Physiol Rev 95: 1025–1109, 2015

Published July 1, 2015; doi:10.1152/physrev.00028.2014

THE SICK AND THE WEAK: NEUROPATHIES/

MYOPATHIES IN THE CRITICALLY ILL
O. Friedrich, M. B. Reid, G. Van den Berghe, I. Vanhorebeek, G. Hermans, M. M. Rich,
and L. Larsson

Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-

University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University
of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of
Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology
and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology,
Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden

Friedrich O, Reid MB, Van den Berghe G, Vanhorebeek I, Hermans G, Rich MM, and

L
Larsson L. The Sick and the Weak: Neuropathies/Myopathies in the Critically Ill. Physiol Rev
95: 1025–1109, 2015; Published July 1, 2015; doi:10.1152/physrev.00028.2014.—
Critical illness polyneuropathies (CIP) and myopathies (CIM) are common complica-
tions of critical illness. Several weakness syndromes are summarized under the
term intensive care unit-acquired weakness (ICUAW). We propose a classification of different
ICUAW forms (CIM, CIP, sepsis-induced, steroid-denervation myopathy) and pathophysiological
mechanisms from clinical and animal model data. Triggers include sepsis, mechanical ventila-
tion, muscle unloading, steroid treatment, or denervation. Some ICUAW forms require strin-
gent diagnostic features; CIM is marked by membrane hypoexcitability, severe atrophy, pref-
erential myosin loss, ultrastructural alterations, and inadequate autophagy activation while
myopathies in pure sepsis do not reproduce marked myosin loss. Reduced membrane excit-
ability results from depolarization and ion channel dysfunction. Mitochondrial dysfunction con-
tributes to energy-dependent processes. Ubiquitin proteasome and calpain activation trigger
muscle proteolysis and atrophy while protein synthesis is impaired. Myosin loss is more
pronounced than actin loss in CIM. Protein quality control is altered by inadequate autophagy.
Ca2⫹ dysregulation is present through altered Ca2⫹ homeostasis. We highlight clinical hall-
marks, trigger factors, and potential mechanisms from human studies and animal models that
allow separation of risk factors that may trigger distinct mechanisms contributing to weakness.
During critical illness, altered inflammatory (cytokines) and metabolic pathways deteriorate
muscle function. ICUAW prevention/treatment is limited, e.g., tight glycemic control, delaying
nutrition, and early mobilization. Future challenges include identification of primary/secondary
events during the time course of critical illness, the interplay between membrane excitability,
bioenergetic failure and differential proteolysis, and finding new therapeutic targets by help of
tailored animal models.

I. INTRODUCTION 1025 I. INTRODUCTION

II. HISTORY, TIME COURSE, AND... 1026
III. RISK FACTORS AND CLINICAL... 1028 “In adults the disease may attack persons in good health,
IV. INTRODUCTION TO... 1035 but who are overworked or ‘run down’ from any cause.
V. INFLAMMATORY CYTOKINES... 1036 Haemorrhage initiates the attack in a few cases. There may
VI. BIOMECHANICS, ... 1041 be repeated chills; the temperature is high, the pulse rapid,
VII. NEUROMUSCULAR TRANSMISSION... 1044 and the respirations are increased. The loss of flesh and
VIII. MEMBRANE AND ION CHANNEL... 1046 strength is very striking.” This description of the symptoms
IX. EXCITATION-CONTRACTION COUPLING,... 1053 in a condition of acute critical illness, in acute broncho-
X. METABOLIC EFFECTS IN CRITICAL... 1058 pneumonic phthisis, by Sir William Osler in his classical
XI. PROTEIN REGULATION IN MUSCLE... 1067 textbook on “principles and practice of medicine” (531) is
XII. ANIMAL AND HUMAN MODELS... 1072 one of the first analytical observations linking an aberrant
XIII. TREATMENT OF ICUAW: DRUG... 1082 systemic inflammatory response to a failure of the periph-
XIV. SUMMARY/OUTLOOK 1088 eral nervous system, i.e., muscle wasting and weakness.

