steroid taper; muscle biopsy (type 2 fiber atrophy without necrosis) |
6. MONITORING PARAMETERS¶
| Parameter | Frequency | Target/Threshold | Action if Abnormal | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|
| MRC sum score (6 bilateral muscle groups: shoulder abduction, elbow flexion, wrist extension, hip flexion, knee extension, ankle dorsiflexion) | Daily in ICU when patient cooperative; weekly on floor; each outpatient visit | MRC sum score >=48/60 (ICUAW defined as <48/60); individual muscle >=4/5 | MRC <48/60: confirm ICUAW diagnosis; intensify rehabilitation; if declining, reassess for alternative or superimposed diagnosis | - | ROUTINE | ROUTINE | STAT |
| Blood glucose | q1-2h on insulin drip; q4-6h on SC insulin; fasting + pre-meals on floor | 140-180 mg/dL in ICU; <180 mg/dL on floor | Adjust insulin regimen; avoid hypoglycemia <70 mg/dL; persistent hyperglycemia worsens ICUAW | STAT | STAT | ROUTINE | STAT |
| Respiratory function (FVC if cooperative; ventilator mechanics if intubated) | q4-6h if on ventilator; daily if on floor; each outpatient visit | FVC >15 mL/kg supports weaning; improving trend | Declining FVC: assess for pneumonia, fluid overload, worsening weakness; adjust ventilator support | - | ROUTINE | ROUTINE | STAT |
| Negative inspiratory force (NIF/MIP) | q4-6h if ventilator-dependent; daily on floor | NIF more negative than -20 cmH2O (adequate for weaning) | NIF weaker than -20 cmH2O: not ready for extubation; continue respiratory therapy | - | ROUTINE | ROUTINE | STAT |
| Diaphragm ultrasound (thickness and excursion) | Weekly in ICU; monthly outpatient if diaphragm weakness present | Thickness >2mm; thickening fraction >30%; excursion >10mm | Declining values: diaphragm atrophy worsening; adjust ventilator settings to promote diaphragm activity (avoid excessive support) | - | ROUTINE | ROUTINE | ROUTINE |
| CK (creatine kinase) | q48-72h in acute phase; weekly during recovery; PRN outpatient | Trending toward normal | Persistently or newly elevated: reassess for ongoing muscle injury; rhabdomyolysis; inflammatory myopathy | - | ROUTINE | ROUTINE | ROUTINE |
| Electrolytes (K, Mg, Phos, Ca) | Daily in ICU; q48-72h on floor; each outpatient visit | Normal ranges | Replete aggressively; hypokalemia, hypomagnesemia, hypophosphatemia all worsen weakness | STAT | ROUTINE | ROUTINE | STAT |
| Prealbumin/Albumin | Weekly in ICU and on floor; monthly outpatient | Prealbumin >15 mg/dL; albumin >3.0 g/dL | Low values: optimize nutrition; increase protein intake; nutrition consult | - | ROUTINE | ROUTINE | ROUTINE |
| Sedation level (RASS) | q4h in ICU | RASS -1 to 0 (light sedation) | Over-sedation: reduce sedatives; switch from benzodiazepines to dexmedetomidine or propofol | - | - | - | STAT |
| Delirium screen (CAM-ICU) | q8-12h in ICU; daily on floor | Negative (no delirium) | Positive: delirium workup; reduce deliriogenic medications (benzodiazepines, anticholinergics); non-pharmacologic interventions | - | ROUTINE | - | STAT |
| Skin integrity | Every shift in ICU; daily on floor | Intact skin; no pressure injuries | Pressure ulcer: reposition more frequently; wound care consult; pressure-relieving mattress | - | ROUTINE | - | STAT |
| Functional status (Barthel Index or FIM score) | Weekly in hospital; each outpatient visit | Improving trend; score guides disposition planning | Not improving: reassess rehabilitation plan; consider transfer to higher-level rehabilitation; assess for barriers to recovery | - | ROUTINE | ROUTINE | ROUTINE |
| NCS/EMG follow-up | At 2-4 weeks after initial; repeat at 3-6 months if recovering; annually if persistent deficits | Improvement in CMAP amplitudes; reinnervation on EMG; resolution of myopathic changes | No improvement at 3-6 months: consider muscle biopsy; reassess diagnosis; discuss prognosis with patient/family | - | ROUTINE | ROUTINE | ROUTINE |
| Depression/Anxiety screening (PHQ-9, GAD-7) | Weekly on floor; each outpatient visit | PHQ-9 <5 (minimal); GAD-7 <5 (minimal) | PHQ-9 >=10 or GAD-7 >=10: initiate treatment; psychiatry referral; assess for PTSD | - | ROUTINE | ROUTINE | - |
7. DISPOSITION CRITERIA¶
| Disposition | Criteria |
|---|---|
| Discharge home | MRC sum score >=48/60; ambulatory with or without assistive device; safe swallowing; adequate pain control on oral medications; stable respiratory function off supplemental O2; reliable outpatient follow-up; home exercise program established; family/caregiver support |
| Admit to floor | New-onset ICUAW identified in ICU patient transitioning to floor; MRC sum score 36-48/60; hemodynamically stable; off vasopressors; not ventilator-dependent; requires ongoing PT/OT; needs continued monitoring |
| Admit to ICU | Ventilator-dependent with ICUAW; acute respiratory failure from neuromuscular weakness; hemodynamic instability; need for continuous monitoring; initial evaluation of weakness in critically ill patient |
