Department of Critical Care Medicine, Saint Luc University hospital, Université catholique de Louvain (UCL), Brussels, Belgium.
Institute of Neuroscience, Pôle Cellulaire et moléculaire, Université catholique de Louvain (UCL), Louvain-la-Neuve 1348, Belgium.
Crit Care Med. 2018 Sep;46(9):1436-1443. doi: 10.1097/CCM.0000000000003263.
As the catabolic state induced by septic shock together with the physical inactivity of patients lead to the rapid loss of muscle mass and impaired function, the purpose of this study was to test whether an early physical therapy during the onset of septic shock regulates catabolic signals and preserves skeletal muscle mass.
Randomized controlled trial.
Tertiary mixed ICU.
Adult patients admitted for septic shock within the first 72 hours.
Patients were assigned randomly into two groups. The control group benefited from manual mobilization once a day. The intervention group had twice daily sessions of both manual mobilization and 30-minute passive/active cycling therapy.
Skeletal muscle biopsies and electrophysiology testing were performed at day 1 and day 7. Muscle biopsies were analyzed for histology and molecular components of signaling pathways regulating protein synthesis and degradation as well as inflammation markers. Hemodynamic values and patient perception were collected during each session. Twenty-one patients were included. Three died before the second muscle biopsy. Ten patients in the control and eight in the intervention group were analyzed. Markers of the catabolic ubiquitin-proteasome pathway, muscle atrophy F-box and muscle ring finger-1 messenger RNA, were reduced at day 7 only in the intervention group, but without difference between groups (muscle atrophy F-box: -7.3% ± 138.4% in control vs -56.4% ± 37.4% in intervention group; p = 0.23 and muscle ring finger-1: -30.8% ± 66.9% in control vs -62.7% ± 45.5% in intervention group; p = 0.15). Muscle fiber cross-sectional area (µm) was preserved by exercise (-25.8% ± 21.6% in control vs 12.4% ± 22.5% in intervention group; p = 0.005). Molecular regulations suggest that the excessive activation of autophagy due to septic shock was lower in the intervention group, without being suppressed. Markers of anabolism and inflammation were not modified by the intervention, which was well tolerated by the patients.
Early physical therapy during the first week of septic shock is safe and preserves muscle fiber cross-sectional area.
由于脓毒症休克引起的分解代谢状态以及患者的身体不活动导致肌肉质量迅速减少和功能受损，本研究旨在测试脓毒症休克发作期间早期进行物理治疗是否可以调节分解代谢信号并保留骨骼肌质量。
随机对照试验。
三级混合 ICU。
在最初 72 小时内因脓毒症休克而入院的成年患者。
患者随机分为两组。对照组每天接受一次手动动员。干预组每天进行两次手动动员和 30 分钟的被动/主动循环治疗。
在第 1 天和第 7 天进行骨骼肌活检和电生理学测试。对肌肉活检进行组织学分析以及调节蛋白质合成和降解的信号通路的分子成分以及炎症标志物的分析。在每次治疗期间收集血流动力学值和患者感知。共纳入 21 例患者。其中 3 例在第二次肌肉活检前死亡。对对照组的 10 例和干预组的 8 例进行了分析。仅在干预组中，第 7 天时调节蛋白分解代谢泛素蛋白酶体途径、肌肉萎缩 F 盒和肌肉指环指 1 信使 RNA 的标志物降低，但组间无差异（肌肉萎缩 F 盒：对照组为-7.3%±138.4%，干预组为-56.4%±37.4%；p=0.23 和肌肉指环指 1：对照组为-30.8%±66.9%，干预组为-62.7%±45.5%；p=0.15）。运动可保留肌纤维横截面积（µm）（对照组为-25.8%±21.6%，干预组为 12.4%±22.5%；p=0.005）。分子调节表明，由于脓毒症休克导致的自噬过度激活在干预组中较低，但并未受到抑制。干预措施并未改变合成代谢和炎症标志物，患者耐受良好。
脓毒症休克发作后第一周进行早期物理治疗是安全的，可以保留肌纤维横截面积。