0031-9333/15 Copyright © 2015 the American Physiological Society 1025

 FRIEDRICH ET AL.
This condition can either affect the peripheral nerves (crit-
ical illness polyneuropathy, CIP), skeletal muscle (critical
illness myopathy, CIM) or both (critical illness polyneuro-
myopathy, CIPNM) (6, 402, 404, 747). These conditions
are the primary cause of muscle weakness and paralysis
during and following critical illness (402). Weakness ap-
pears to be triggered by critical illness and the ICU course
regardless of the underlying primary condition (382, 453,
528). The chance of developing muscle weakness correlates
with the severity of critical illness, as assessed by several
organ dysfunction scores (149, 181, 370, 763), and repre-
sents a pathophysiological process that cannot be explained
by immobilization alone (181). Mechanical ventilation and
muscle immobilization, severe sepsis, and multiple organ
dysfunction as well as neuro/myotoxic agents are among
the primary risk factors of ICU-acquired neuromyopathy
(215, 302, 747). With the advancements in modern inten-
sive care medicine, mortality of sepsis-related ICU condi-
tions has dropped; however, at the cost of a growing inci-
dence of such intensive care unit (ICU)-acquired weak-
nesses (ICUAW) (64, 332, 622). As sepsis ranks among the
top three causes of mortality in some Western countries
(185), with incidences of weakness as high as 50 –100% in
critically ill patients (145, 361, 781), ICUAW is becoming a
major problem. Its prevalence not only influences patient
prognosis but also bears threats for secondary complica-
tions (infection, embolism, etc.), prolongs ICU treatment
and rehabilitation, and greatly raises the costs of intensive
care medicine worldwide (406, 458). As will be detailed
later, the recently introduced term ICUAW (618) shall be
considered a syndromal umbrella term and is not synony-
mous with CIM or CIP “per se” but more pragmatically
describes a syndromal complex of weakness in critically ill
patients who may be suffering from different pathophysio-
logical entities. For most of these ICUAWs, specific thera-
pies do not yet exist, i.e., for CIP and CIM, because of our
patchy knowledge of their underlying pathological mecha-
nisms. However, recent research has identified several inter-
playing pathways and candidates that might serve as ther-
apy targets. An important issue in dissecting the different
entities of ICUAW and their pathophysiological mecha-
nisms, the definition of proper animal models that as closely
as possible mimick the phenotype of muscle weakness seen
in ICU patients, is crucial. Therefore, in addition to sum-
marizing and discussing the paucity of pathophysiological
data, our review will also provide a special emphasis on
such animal models and compare the pros and cons in-
volved.
II. HISTORY, TIME COURSE, AND
CLINICAL FEATURES OF ICU-RELATED
WEAKNESS
In the 19th century, patients with life-threatening infections
were reported to lose “a lot of flesh and strength” (531).
During the next decades, occasional case reports indicated
1026 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
the occurrence of polyneuropathies in coma patients fol-
lowing shock, cardiac arrest, and acute intoxication and in
burn patients (65). However, it took another century before
this syndrome was described in more detail and was labeled
as CIP (67). Almost simultaneously, several authors re-
ported the occurrence of profound flaccid and symmetrical
weakness after a severe disease (35, 66, 68, 134, 590, 812).
The weakness was accompanied by muscle wasting and
often, but not necessarily, by reduction or loss of tendon
reflexes but with a relative sparing of the facial muscles.
This typically results in grimacing of the facial muscles upon
painful limb stimulation but with evoking only limited to
absent limb movement. Distal muscles (781, 812) and lower
limbs (68, 206, 360, 406, 414) appeared most severely af-
fected. The predominant symptom pointing to the presence
of CIP was often weaning failure, as respiratory muscles are
also involved (52, 145, 414, 781). Sensory loss, including
reduced sensitivity to pain, temperature, and vibration, was
variably present (414, 808), but sensory testing in these
patients is often unreliable (52, 64, 808, 812) (TABLE 1).
Electrophysiological studies revealed reduced compound
motor action potentials and sensory nerve action potentials,
variably accompanied by the widespread presence of fibril-
lation potentials or positive sharp waves. In contrast to the
Guillain-Barré syndrome where a demyelination of periph-
eral nerves results in delayed action potential conduction,
nerve conduction velocity was found to be normal or near
normal (52, 68, 126, 414, 781, 808, 812). Biopsy and au-
topsy findings confirmed that the underlying problem was a
primary distal axonal degeneration of motor and sensory
fibers (44, 67, 68, 193, 812). Later, it was shown that in
some patients with electrophysiological evidence of CIP,
nerve histology was normal (403), indicating that func-
tional changes may precede structural changes. Consistent
with this, rapidly reversible neuropathy was later described
(515). Whether this concerns a distinct entity or a different
grade of severity is yet unresolved (TABLE 1). When consid-
ering weaning failure, electrophysiological and autopsy
studies supported the involvement of the phrenic nerve,
diaphragm, as well as the intercostal and other accessory
muscles in the process of axonal degeneration and denerva-
tion-associated muscle atrophy (450, 611, 781, 808, 812).
Recovery from CIP first occurs in the upper and proximal
lower limbs. This is then followed by recovery of the respi-
ratory system and finally by the distal lower limbs (812).
In parallel with the description and characterization of CIP,
a case of acute quadriplegia developing in a patient treated
with corticosteroids and neuromuscular blocking agents
was reported (448). Several other authors, by use of muscle
biopsies, confirmed the occurrence of an acute myopathy in
the intensive care unit, associated with the use of cortico-
steroids and neuromuscular blocking agents (37, 141, 165,
314, 382). These patients exhibited preferential myosin loss
and also demonstrated flaccid weakness and failure to wean
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL

Table 1. Clinical and histological characteristics of CIP and CIM

Clinical Signs Spectrum of Histological Findings

Critical illness polyneuropathy

Flaccid, symmetrical atrophy, and weakness of the limbs Nerve:*
Distal⬎proximal Normal
Lower limbs⬎upper limbs Mildly reduced myelin fiber density with sporadic axonal
degeneration
Facial muscles mostly spared Marked fiber loss with abundant degenerative changes
Deep tendon reflexes mostly reduced to absent but may be Variable fiber regeneration
preserved
Variable distal sensory loss to pain, temperature, and vibration Muscle:
Weaning failure Denervation atrophy

Critical illness myopathy

Flaccid, symmetrical atrophy and weakness of the limbs and Nerve:
neck flexors Normal
Proximal⬎distal Muscle:
Fiber atrophy with abnormal variation in size of muscle fibers,
angulated fibers, fatty degeneration, fibrosis; mostly
affecting both fiber types, may be limited to type II fibers
Facial muscles mostly spared Focal or diffuse loss of thick myosin filaments
Deep tendon reflexes mostly reduced to absent but may be Scattered to more prominent myonecrosis, vacuolization, and
preserved phagocytosis of muscle fibers
No sensory loss
Weaning failure

*No evidence of primary demyelination or inflammatory infiltrates.