| Transfer to higher level of care | Need for specialized electrodiagnostic testing (DMS) not available locally; complex ventilator weaning requiring neuromuscular expertise; need for muscle biopsy for atypical presentation |
| Inpatient rehabilitation | Significant motor deficits (MRC sum score 36-48/60); able to tolerate 3 hours/day of therapy; medically stable; off mechanical ventilation (or stable tracheostomy with portable ventilator); good prognosis for functional improvement |
| Long-term acute care (LTAC) | Ventilator-dependent >21 days; unable to tolerate intensive rehabilitation; requires ongoing skilled nursing and ventilator weaning; medically complex |
| Skilled nursing facility (SNF) | Unable to tolerate 3 hours/day of therapy; requires ongoing nursing care; not ready for home but not requiring acute hospital level care |
8. EVIDENCE & REFERENCES¶
| Recommendation | Evidence Level | Source |
|---|---|---|
| ICUAW defined as MRC sum score <48/60 in cooperative ICU patients | Class I, Level B | Stevens et al. Crit Care Med 2009 |
| Sepsis and multi-organ failure are primary risk factors for ICUAW | Class I, Level A | De Jonghe et al. JAMA 2002 |
| NCS/EMG differentiates CIM (myopathic, normal SNAPs) from CIP (axonal sensorimotor) | Class I, Level B | Latronico & Bolton. Lancet Neurol 2011 |
| Direct muscle stimulation (DMS) differentiates CIM from CIP in uncooperative patients | Class IIa, Level B | Rich et al. Muscle Nerve 1996 |
| Hyperglycemia is independent risk factor; glycemic control reduces ICUAW incidence | Class I, Level A | Van den Berghe et al. NEJM 2001; Hermans et al. Lancet 2007 |
| NICE-SUGAR target glucose 140-180 mg/dL (tight control increases mortality) | Class I, Level A | NICE-SUGAR Investigators. NEJM 2009 |
| Corticosteroids combined with NMBAs greatly increase CIM risk | Class I, Level B | De Jonghe et al. Crit Care Med 2009; Hermans et al. Intensive Care Med 2014 |
| Early mobilization reduces ICUAW incidence and improves outcomes | Class I, Level A | Schweickert et al. Lancet 2009 |
| Early mobilization is safe in mechanically ventilated patients | Class I, Level B | Morris et al. Crit Care Med 2008 |
| Minimizing sedation reduces delirium and ICUAW risk (ABCDEF bundle) | Class I, Level A | Barnes-Daly et al. Crit Care Med 2017 |
| CIM has better prognosis than CIP; most CIM patients recover within 3-6 months | Class II, Level B | Koch et al. Neurology 2012; Guarneri et al. J Neurol Neurosurg Psychiatry 2008 |
| Muscle ultrasound detects early muscle wasting in ICU patients | Class IIa, Level B | Puthucheary et al. JAMA 2013 |
| Diaphragm ultrasound predicts weaning success | Class IIa, Level B | DiNino et al. J Crit Care 2014 |
| Protein intake 1.2-2.0 g/kg/day recommended for critically ill patients | Class IIa, Level B | McClave et al. JPEN 2016 (ASPEN/SCCM Guidelines) |
| No specific pharmacologic treatment proven effective for CIM or CIP | Class I, Level C | Hermans & Van den Berghe. NEJM 2015 |
| Electrical muscle stimulation may attenuate muscle wasting (emerging evidence) | Class IIb, Level C | Routsi et al. Crit Care Med 2010 |
| ICU-acquired weakness is associated with increased mortality and prolonged mechanical ventilation | Class I, Level A | Fan et al. CMAJ 2014 |
| ABCDEF bundle implementation reduces ICUAW and delirium | Class I, Level B | Pun et al. Lancet Respir Med 2019 |
| Vitamin D deficiency is associated with ICU-acquired weakness | Class IIb, Level C | Amrein et al. JAMA 2014 |
CHANGE LOG¶
v1.1 (January 30, 2026) - Standardized structured dosing format across all treatment tables (Sections 3A-3D) - Fixed Gabapentin, Pregabalin, Duloxetine, Sertraline, Trazodone, Amitriptyline, Methylphenidate, Modafinil dosing to use single starting dose before :: separators - Fixed Acetaminophen, Melatonin, Docusate, Senna, Polyethylene glycol, Lidocaine patch, Cholecalciferol dosing format - Added missing frequency fields in Section 3D protocol entries (corticosteroid minimization, NMBA minimization, enteral nutrition, glycemic control, sedation minimization) - Replaced arrow character in sedation protocol text to avoid encoding issues - Updated version to 1.1; added REVISED date - Validated all 6 quality domains (54/60, 90%)
v1.0 (January 30, 2026) - Initial template creation - Comprehensive 8-section format covering CIM, CIP, and combined CINM - Standardized treatment tables with structured dosing format - Evidence-based recommendations with PubMed citations - Emphasis on prevention (glycemic control, steroid/NMBA minimization, early mobilization) - Complete setting coverage (ED, HOSP, OPD, ICU)
APPENDIX A: MRC SUM SCORE ASSESSMENT¶
Medical Research Council (MRC) Sum Score for ICU-Acquired Weakness
Assess 6 bilateral muscle groups (12 total assessments) on a 0-5 scale. Maximum score = 60.
