Intensive Care Unit-Acquired Weakness after Liver Transplantation: Analysis of Seven Cases and a Literature Review

Abstract

Intensive Care Unit (ICU)-Acquired Weakness (ICU-AW) is a generalized muscle weakness that is clinically detected in critical patients and has no plausible etiology other than critical illness. ICU-AW is uncommon in patients undergoing orthotopic liver transplantation (OLT). Our report sheds light on the highest number of ICU-AW cases observed in a single center on OLT patients with early allograft dysfunction. Out of 282 patients who underwent OLT from January 2015 to June 2023, 7 (2.5%) developed generalized muscle weakness in the ICU and underwent neurophysiological investigations. The neurologic examination showed preserved extraocular, flaccid quadriplegia with the absence of deep tendon reflexes in all patients. Neurophysiological studies, including electromyography and nerve conduction studies, showed abnormalities with fibrillation potentials and the rapid recruitment of small polyphasic motor units in the examined muscles, as well as a reduced amplitude of the compound muscle action potential and sensory nerve action potential, with an absence of demyelinating features. Pre-transplant clinical status was critical in all patients. During ICU stay, early allograft dysfunction, acute kidney injury, prolonged mechanical ventilation, sepsis, hyperglycemia, and high blood transfusions were observed in all patients. Two patients were retransplanted. Five patients were alive at 90 days; two patients died. In non-cooperative OLT patients, neurophysiological investigations are essential for the diagnosis of ICU-AW. In this setting, the high number of red blood cell transfusions is a potential risk factor for ICU-AW.

Keywords: critical illness myopathy; critical illness polyneuropathy; early allograft dysfunction; liver transplant; neurophysiological studies; red blood cell transfusions.

Figure 1

(A): Needle EMG, spontaneous activity with sporadic fibrillation potentials. (Amplitude: 0.1 mV/Division; duration 10 ms/Division). (B): Needle EMG, early recruitment with low amplitude, full interference pattern at a less-than-maximal effort of contraction. (Amplitude: 1 mV/Division; duration 50 ms/Division).

Figure 1

(A): Needle EMG, spontaneous activity with sporadic fibrillation potentials. (Amplitude: 0.1 mV/Division; duration 10 ms/Division). (B): Needle EMG, early recruitment with low amplitude, full interference pattern at a less-than-maximal effort of contraction. (Amplitude: 1 mV/Division; duration 50 ms/Division).