from the respirator. Terms used for this syndrome include
acute quadriplegic myopathy, acute myopathy of the inten-
sive care, critical care myopathy, acute illness myopathy,
and acute myopathy with selective loss of myosin filaments
(69). As many critically ill patients, including those with
sepsis and multiple organ failure, appeared to have primary
muscle involvement not secondary to muscle denervation
(125, 403, 812), the term critical illness myopathy was intro-
duced (383, 653, 811). Muscle histology studies (TABLE 1)
further identified other myopathic changes, in addition to
preferential myosin loss, which have been variably classified
as subtypes of critical illness myopathy (69, 70, 87, 332,
402, 535). In some patients muscle necrosis was present
(297, 331, 360, 383, 384, 812), accompanied by variable
elevation of creatine kinase levels (69, 150, 382, 383, 384).
Finally, in some myopathies, histological changes may be
limited to overall atrophy (382, 383), which may be more
pronounced in fast type II (IIa and IIx in humans; IIa, IIx,
and IIb in rodents) fibers (59, 279) or even be absent in the
myopathy with purely functional impairment (402). The
generalized flaccid weakness in CIM may be more proxi-
mally pronounced (384). Tendon reflexes are generally at-
tenuated. Facial and extraocular muscles are generally
spared but may occasionally be involved (100, 382, 529,
643). As in CIP, weaning failure is reported as a dominant
symptom (382, 383). CIM itself does not account for
changes in sensory nerve function. TABLE 1 lists clinical
symptoms that may differentiate between CIM and CIP.
Accumulating evidence from studies involving detailed elec-
trophysiological testing, including direct muscle stimula-
tion, and muscle histology revealed that both neuropathy
and myopathy may co-occur in patients (43, 147, 150, 360,
361). Interestingly, myopathy rather than neuropathy ap-
peared to be the most frequent cause of weakness (43, 125,
297, 370, 383, 403, 413, 577, 583, 614, 764). This led to
the concept that CIP and CIM are part of a spectrum of
neuromuscular diseases affecting critically ill patients,
rather than being separate and distinct disorders (43). The
co-occurrence may imply a common pathogenic factor, af-
fecting both the nerves and the muscle in critically ill pa-
tients (112, 164, 361, 403). An alternative explanation may
be that denervation due to CIP results in increased vulner-
ability of muscles to several noxious stimuli (70, 145, 382).
On the other hand, the diseased muscle might also signal
back to affect innervation and the neuromuscular junction.
Clinical examination usually cannot differentiate between
CIP and CIM as key clinical features are similar and sensory
evaluation is typically unreliable (382, 383, 407). Conven-
tional electrophysiological screening including nerve con-
duction studies and needle electromyography also does not
distinguish between the two entities (403). Both in CIP and
CIM, reduced compound motor action potentials (CMAPs)
are found. Abnormal spontaneous electrical activity pre-
senting as fibrillation potentials or positive sharp waves
may be due to denervation in CIP but also may occur in
CIM due to muscle sodium channel dysfunction (580, 581)