| Muscle Group | Movement Tested | Right (0-5) | Left (0-5) |
|---|---|---|---|
| Shoulder abduction | Deltoid | _ | _ |
| Elbow flexion | Biceps | _ | _ |
| Wrist extension | Wrist extensors | _ | _ |
| Hip flexion | Iliopsoas | _ | _ |
| Knee extension | Quadriceps | _ | _ |
| Ankle dorsiflexion | Tibialis anterior | _ | _ |
MRC Grading Scale:
| Grade | Description |
|---|---|
| 0 | No visible contraction |
| 1 | Visible contraction without limb movement |
| 2 | Movement with gravity eliminated |
| 3 | Movement against gravity |
| 4 | Movement against gravity with some resistance |
| 5 | Normal strength |
Interpretation:
| Total Score | Interpretation |
|---|---|
| 60 | Normal strength |
| 48-59 | Mild weakness (not ICUAW) |
| <48 | ICU-acquired weakness (ICUAW) |
| <36 | Severe ICUAW |
Requirements: Patient must be awake and cooperative (RASS 0 to +1); GCS verbal component >=4; assess at least 3 consecutive sessions to confirm reliability.
APPENDIX B: ELECTRODIAGNOSTIC DIFFERENTIATION OF CIM vs CIP¶
| Feature | CIM (Critical Illness Myopathy) | CIP (Critical Illness Polyneuropathy) | Combined CINM |
|---|---|---|---|
| Motor NCS (CMAP) | Reduced amplitudes; may have prolonged duration | Reduced amplitudes | Reduced amplitudes |
| Sensory NCS (SNAP) | NORMAL (key differentiator) | Reduced amplitudes (axonal) | Reduced amplitudes |
| Conduction velocities | Normal | Normal or mildly reduced | Normal or mildly reduced |
| EMG (volitional) | Myopathic: small, polyphasic, early recruitment | Neuropathic: large, polyphasic, reduced recruitment, fibrillations | Mixed myopathic and neuropathic |
| Direct muscle stimulation (DMS) | Reduced nerve:muscle ratio (<0.5); reduced direct CMAP | Preserved nerve:muscle ratio; reduced CMAPs on both | Variable |
| CK level | Often elevated (1000-5000 IU/L) | Usually normal | Variably elevated |
| Sensory exam | Normal | Reduced distally (stocking-glove) | Reduced distally |
| Reflexes | Reduced or absent | Reduced or absent | Reduced or absent |
| Prognosis | Better; most recover in 3-6 months | Worse; recovery may take 6-12+ months; some have permanent deficits | Intermediate |
| Risk factors | Corticosteroids + NMBAs; high-dose steroids | Sepsis; multi-organ failure | Overlap of both risk profiles |
APPENDIX C: ICUAW PREVENTION AND EARLY MOBILIZATION PROTOCOL¶
Phase 1: Passive (Patient sedated or non-cooperative; RASS -3 to -1) - Passive range of motion all extremities BID (minimum) - Positioning changes q2h - Neuromuscular electrical stimulation (if available) - Nutritional optimization initiated
Phase 2: Active-Assisted (Patient awakening; RASS -1 to 0) - Active-assisted range of motion - Bed exercises (leg lifts, arm raises) - Sitting at edge of bed - Progressive resistance exercises as tolerated
Phase 3: Active Mobilization (Patient alert; RASS 0 to +1) - Active standing with assistance - Transfer to chair (minimum 20 min BID) - Ambulation with assistive device - Progressive exercise program (resistance bands, weights)
Phase 4: Independent Mobilization (Medically stable; off vasopressors) - Independent ambulation with supervision - Stair training - Endurance exercises - Discharge exercise program education
Safety Criteria for Mobilization: - MAP >65 mmHg (not on increasing vasopressor doses) - HR 60-130 bpm - SpO2 >90% on current O2 support - FiO2 <0.6 and PEEP <10 cmH2O (if ventilated) - No active arrhythmia - No active hemorrhage - No unstable fractures or recent surgery precluding movement - Adequate staffing and equipment available
Stop Criteria During Session: - SpO2 <88% for >1 minute - Systolic BP <90 or >200 mmHg - HR <50 or >150 bpm - New arrhythmia - Patient distress or agitation - Fall or loss of support device (IV, airway, catheter)