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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 9  |  Page : 1229-1235

ICU-acquired weakness: A multicentre survey of knowledge among ICU clinicians in South-Western Nigeria


1 Adjunct Professor (Physiotherapy), School of Health Sciences, Fiji National University, Suva, Fiji Islands, Fiji
2 Physiotherapist, College of Medicine, University of Ibadan, Ibadan, Nigeria
3 Professor of Neuro-Physiotherapy, College of Medicine, University of Ibadan, Ibadan, Nigeria

Date of Acceptance17-May-2019
Date of Web Publication6-Sep-2019

Correspondence Address:
Dr. A A Akinremi
School of Health Science, College of Medicine, Nursing and Health Sciences, Fiji National University, Suva
Fiji
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_338_18

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   Abstract 


Background: Knowledge of ICU clinicians about Intensive Care Unit Acquired Weakness (ICU-AW) is a vital step in implementing prevention strategies. Aim of Study: The purpose of this study was to investigate the level of knowledge of ICU clinicians in teaching hospitals in Southwest Nigeria about ICU-AW. Methods: ICU clinicians were surveyed using a self-administered questionnaire to obtain data on knowledge about ICUAW. Data were summarized as frequency and percentages, mean and standard deviation using SPSS version 20. Results: Total of 134 ICU clinicians (56 anesthetists, 35 physiotherapists, and 43 nurses) responded to the questionnaire, of which 100 were aware of ICUAW. Three of the 100 correctly identified ICU-AW as a neuromuscular disease. Totally, 40% correctly indicated Medical Research Council Scoring Scale as a diagnostic tool for ICU-AW. Severe sepsis and prolonged mechanical ventilation were the two highest identified risk factors for ICU-AW. However, only 35% of respondents were able to identify either use of aminoglycosides, and prolonged use of vasopressors as risk factors for ICUAW. Almost half (49%) reported having methods of managing ICUAW at their institution. Conclusion: Though awareness about Intensive care unit-acquired weakness (ICUAW) among clinicians in teaching hospitals in the Southwestern Nigeria is high, but knowledge about diagnosis and classification is low. This highlights the need for specialized training of ICU clinicians about ICUAW to enhance prevention and early detection.

Keywords: ICU-acquired weakness, intensive care unit, knowledge, southwestern Nigeria


How to cite this article:
Akinremi A A, Erinle O A, Hamzat T K. ICU-acquired weakness: A multicentre survey of knowledge among ICU clinicians in South-Western Nigeria. Niger J Clin Pract 2019;22:1229-35

How to cite this URL:
Akinremi A A, Erinle O A, Hamzat T K. ICU-acquired weakness: A multicentre survey of knowledge among ICU clinicians in South-Western Nigeria. Niger J Clin Pract [serial online] 2019 [cited 2019 Sep 16];22:1229-35. Available from: http://www.njcponline.com/text.asp?2019/22/9/1229/266163




   Introduction Top


There is growing evidence that critical illness and its associated treatments could lead to muscle and nerve injury, resulting neuromuscular dysfunction in the critically ill.[1],[2] Intensive Care Acquired Weakness (ICUAW) is a common complication of ICU admission and often classified into three types: critical illness myopathy (CIM), critical illness polyneuropathy (CIP), and critical illness poly-neuromyopathy.[2],[3],[4],[5] It is associated with prolonged ICU admission, prolonged mechanical ventilation, prolonged hospitalization and increased mortality.[6],[7],[8]

Increase in survival rate of critically ill patients has led to a relatively new focus on factors that affect post-ICU function and quality of life.[9],[10] Morbidity following ICU admission is often related to neuromuscular dysfunction and neuropsychological maladjustment.[11],[12] Optimizing early mobilization and physical activity among critically ill patients has been advocated.[10] As a first step towards implementing strategies aimed at preventing ICU-AW we investigated knowledge of ICU clinicians about Intensive Care Unit-Acquired Weakness in Southwest Nigeria.


   Materials and Methods Top


Participants

Participants in this study were physiotherapists, nurses and anesthetists of six teaching hospitals in Southwest Nigeria. Anesthetists who are not working primarily in the ICU or physicians rotating through anesthesia posting were excluded from the study. Also, physiotherapists who have not worked in/rotated through the ICU in the last 1 year were excluded from the study.

Venue of study

Participants of this were recruited from University College Hospital (UCH), Ibadan; Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile Ife; Lagos University Teaching Hospital (LUTH), Idi Araba; Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu; Lagos State University Teaching Hospital (LASUTH), Ikeja and Ladoke Akintola University of Technology Teaching Hospital (LTH), Osogbo.