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 FRIEDRICH ET AL.
or secondary involvement of nerve endings in primary my-
opathy (126, 403, 577, 742). Terms such as critical illness
polyneuromyopathy or the acronym CRIMYNE subse-
quently emerged (401, 405, 528). To emphasize the clinical
problem of muscle weakness, regardless of its cause, de-
scriptive terminology such as ICU acquired paresis, critical
illness neuromuscular abnormalities, acquired neuromus-
cular disorders, or ICU-acquired (muscle) weakness was
launched (145, 618). Although encompassing both entities
is useful from a practical point of view, some evidence sug-
gests that for prognostic reasons, it may be relevant to dif-
ferentiate between CIP, CIM, and other myopathies (381).
Early data indicated similar outcome for CIP and CIM
(383), but recently it was shown that patients with CIM
may recover earlier and better than those with CIP (273).
The co-occurrence of CIP with CIM appeared to hamper
recovery (370) and was responsible for persisting disabili-
ties (344); however, the majority of patients recover within
the first 6 –12 mo (190, 504).
Although CIM and CIP are mostly described in association
with adult and aged ICU patient populations, they are also
a problem in pediatric ICUs (608); however, occurrence of
ICU-related weakness in children has only occasionally
been reported. From the existing literature it is concluded
that clinical and electrophysiological conditions are similar
in adults and children (779), but there is still a lack of
clinical and animal studies elucidating the significance and
nature of weakness in critically ill children.
III. RISK FACTORS AND CLINICAL
DIAGNOSTIC TOOLS FOR CIP/CIM
A. Risk Factors for the Development of ICU-
Acquired Neuromuscular Complications
Several risk factors have been implicated in the development of
neuromuscular complications in the ICU (FIGURE 1A). Several
studies attempted to identify independent risk factors by per-
forming multivariable analysis on data obtained during pro-
spective observational studies (44, 100, 147, 149, 231, 499,
763). Additional information on risk factors was based on a
number of randomized controlled trials (RCTs) intervening
with a particular risk factor and reporting on neuromuscular
complications, although in none of these neuromuscular out-
come was the primary end point (TABLE 2).
Based on these data, several key players were suggested.
First, the presence and persistence of sepsis, systemic in-
flammatory response syndrome (SIRS), and multiple organ
failure appear to hold a central role. Sepsis was the main
suspect in the early days of the discovery of CIP, as it was a
common feature in the first case reports (67, 812), and the
incidence of CIP reported in patients with sepsis was very
high (52, 333). Sepsis, multiple organ failure, and its sever-
1028 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
ity were found to be associated with CIP (166, 403, 415,
416). Sepsis, as such, was identified as an independent risk
factor for neuromuscular complications (122, 300) as well
as bacteremia (499, 738). The role of the presence and
persistence of SIRS and multiple organ failure (44, 147,
149) as well as of certain inflammatory markers (763), how-
ever, were confirmed in several studies. As some of these
trials specifically focused on septic patients, and sepsis is a
major cause of SIRS and organ failure, sepsis was likely to
be a crucial factor (146). Indirect evidence for the central
role of sepsis is also provided by the independent associa-
tion of the use of catecholamines (735) as well as central
neurological failure (231), which develops earlier during
sepsis, with neuromuscular complications. Furthermore, it
is confirmed that severity of illness independently predicts
the risk of neuromyopathy in critically ill individuals (44,
100, 149). As will be detailed later, animal models have
allowed the separation of sepsis and other confounding risk
factors, e.g., mechanical ventilation and muscle unloading,
which are usually present in combinations in ICU patients.
For instance, pure sepsis in animal models has not been able
to reproduce hallmarks of the CIM phenotype (see below)
when animals were not mechanically ventilated, mechani-
cally unloaded, or subjected to a similar ICU-situation to
mimick the situation in patients. However, in septic ICU
patients, the CIM phenotype will most likely be seen be-
cause critically ill septic patients will almost always also be
found subjected to mechanical ventilation, muscle unload-
ing and other contributing factors.
For further discussion of risk factors for ICUAW, it is nec-
essary to define the different syndromes causing weakness.
In particular, it is necessary to define what is meant by the
term CIM. Many critically ill patients presenting with CIM
show several symptoms and alterations on the organ, cellu-
lar, and subcellular level of affected muscle, not all of which
may be detectable in each patient or at a given stage of
investigation: electrical hypoexcitability of muscles; severe
atrophy; preferential and significant myosin loss; disorga-
nization of sarcomeres, ultrastructural abnormalities; and
impaired autophagy and altered protein turnover.
Whether severe sepsis and sepsis-induced organ failure are
already on their own sufficient to create the full-blown
pathological manifestations of CIM (in particular the pref-
erential myosin loss) remains unclear. There is no study to
date showing preferential or selective loss of myosin sec-
ondary to sepsis in the absence of mechanical ventilation
and immobilization. In animal models (see sect. XII) where
sepsis and immobilization can be separated, sepsis does not
trigger preferential loss of myosin pointing towards a dif-
ferential pathophysiological process in pure sepsis.
Immobilizing patients and mechanically ventilating them
during the acute phase of critical illness is suggested to
contribute to muscle atrophy and weakness. By itself, the
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL

Steroids
Mechanical
Silencing
Prolonged Malnutrition
Respirator
Ventilation

Sepsis
? ICUAW

Hyperglycemia/
Insulin Resistance
Denervation,
Neuromuscular Blockade

B
ICUAW clinically descriptive
Intensive-Care Unit syndromal term
Acquired Weakness

CIP CIM SIM SDM

Critical Illness Critical Illness Sepsis-induced Steroid-Denervation
Polyneuropathy Myopathy Myopathy Myopathy

• mechanical ventilation • mechanical ventilation • muscle hypoexcitability • muscle immobilization

• muscle immobilization
• muscle excitable (direct
muscle stimulation)
• atrophy
• muscle immobilization
• muscle hyopexcitability
• severe atrophy
• preferential myosin
proteolysis
• disorganized sarcomeres
• atrophy
• no preferential
myosin proteolysis
• disorganized sarcomeres
• mostly no ventilation in
animal models but in
patients with sepsis/severe
sepsis
• muscle hypoexcitability
• severe atrophy
• preferential myosin
proteolysis
• disorganized sarcomeres

Putatively distinct pathophysiologic processes separable in animal models that are

currently postulated to combine to produce weakness in critically ill patients
FIGURE 1. Risk factors contributing to the development of peripheral nervous system dysfunction seen as
muscle weakness in ICU patients and potential differences in disease entities. A: in intensive care unit (ICU)
patients, several conditions and risk factors have been associated with the development of muscle weakness
pointing to a failure in the peripheral nervous system. Clinically, in the past, the presence of “weakness” has
pragmatically been lumped together in the term ICU-acquired weakness (ICUAW), although this term neither
discriminates between primary neuropathy or primary myopathy, nor does it account for potentially different
mechanisms leading to neuropathy/myopathy. Apart from steroids, denervation, and sepsis, mechanical ventila-
tion and immobilization itself is a prominent risk factor that contributes to the development of ICU-related myopa-
thies. Critical illness myopathy (CIM) seen in critically ill patients is almost exclusively associated with altered muscle
excitability, severe atrophy, and a preferential myosin loss, usually seen in critically ill patients who are exposed to
several trigger factors at once. ICUAW, on the other hand, is a clinically pragmatic term that can be applied in the
absence of any further special electrophysiology or biopsy testing. B: the separation of the distinct disease entities
summarized under the term ICUAW as well as unraveling the specific differences of the underlying pathophysio-
logical mechanisms defining those separate disease entities is still a matter of active research, and results from
animal models suggest that some of those trigger factors on their own may be able to produce CIM while others
may not (e.g., pure sepsis without steroid/denervation and/or mechanical ventilation/immobilization). In ICU
patients suffering ICUAW, trigger factors usually combine, and septic ICU patients that are ususally subjected to
mechanical ventilation and muscle unloading will present with CIM rather than SIM.

