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摘要: ICU获得性衰弱(intensive care unit acquired weakness，ICU-AW)作为重症监护室脓毒症患者的常见并发症，多累及骨骼肌、呼吸肌及平滑肌等，会导致脱机困难、住院时间延长、医疗费用剧增，并严重影响患者远期生活质量。但脓毒症ICU-AW的发病机制尚不明确、诊断评估标准缺乏统一、治疗时机和方案选择仍无具体标准。鉴于该病发病机制和诊疗选择存在争议，本文结合国内外文献资料，对脓毒症患者ICU-AW的发病机制及诊疗措施相关研究进展进行综述，以期加深临床多学科对该病的认知并针对性提高疾病的早期认识、诊断及诊疗协作能力。Abstract: Intensive care unit acquired weakness(ICU-AW), as a common complication of patients with sepsis in intensive care unit, mostly involves skeletal muscle, respiratory muscle and smooth muscle, which will lead to difficulty in weaning from mechanical ventilation, prolonged hospital stay, sharp increase in medical costs, and seriously affect the long-term quality of life of patients. However, the pathogenesis of sepsis ICU-AW is still unclear, the diagnostic and evaluation criteria are lack of unity, and there is still no specific standard for the choice of treatment timing and regimen. In view of the controversy about the pathogenesis, diagnosis and treatment of this disease, this article reviews the research progress on the pathogenesis, diagnosis and treatment of ICU-AW in patients with sepsis based on domestic and foreign literature, in order to deepen the clinical multidisciplinary understanding of this disease and improve the early recognition, diagnosis and treatment collaboration ability.
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Key words:
- sepsis /
- intensive care unit acquired weakness /
- muscle weakness /
- pathogenesis /
- diagnostic evaluation
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表 1 各诊断评估技术对脓毒症ICU-AW的实施方式及优缺点
技术 方式 优点 缺点 患者无法配合 超声技术[45-49] 评估目标肌肉质量、厚度和肌肉强度；观察运动过程中肌肉的收缩情况和力量变化；筛查肌肉坏死和筋膜炎 ①非侵入性床旁检测、安全便捷且方便动态测量，测量设备ICU内常见；②可与MRI和CT结果综合评估；③可早期筛查和预后判断 ①对肌无力的判断容易受评估者主观影响；②易受肥胖和水肿的影响；③不能直接测量评估肌肉力量变化；④对深层肌群的评估准确度不佳 CT技术与MRI技术[46-47, 50-51] 评估脂肪组织有无浸润肌肉组织 ①非侵入性检测；②精确定位、可靠性高；③不受肥胖和水肿的影响；④可评估深层肌群 ①便捷性差，需转运患者；②对检测设备硬件及软件要求度高；③CT存在辐射暴露因素 身体成分测定技术[47, 52-53] 双能X射线吸收测量法(脂肪、骨骼和肌肉)；中子活化分析法(中子和原子)；生物电阻抗测量法(躯体水分) 非侵入性检测 ①易受肥胖和水肿的影响(双能X射线吸收测量、生物电阻抗测量)；②对检测设备要求度高(双能X射线吸收测量、中子活化分析)；③辐射暴露(双能X射线吸收测量法、中子活化分析法) 疾病预测模型[49, 54-55] 利用不同数据采用不同模型预测疾病风险因素 ①非侵入性检测；②适用于不同目标人群；③不同测评方式间的互补 ①内容较为烦琐；②部分未进行外部验证、结果可能存在偏倚；③需大样本、大数据进一步验证模型稳定性 直接肌肉刺激与神经、肌肉活检技术[46, 56-57] 肉眼直接观察目标的肌肉兴奋性；镜下观察神经、肌肉组织有无萎缩、坏死、炎症、脂肪浸润、纤维化等 ①无须患者配合；②可用于鉴别诊断危重症多发肌病与危重症神经肌肉病变；③有利于发病机制的研究 ①活检技术为侵入性，有并发症风险；②对疾病本身预后无明显价值 患者可部分配合 神经传导检查与针状肌电图[45-46, 58] ≥两个神经SNAP振幅小于正常值80%；(无传导阻滞)≥两个神经CMAP振幅小于正常正常值80% ①可用于鉴别诊断危重症多发肌病；②适用于无法直接手动测试肌力患者 ①侵入性检查(肌电图)；②需要患者部分合作(肌电图)；③凝血功能障碍患者不适用 患者清醒且配合，理解测评方式 MRC六分级[59-60](60分)：0级，未见肌肉收缩；1级，可见肌肉收缩，未见肢体运动；2级，可见肢体运动，无法抵抗重力；3级，仅可抵抗重力；4级，可抗阻力运动；5级，正常力量 需双侧对称测量肩外展、肘屈曲、腕伸曲、髋屈曲、膝伸展、足背曲显著虚弱，>48分严重无力，＜36分 ①非侵入性床旁检测且安全便捷；②在遵循严格的标准化测试流程和位置指南前提下可靠性较高；③便于评估患者整体肌肉功能状态 ①受患者体位和肢体功能状态影响(如：疼痛、敷料、固定装置的限制)；②对肌肉功能细微变化的区分敏感性较低，对临界值的判断易受评估者主观影响 MRC四分级[60-61](36分)：0级，完全瘫痪；1级，>50%力量丧失；2级，＜50%力量丧失；3级，正常肌力 测量方式部位同上，肌无力＜24分 同MRC六分级，但相比6级测量更为便捷 同MRC六分级 手持式肌力测量仪[60, 62] 双侧对称测量肌无力：男＜11 kg，女＜7 kg ①非侵入性床旁检测且安全便捷；②金标准，客观性评价；③高灵敏度、特异度 ①若评估整体肌肉力量需借助其他装置；②应鉴别是否因其他原因引起的肌力下降；③肢体功能状态影响 PFIT-s评分[63-65](每项0~3分) ICU功能状态评分(每项0~7分) 肩屈曲强度、膝伸展力量、每分钟踏频、坐立协助滚动躯体、翻身到坐起、坐立于床边、坐姿到站立、正常走动 ①非侵入性床旁检测且安全便捷；②评估患者的功能能力经过验证 ①存在高限、低限效应；②对临界值的判断容易受评估者主观影响 六分钟步行实验[66-67] 步行6 min ①非侵入性床旁检测且安全便捷；②对部分疾病预后具有一定预测能力 仅适用于可行走患者 注：CMAP，复合肌肉运动动作电位反应；SNAP，感觉神经动作电位；PFIT-s，重症监护身体功能测试评分。 
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