Elsevier

Pediatric Neurology

Volume 21, Issue 4, October 1999, Pages 749-753
Pediatric Neurology

Case Reports
Critical illness neuropathy in pediatric intensive care patients

https://doi.org/10.1016/S0887-8994(99)00076-4Get rights and content

Abstract

Critical illness neuropathy is an axonal polyneuropathy recognized more frequently in adult intensive care patients with sepsis and multiple organ dysfunction. In children the diagnosis is rarely made. Within 1 year the authors observed two children with critical illness neuropathy. Both patients, a male 6 years, 6 months of age with a brain contusion and a male 2 years, 6 months of age who underwent craniectomy for Crouzon’s disease, required prolonged mechanical ventilation and developed sepsis with multiple organ dysfunction. Three to 4 weeks after successful treatment of the sepsis, a flaccid tetraparesis was noticed in both patients. Laboratory investigations of blood and cerebrospinal fluid and spinal magnetic resonance imaging revealed normal results. Electrophysiologic examinations were indicative of an axonal polyneuropathy. Spontaneous improvement occurred within several months. It is likely that critical illness neuropathy occurs more often in critically ill children than previously thought. Careful neurologic examination and early electrophysiologic investigations are necessary to establish the diagnosis. Important differential diagnoses of acquired lower motor neuron weakness in pediatric intensive care medicine are discussed.

Introduction

Critical illness neuropathy (CIN) is a primary axonal polyneuropathy recognized more frequently over the past several years in adult intensive care patients with sepsis and multiple organ dysfunction [1], [2], [3]. About 70% of these patients demonstrate electrophysiologic changes indicative of an axonal polyneuropathy, and about 30% develop clinical signs, such as flaccid tetraparesis or paraparesis, and difficulties in weaning from mechanical ventilation [2].

Although sepsis requiring intensive care treatment is a frequent complication of various diseases in childhood, the diagnosis of CIN in children has rarely been established. Within 10 months, two children (2 years, 6 months of age and 6 years, 6 months of age) with CIN were observed in our pediatric intensive care unit. Clinical and electrophysiologic data are presented and important differential diagnoses discussed to contribute to the understanding of CIN in childhood.

Section snippets

Patient 1

After a traffic accident that resulted in a skull fracture and left temporoparietal brain contusion, a previously healthy male 6 years, 6 months of age was treated under intracranial pressure monitoring by deep analgesia and sedation (fentanyl, midazolam) and mild hyperventilation because of diffuse brain edema. He received pancuronium for muscle relaxation for 4 days and was fed using a nasogastric tube with 60-80 kcal/kg daily. Vitamin B complex was provided intravenously. Computed tomography

Discussion

Several investigations during the past 20 years revealed that a significant number of adult patients with sepsis and multiple organ dysfunction develop CIN [1], [2], [3]. Although sepsis requiring intensive care treatment is also a frequent complication of various diseases in childhood, only a few case reports of children with CIN have been published [4], [5], [6], [7].

According to the studies of critically ill adult patients, CIN is characterized by a rapidly developing flaccid tetra- or

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