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1030
Table 2. Randomized trials intervening with presumed risk factors and reporting on neuromuscular outcome using electrophysiological or clinical evaluation
Effect of Intervention on Neuromyopathy Other Independent Risk Factors
Reference
No. Population Diagnosis Intervention Intervention Control P value Risk factors Relative risk (95%CI) P Value

735 SICU ⱖ7 days Electrophysiological IIT 46/181 (25%) 109/224 (49%) ⬍0.0001 Vasopressor support OR: 1.06 (1.02–1.11) 0.009
diagnosis (SEA)
738 Duration of ICU stay OR 1.05 (1.03–1.08) ⬍0.0001
RRT OR 1.9 (1.0–3.8) NA
Bacteremia OR 2.3 (1.3–4.1) NA
658 ARDS ⱖ7days Pragmatic diagnosis* Corticosteroids 26/88 (30%)⫹ 21/91 (22%)⫹ 0.2 NA NA NA
654 Septic shock Clinical diagnosis Corticosteroids 2/234 (1%) 4/232 (2%) NS NA NA NA
⬍72 h
309 MICU ⱖ7 days Electrophysiological IIT 81/208 (39%) 107/212 (51%) 0.02 Age OR 0.98 (0.96–0.99) 0.003
diagnosis (SEA)
Prolonged NMBA OR 2.01 (1.10–3.99) 0.02
CS (protective) OR 0.97 (0.94–0.99) 0.02
536 ARDS ⱕ48 h Clinical diagnosis MRC 48 h of NMBA 40/112 (36%) 28/89 (31%) 0.5 NA NA NA
sums score ⬍48
623 MV ⱕ72 h Clinical diagnosis MRC Early physical and 15/49 (31%) 27/55 (49%) 0.09 NA NA NA
sum ⬍48 occupational
therapy
300 MICU or SICU Clinical diagnosis MRC Late versus early 105/305 (34%) 127/295 (43%) 0.03 Age OR 1.03 (1.01–1.05) 0.001
ⱖ8 days and sum ⬍48 supplementation of
random set insufficient enteral
of nutrition in the
FRIEDRICH ET AL.

short-stayers first week in ICU

APACHE II OR 1.08 (1.04–1.11) ⬍0.001
Sepsis OR 2.20 (1.30–3.71) 0.003
Admission categories 0.03
(as compared with
medical)
Emergency surgical ICU OR 0.77 (0.42–1.43) 0.4
Elective surgical ICU OR 2.61 (0.77–8.88) 0.12
Cardiac surgery OR 1.8 (0.80–4.05) 0.15

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Time to first MRC OR 1.05 (1.01–1.10) 0.01
measurement
CS OR 2.70 (1.73–4.22) ⬍0.001
NMBA OR 2.72 (1.65–4.51) ⬍0.001
New infection OR 2.75 (1.69–4.45) ⬍0.001