Instruments

A bio-data form was administered to obtain socio-demographic information on age, sex, name of institution, occupation, highest academic qualification, years of clinical experience, and years of ICU experience. Questions were generated by searching for relevant literature on ICU-AW from medical and allied health-specific databases. Content areas of interest (domains) and specific questions within each domain were developed. A panel of experts, comprising 4 physiotherapists and 2 physicians assessed the comprehensiveness, clarity, face validity, as well as the methodological rigor of questions as framed. The final questionnaire was also approved by this panel, after it was pre-tested.

The questionnaire contains questions on 6 domains namely: definition (2), classifications (3), diagnosis (8), risk factors (13), and prevention (10) of Intensive Care Unit-Acquired Weakness. Participants were to indicate “True,” “False,” or “I do not know” for each question in each domain. Level of knowledge was classified as poor, if less than 50% of the participants answered each question correctly, fair knowledge if between 51 and 80% answered the question correctly and good if between 81 and 100% of the participants answered the question correctly.[13]

Study design

Cross-sectional survey was conducted to assess knowledge of clinicians about ICUAW.

Sampling and sample size

Purposive sampling technique was used to recruit participants in this study and all consenting individuals who met the inclusion criteria participated in the study.

Procedure for data collection

Ethical approval was sought and obtained from the University of Ibadan/University College Hospital (UI/UCH) Health Research Ethics Committee before the commencement of the study. An informed consent was obtained from participants. Participants were assured of confidentiality and anonymity. A bio-data form was administered to obtain socio-demographic information on age, sex, name of institution, occupation, highest academic qualification, years of clinical experience, and years of ICU experience. Data on participants' knowledge of the definition, classifications, diagnosis, facilitators, barriers, risk factors, and prevention of Intensive Care Unit-Acquired Weakness were obtained using the questionnaire.

Data analysis

Data obtained were coded and entered into spread sheet. Analysis was done using SPSS version 20. Descriptive statistics such as frequency counts, percentages, mean and standard deviation were used to summarize and present the result, while differences in proportion of correct responses were tested using Chi-square and Fisher's exact tests.


   Results Top


A total of 154 questionnaires were administered, but responses from 134 clinicians (65 males; 68 females) were received across the six teaching hospitals, giving a response rate of 87%. Of the 134 respondents, 34 indicated they were not aware of ICUAW [Table 1]. Responses from 100 clinicians who were aware of ICUAW were reported in this study. They consist of 44 anesthetists, 25 physiotherapists and 31 nurses, all between the ages of 26 and 55 years.
Table 1: Demographics and characteristics of respondents

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Fourteen (25%) of the anesthetists were consultants while 42 (75%) were resident doctors. Most (48.6%) of the physiotherapists in this study were from neurology specialty and 6 (17.1%) were from cardiopulmonary, or orthopedics specialty. Twenty-nine (67.4%) of the nurses were ICU-trained, 3 (7%) were from public health, 4 (9.3%) from midwifery. Socio-demographics and characteristics of participants are shown in [Table 1].

Good level of knowledge

[Table 2] shows domain in which participants demonstrated good knowledge about ICU-acquired weakness. Most (70%) of the respondents, comprising 34 anesthetists, 17 physiotherapists, and 19 nurses, correctly identified ICU-AW as a neuromuscular disease. Only 3 of these 70 respondents indicated that ICU-AW was neither a musculoskeletal nor pulmonary disease. A third of the respondents demonstrated knowledge on the manifestations of ICU-AW as critical illness myopathy (CIM), critical illness polyneuropathy (CIP), and critical illness polyneuro-myopathy (CIPNM). About 16% of respondents demonstrated excellent knowledge on diagnostic tools for ICU-AW by identifying the four listed diagnostic tools: Nerve Conduction Studies (NCS), Medical Research Council Scoring Scale (MRC), Manual Muscle Testing (MMT), and electromyography (EMG).
Table 2: Domains in which participants demonstrated good knowledge about ICU-acquired weakness

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Less than a tenth of study participants demonstrated excellent knowledge of risk factors for ICU-AW by correctly identifying all the 10 risk factors for ICU-AW that were listed. About half were able to identify at least 7 out of the 10 risk factors; thus, demonstrating good knowledge about the risk factors. A quarter of the respondents had poor knowledge of the risk factors; they could not identify at least one risk factor correctly. Participants demonstrated good knowledge about risk factors and prevention strategies for ICUAW only in two knowledge domains items: ICUAW is clinically detected weakness acquired in the ICU and that it is a neuromuscular disease. [Table 3] shows participants responses about measures of preventing ICU-AW. About a fifth of the participants had excellent knowledge about strategies to prevent ICU-AW, by correctly identifying all seven responses. Another 43% had very good knowledge by identifying six correct responses. About a tenth of the participants had poor knowledge of strategies to prevent ICU-AW; indicating less than 3 correct options. Methods for preventing ICU-AW include: careful electrolyte management, electrical muscle stimulation, ventilator-weaning protocols, daily interruption of sedation, optimal nutrition, intensive insulin therapy, and early mobilization.
Table 3: Domains in which participants demonstrated fair knowledge about ICU-acquired weakness