SICU, surgical intensive care unit; MICU, medical intensive care unit; ARDS, acute respiratory distress syndrome; SEA, spontaneous electrical activity; MRC, Medical Research Council;
IIT, intensive insulin therapy; MV, mechanical ventilation; OR, odds ratio; CI, confidence interval; RRT, renal replacement therapy; NMBA, neuromuscular blocking agents; CS,
corticosteroids; NS, not significant; NA, not available. *Presence of the terms “myopathy,” “myositis,” “neuropathy,” “paralysis,” or “unexplained weakness” in the medical record. ⫹The
first 88 patients were retrospectively evaluated.
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
immobilization (pure bed rest) may not be sufficient to ex-
plain the degree of muscle atrophy and weakness observed
in acutely ill patients (146). “Mechanical silencing” (loss of
weight bearing and internal strain caused by activation of
contractile proteins) and mechanical ventilation in animal
models are sufficient to produce the preferential and signif-
icant myosin loss seen in patients (435, 517). Several clinical
trials, however, found indicators of the duration of immo-
bilization to be independently related to the occurrence of
neuromuscular complications in critical care (147, 735,
781) and the presence of weakness up to 2 yrs after acute
respiratory distress syndrome (ARDS) (190). Immobiliza-
tion, therefore, is likely to contribute to CIM also in pa-
tients. This provided the basis for the development of trials
to examine the effects of interventions aimed at reducing the
duration of immobilization on ICUAW (see sect. XIII). Sed-
ative and analgesic use, by association with time to awak-
ening, can be expected to affect duration of immobilization,
but was not found to be independently related with the risk
of neuromyopathy in several trials (147, 149, 763).
Hyperglycemia was associated with neuromyopathy in ret-
rospective (51, 306) and prospective studies (100, 147) and
was also identified as an independent risk factor (499, 781)
(FIGURE 1A). These findings launched the hypothesis that
hyperglycemia might impair the microcirculation in the
nerves, contributing to the development of CIP (64). In
addition, during critical illness, organs depending on pas-
sive uptake of glucose, such as the nervous system, may be
subjected to glucose overload resulting in acute neurotox-
icity because of the hyperglycemia caused by insulin resis-
tance (308). Hyperglycemia may also contribute to nerve
excitability changes or increased generation and deficient
scavenging of reactive oxygen species (303, 308). Such ob-
servations drove the exploration of restored neuromuscular
function by normalizing hyperglycemia in critically ill pa-
tients (see sect. XIII).
Myopathy is a well-known adverse effect of glucocorticoid
treatment (542). Corticosteroids reduce protein synthesis
and increase protein breakdown, resulting in atrophy and
weakness. Not surprisingly, after the first case report (448)
many followed, suggesting corticosteroids as the culprit of
myopathy occurring in critically ill subjects, especially in
patients treated with a combination of corticosteroids and
neuromuscular blocking agents. Results of prospective tri-
als, however, were equivocal. Some found that corticoste-
roids were independently associated with neuromyopathy
(100, 147, 311), whereas most other trials could not con-
firm this (44, 51, 149, 231, 499, 654, 658, 735, 763). Sev-
eral explanations are possible for these divergent findings.
First, in addition to the well-known catabolic effects, corti-
costeroids may improve outcome and shorten duration of
organ failure in certain ICU populations, which by itself is
an important risk factor for neuromyopathy (21, 22, 473).
Although CIP and CIM are characterized by inflammatory
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
infiltrates (150, 193), inflammatory processes are likely in-
volved and corticosteroids could hypothetically downregu-
late potential detrimental pathways. Corticosteroids also
induce hyperglycemia, another risk factor for neuromyopa-
thy. Therefore, clinical effects of corticosteroids may be
complex and the impact on the nerves and the muscles
could be distinct. Effects may also depend on timing and
dosing, as well as on controlling the resulting hyperglyce-
mia (309).
The presumed harmful effects of neuromuscular blocking
agents (NMBAs) were extensively reported in many case
reports (265). Nondepolarizing agents, often combined
with corticosteroids, were considered to be detrimental
(165). Pharmacological denervation with neuromuscular
blocking agents may increase muscle susceptibility to corti-
costeroids, as observed in anatomical denervation (466).
Despite this well founded hypothesis, again, data from sev-
eral trials did not consistently show negative effects (44,
149, 150, 190, 306, 499, 735, 763). In three trials, NMBAs
were independently associated with neuromuscular compli-
cations (231, 300, 309). Type and duration of exposure to
NMBAs could possibly explain differential findings. Recent
data from an RCT (48 h of NMBAs versus placebo in ARDS
patients) indeed did not find an increased incidence of
weakness in the intervention group (536). In addition, ear-
lier data may have been confounded by other treatment
strategies associated with administration of NMBAs, such
as ventilator strategies and sedation regimens no longer
used in ICUs (562).
Two trials identified age as an independent predictor of
neuromuscular complications in the ICU (300, 309). The
role of nutrition has been debated since the first description
of CIP. It was hypothesized that malnutrition was a major
cause of ICUAW and that the catabolic process could be
revoked by adequate parenteral nutrients (67). Some trials
evaluating the role of parenteral nutrition, however, could
not confirm an association (309, 499, 781). In one trial,
parenteral nutrition was an independent risk factor for CIP
(231), and in a recent RCT, early parenteral nutrition in-
creased the incidence of ICU-acquired weakness (300). Del-
eterious effects of refeeding, high amounts of polyunsatu-
rated fats, or metabolic derangements contributing to dis-
turbances in the microcirculation were proposed as
mechanisms (752). Autophagy is another pathway that may
be involved in neuromuscular effects of nutrition in criti-
cally ill individuals. Autophagy is a cellular housekeeping
system required for the elimination of damaged organelles
and large protein aggregates (122). The process is impor-
tant for maintaining muscle quality (465). Nutrients, espe-
cially amino acids, are powerful suppressors of autophagy
(155, 247). Insufficient activation of autophagy was found
in muscle biopsies of fed critically ill patients (728), and
higher protein delivery in the first week of critical illness
was even associated with greater muscle wasting (563).
1031
 FRIEDRICH ET AL.
Therefore, muscle quality could be negatively affected by
nutrition as shown in a recent RCT (300) (see sect. X).
Several other risk factors were identified in single trials, but
current evidence for a role of these factors is limited: low
serum albumin (781), hyperosmolality (231), female sex
(147), aminoglycosides (499), and renal replacement ther-
apy (738).
B. Aspects of Clinical Evaluation and
Diagnostics
There are several potential approaches for diagnosing the
problem of intensive care unit acquired weakness as a syn-
drome (ICUAW). In awake and cooperative patients, a bed-
side clinical approach can be used. Muscle strength can be
quantified using the Medical Research Council (MRC) sum
score, a validated ordinal scale which grades muscle weak-
ness in six bilateral muscle groups from upper and lower
limbs between 0 (no contraction) and 5 (normal strength)
(TABLE 3). Adding these subscores results in a maximum
sum score of 60 (369). ICUAW was defined as MRC sum
score for muscle strength to be ⬍48, provided no other
cause of weakness could be identified (147). Since then,
many other publications have used the MRC sum score to
diagnose ICUAW (10, 44, 51, 143, 144, 149, 189, 273,
305, 325, 413, 499, 536, 598, 623, 632) without referring
to the precise underlying disease entity (FIGURE 1B). This
clinical approach revealed that weakness affects proximal
Table 3. MRC sum score
MRC Sum Score Criteria
Evaluation of adequate awakening
Open/close your eyes
Look at me
Open your mouth and put out your tongue
Nod your head
Raise your eyebrows when I have counted up to 5
Muscle groups evaluated
Wrist extension
Elbow flexion
Shoulder abduction
Dorsiflexion of the foot
Knee extension
Hip flexion
Appointed scores
0 no visible/palpable contraction
1 visible/palpable contraction without movement of the
limb
2 movement of the limb, but not against gravity
3 movement against gravity
4 movement against gravity and some resistance
5 normal force
1032 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
muscles more than distal muscles (147, 305, 413). The
MRC sum score was proposed as a routine and first line
screening tool in the ICU for patients at risk for developing
ICUAW (268, 402, 622, 661). As reported in various clin-
ical settings [mechanically ventilated patients with acute
stroke (267), Guillain-Barré syndrome (369), stimulants
(189), post ICU (40, 325)], inter-rater reproducibility was
found to be good in a large study of critically ill patients
(301), and one smaller series (10), but not in two other
small studies (129, 325). Methodological issues such as
judging the adequate awakening and cooperation of the
patient required to perform the test may be very important.
Also, the use of a detailed and stringent protocol adapted
for bedridden patients may be crucial (305). MRC sum
score ⬍48 is associated with important clinical outcomes
(TABLE 4) and is found to be an independent predictor of
prolonged weaning, ICU and hospital stay, as well as ICU,
hospital, and 180 day mortality (TABLE 4). In addition,
MRC sum score ⬍48 independently predicted 1 yr mortal-
ity (307) and pharyngeal dysfunction (487). The clinical
approach is easy and cheap. Drawbacks include the require-
ment of adequate awakening and cooperation, which limits
the number of critically ill patients actually evaluable. Re-
ported figures range from 25% (325) up to 90% (51) during
ICU stay. Pain may also interfere with maximal effort. Due
to the ordinal character of the scale, subtle changes may not
be detected. The MRC sum score only points to weakness
but does not provide information on the underlying patho-
physiological processes (FIGURE 1B). It is important to rule
out other known causes of weakness, in particular when the
clinical picture does not correspond to flaccid and symmet-
rical weakness, facial muscle sparing, and reduced to absent
tendon reflexes. Finally, clinical muscle strength testing
does not allow differentiating between a neuropathic and
myopathic component of the weakness. Other clinical
methods of measuring muscle strength in critically ill pa-
tients have been evaluated. These include hand-grip
strength measurement using a dynamometer. This proved
to be a reliable tool in the ICU with good interobserver
reliability (29, 301). Hand grip strength showed good test
performance in predicting MRC sum score ⬍48 and was
independently associated with mortality in a medical ICU
(10). To avoid problems of maximal effort, use of electrical
(181) or magnetic (288) muscle stimulation of the adductor
pollicis has been described. Data on clinical impact of this
kind of measurements are currently lacking. Respiratory
muscles are frequently involved in ICUAW. Evaluation of
respiratory muscle strength using maximal inspiratory pres-
sure was also suggested as a surrogate marker for ICUAW
because of good predictive value for MRC ⬍48 (722) and
its association with duration of weaning (143, 722). Simi-
larly, bilateral anterior magnetic stimulation of the phrenic
nerves, recording the resulting diaphragmatic contraction
using gastric and esophageal balloons, appears feasible and
safe, though complex and expensive and, therefore, not
 Table 4. Studies evaluating clinical outcomes associated with ICUAW determined using the MRC sum score
Reference Timing of Multivariate/Matched Relative Risk (95% CI) or
No. Population Incidence of ICUAW Measurement Univariate Analysis P Value Analysis Weak Versus Not Weak P Value

Prospective studies
144,147 MV ⱖ7 days 24/95 (25%) D7 after 1 Duration of MV ⬍0.001 Prolonged weaning HR 2.4 (1.4–4.2) 0.001
awakening
143,632 MV ⱖ7 days 75/115 (65%) At awakening Low MRCb delays successful 0.001 Low MRCb delays HR 1.96 (1.27–3.02) 0.002
extubation successful
extubation
1ICU mortality 0.006 1ICU mortality OR 7.99 (0.99–64.29) 0.05
1Hospital mortality 0.02 1Hospital mortality OR 2.02 (1.03–8.03) 0.048
499 ICU stay 50/474 (11%) At awakening 1ICU mortality ⬍0.05 NA NA NA
ⱖ24 h
ICU stay 44/185 (24%) 1ICU mortality ⬍0.05
⬎10 days
10 MV ⱖ5 days 35/136 (26%) At awakening 1Duration of MV ⬍0.001 2Hospital free days 41% (12–60%) 0.007
1ICU stay ⬍0.001 2ICU free days 54% (67–36%) 0.001
2ICU-free to day 30 ⬍0.001 1Hospital mortality OR 7.8 (2.4–25.3) 0.001
1Hospital stay ⬍0.001
2Hospital-free to day 60 ⬍0.001
1ICU readmission 0.01
1Discharged to other 0.01
location than home
1Hospital mortality ⬍0.001
82 SIRS and 13/39 (33%)a ICU 1Duration of MV 0.001 1Death before 180 NA 0.009
MV ⱖ48 discharge days
h
1ICU stay 0.005
2Functional outcome 0.01
(Barthel index) at D28
1Death before 180 days 0.03
1Resources needed 0.008
(cumulative TISS-28

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NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL

scores)
722 ICU stay ⱖ7 17/33 (51%) At awakening Prolonged weaning ⬍0.05 NA NA NA
days
1ICU stay 0.001
2MIP ⬍0.001
410c SICU 44/95 (46%) At awakening 1ICU stay 0.002 1ICU stay IRR 0.98 (0.97–0.98) ⬍0.001
1Hospital stay 0.001 1Hospital stay IRR 0.97 (0.97–0.98) ⬍0.001
1Mortality 0.006 1Hospital mortality OR 0.95 (0.90–0.99) 0.04
1Duration of MV 0.01
304 ICU stay 227/415 (55%) At awakening 1Time to alive weaning ⬍0.001 1Time to alive 11d (7–22) versus 8d 0.009
ⱖ8days weaning (5–14)

Continued

1033
1034
Table 4. —Continued
Reference Timing of Multivariate/Matched Relative Risk (95% CI) or
No. Population Incidence of ICUAW Measurement Univariate Analysis P Value Analysis Weak Versus Not Weak P Value