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Knowledge on classification and manifestation of ICU-AW

[Table 4] shows domain were participants demonstrated poor knowledge about ICU-acquired weakness. Most (70%) of the respondents, comprising 34 anesthetists, 17 physiotherapists, and 19 nurses, correctly identified ICU-AW as a neuromuscular disease. Only 3 of these 70 respondents indicated that ICU-AW was neither a musculoskeletal nor pulmonary disease. A third of the respondents demonstrated knowledge on the manifestations of ICU-AW as critical illness myopathy (CIM), critical illness polyneuropathy (CIP), and critical illness polyneuromyopathy (CIPNM).
Table 4: Domains in which participants demonstrated poor knowledge about ICU-acquired weakness

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Diagnostic tools for ICU-AW

About 16% of respondents demonstrated excellent knowledge on diagnostic tools for ICU-AW by identifying the four listed diagnostic tools: Nerve Conduction Studies (NCS), Medical Research Council Scoring Scale (MRC), Manual Muscle Testing (MMT), and electromyography (EMG).

Risk factors for ICU-AW

Less than a tenth of study participants demonstrated excellent knowledge of risk factors for ICU-AW by correctly identifying all the 10 risk factors for ICU-AW that were listed. About half were able to identify at least 7 out of the 10 risk factors; thus, demonstrating good knowledge about the risk factors. A quarter of the respondents had poor knowledge of the risk factors; they could not identify at least one risk factor correctly.

Prevention and management of ICU-AW

[Table 3] shows participants responses about measures of preventing ICU-AW. About a fifth of the participants had excellent knowledge about strategies to prevent ICU-AW, by correctly identifying all seven responses. Another 43% had very good knowledge by identifying six correct responses. About a tenth of the participants had poor knowledge of strategies to prevent ICU-AW; indicating less than 3 correct options. Methods for preventing ICU-AW include: careful electrolyte management, electrical muscle stimulation, ventilator-weaning protocols, daily interruption of sedation, optimal nutrition, intensive insulin therapy and early mobilization.

Knowledge on classification and manifestation of ICU-AW

Most (70%) of the respondents, comprising 34 anesthetists, 17 physiotherapists, and 19 nurses, correctly identified ICU-AW as a neuromuscular disease. Only 3 of these 70 respondents indicated that ICU-AW was neither a musculoskeletal nor pulmonary disease. A third of the respondents demonstrated knowledge on the manifestations of ICU-AW as critical illness myopathy (CIM), critical illness polyneuropathy (CIP), and critical illness polyneuromyopathy (CIPNM).

Diagnostic tools for ICU-AW

About 16% of respondents demonstrated excellent knowledge on diagnostic tools for ICU-AW by identifying the four listed diagnostic tools: Nerve Conduction Studies (NCS), Medical Research Council Scoring Scale (MRC), Manual Muscle Testing (MMT), and electromyography (EMG).

Risk factors for ICU-AW

Less than a tenth of study participants demonstrated excellent knowledge of risk factors for ICU-AW by correctly identifying all the 10 risk factors for ICU-AW that were listed. About half were able to identify at least 7 out of the 10 risk factors; thus, demonstrating good knowledge about the risk factors. A quarter of the respondents had poor knowledge of the risk factors; they could not identify at least one risk factor correctly.

Prevention and management of ICU-AW

[Table 3] shows participants responses about measures of preventing ICU-AW. About a fifth of the participants had excellent knowledge about strategies to prevent ICU-AW, by correctly identifying all seven responses. Another 43% had very good knowledge by identifying six correct responses. About a tenth of the participants had poor knowledge of strategies to prevent ICU-AW; indicating less than 3 correct options. Methods for preventing ICU-AW include: careful electrolyte management, electrical muscle stimulation, ventilator-weaning protocols, daily interruption of sedation, optimal nutrition, intensive insulin therapy and early mobilization.


   Discussion Top


Socio-demographics and clinical attributes of participants

Care of the critically ill requires specialized staffing and training; hence, most of the physicians and nurses in this study were specially trained or being trained to work specifically in the ICU. However, majority of physiotherapists in this study specialized in neurology. Since physiotherapists rotate through various units, especially during call duty hours, it is possible for a physiotherapist in other specialization to attend to patients in the ICU. The high proportion of neurological physiotherapists in this study may also be a reflection of the pathology of patient mostly admitted into the ICU. Neurological critical care may be as high as 50% in a general ICU.[14]

Participants in this study are highly qualified professionals and about 47.8% of them have first degree qualification. Most (70.4%) of the anesthetists have either a bachelor's degree or a postgraduate diploma qualification, while most (54.3%) of the physiotherapists in this study had bachelor's degree. This could be as a result of the fact that a bachelor's degree is the minimum entry requirement for a physiotherapist or a resident doctor in tertiary hospitals.

Awareness of ICU-AW and knowledge on classification of ICU-AW

Most (74.6%) of the participants indicated they were aware of ICU-AW. Most ICUs have in-house training programs for update in patient management. In addition, routine ground rounds and weekly morbidity and mortality meetings might have played a role in the in the high level of awareness of ICU-AW observed in the study participants. This is however in contrast with the observation that majority of the respondents wrongly assumed ICU-AW to be a neuromuscular as well as a musculoskeletal disease.

Knowledge on diagnostic tools and risk factors for ICU-AW

Knowledge on the diagnosis of this acquired weakness was very low, with almost all participants being unaware of the use of Medical Research Council Scoring Scale—an inexpensive tool—for ICU-AW diagnosis. It may be inferred from this observation that functional assessment in critically ill patient is not routinely carried out in most critical care settings in low resource settings. This may stem from a wrong notion that ICU-AW is not a real problem in this environment, where there are more emergent acute situations and shortage of manpower and equipment to deal with it.

Out of 100 respondents who indicated being aware of ICU-AW, 7 had excellent knowledge of the risk factors by correctly identifying risk factor for ICU-AW, while almost half of the respondents had average or below-average knowledge on the risk factors for developing ICU-AW. Predictably, many identified severe sepsis and prolonged mechanical ventilation as most prominent risk. This is in line with the fact that one of the earliest descriptions of weakness in critical illness was in patients with sepsis.[15] In addition, several prospective studies of mechanically ventilated, critically ill patients have found sepsis to be the most important risk factor for ICU-AW.[16],[17],[18] However, most of the participants had no idea about the use of aminoglycosides and prolonged use of vasopressors as risk factors for ICU-AW.

Prevention and management of ICU-AW

Eighteen percent (18%) of the 100 respondents who had initially indicated awareness about ICU-AW identified all seven (7) preventive measures for ICU-AW on the list. Yet none of this 18 was able to identify all three other items on the list that were not preventive measures for ICU-AW. The most identified preventive measure for ICU-AW was early mobilization of critically ill patients, being identified by 96% of the participants. Many studies have actually reported that physical rehabilitation can begin as early as possible in critically ill patients as they have sufficient medical stability to accommodate the increased vascular demands that accompany physical examination and intervention.[19],[20],[21],[22],[23] Cumulatively, 92% of all 100 respondents identified at least four out of the seven listed preventive measures.

In patients who require prolonged mechanical ventilation, neuromuscular recovery is typically prolonged and incomplete.[10] Studies show that up to 65% of such patients have functional limitations after discharge from the hospital.[24],[25] Functional disability, a natural consequence of weakness, is a frequent and long-lasting complication in survivors of critical illness.[26] Sacanella et al.,[27] reported a significant reduction in functional status in elderly survivors of critical illness who have had normal functional status at ICU admission; the decline in functional status persisted a year after discharge. Immobility and disuse atrophy play vital role in the pathophysiology of ICU-AW.[28] No curative treatment exists for ICU-AW, understanding its aetiology, pathophysiology, and risk factors may be important for its prevention.[2]

Decreasing mortality from critical illness has led to an increasing number of ICU survivors.[29],[30] Muscle weakness acquired during the ICU stay contributes to long-term morbidity and impaired quality of life post-ICU.[25] Patients who had respiratory failure, circulatory failure, acute respiratory distress syndrome (ARDS),[12] sepsis [31] are at higher risk of developing ICU-AW.


   Conclusion Top


The findings of this study suggested a high level of awareness among clinicians working in the ICU in south-western Nigeria, but the level of knowledge about specific areas ICU acquired weakness was low. There may be need for educational interventions such as continuous professional training on ICU acquired weakness among study participants.

Presentation

Preliminary data were presented at the Pan Africa Thoracic Society Conference in Kenya, 2016 Poster attached.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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