1Time to alive ICU ⬍0.001 1Time to alive ICU 8d (2–14) versus 3d (0–8) 0.008
discharge discharge
1ICU mortality 0.02 1Time to alive 36d (16–83) versus 23d 0.007
hospital discharge (13–41)
1Time to alive hospital ⬍0.001 2 6 min WD 66m (0–207) versus 191m 0.01
discharge (90–270)
1Hospital mortality ⬍0.001 1Total billed 23,277€ (15,370–36,147) 0.04
hopsitalization versus 17,834€
costs (12,227–31,306)
26 min WD 0.002 11 yr mortality 30.6% versus 17.2% 0.014
1Total billed hopsitalization ⬍0.001
costs
11 yr mortality ⬍0.001
487 Long-term 20/30 (67%) Within 24 h Pharangeal dysfunction Pharangeal
ventilated of FEES dysfunction
(ⱖ10
days),
FRIEDRICH ET AL.

FEES
clinically
indicated
PAS ⬎1 0.038 PAS ⬎1 9 (1.3–61.14) 0.038
VPSR ⬎1 0.014 VPSR ⬎1 5.4 (1–28.5) 0.014
Symptomatic aspiration 0.003 Symptomatic 9.8 (1.6–60) 0.009
(retrospective analysis) aspiration
Retrospective studies

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51 ARDS 27/45 (60%) At awakening 1ICU stay 0.001 NA NA NA
1Duration of MV (at 28d) 0.02

MV, mechanical ventilation; ICUAW, intensive care unit acquired weakness; MRC, medical research council; ICU, intensive care unit; NA, not available; CI, confidence interval; HR,
hazard ratio; OR, odds ratio; IRR, incidence rate ratio. All studies used MRC ⬍48 to diagnose ICUAW and to examine relationship with outcome unless explicitly stated: aankle
dorsiflexion not included, ICUAW defined as sum score ⬍35/50; bMRC sum score ⱕ41; cMRC sum score used as a continuous variable in the predictive models. Additional univariate
analysis with MRC cut-off of 48 showed significant association with days on MV, ICU, and hospital stay.
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
routinely applicable in the ICU. Reduced diaphragmatic
muscle strength had been shown (299, 387, 760). A clear
relationship between respiratory muscle weakness using
this technique and worse outcome was recently demon-
strated (153, 677). Another way to get around the problem
of consciousness and full cooperation is the use of electro-
physiological testing, e.g., in combination with direct mus-
cle stimulation (see below).
C. Clinical Diagnostic Tools and Potential
Contributing Mechanisms
Determining mechanisms contributing to weakness in the
acute setting is complicated by a number of factors. One
problem is that critically ill patients often cannot cooperate
with motor and sensory examination due to sedation or
encephalopathy. Because patients cannot cooperate, they
are unable to voluntarily recruit motor units during EMG
assessment. This prevents use of motor unit morphology
and recruitment to distinguish between neuropathy and
myopathy. Many studies have used the presence of sponta-
neous activity on EMG as an indicator of denervation and
thus the presence of neuropathy. However, spontaneous
activity is also present in CIM, such that this has led to
over-diagnosis of neuropathy as the mechanism underlying
weakness. To further complicate interpretation of motor
unit recruitment during EMG, a recent study in rats has
identified reduced motor neuron excitability as a possible
contributor to reduced motor unit recruitment (500). Thus,
while classic nerve conduction/EMG can be used to serially
follow development and resolution of neuropathy and my-
opathy, it should not be used in isolation to determine
mechanisms underlying weakness.
To distinguish between neuropathy and myopathy, more
detailed electrophysiological tests, like direct muscle stimu-
lation to measure muscle fiber conduction velocity (12) and
velocity recovery cycles of muscle action potentials (801),
are needed. In nerve, specialized tests such as strength-du-
ration time constant, threshold electrotonus, current-
threshold relationship, and recovery cycles are necessary to
identify reduced excitability (800). If nerve and muscle ex-
citability are normal, but sensory and motor amplitudes are
reduced, it is likely that axon degeneration is present and
the patient has critical illness neuropathy. If small motor
units are present that are recruited in a myopathic fashion,
it is probably safe to conclude myopathy is present. Muscle
biopsy can be used to study atrophy (myofibrillar protein
loss equally affecting actin and myosin without change in
acto-myosin ratios in pure atrophy) or preferential myosin
loss (with significantly decreased myosin-to-actin ratios as
in CIM patients and animal models of CIM). Ultrasound
might be used to follow muscle atrophy serially. Nerve bi-
opsy is needed to study axon loss. Serum CK can give some
estimate of muscle fiber death. By focusing on mechanisms
that underlie ICUAW, it may be possible to get a better
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
indication of prognosis. Different mechanisms that contrib-
ute to weakness are likely to have a different prognosis for
recovery. For example, it appears that loss of electrical ex-
citability in muscle and nerve may be fully reversible and
thus have a good prognosis for recovery (515, 583). Other
changes such as axon degeneration almost certainly have a
poor prognosis. The prognosis of severe myosin loss and
severe muscle atrophy are less clear.
Mechanisms underlying weakness may vary with time.
Within a few days of onset of critical illness, nerve conduc-
tions reveal reduced sensory and motor amplitudes (361,
698, 699). One likely contributor to early reduction in
nerve conduction amplitudes is ion channelopathy (515).
As available evidence suggests reduction/loss of electrical
excitability is fully reversible (515, 583), it is unlikely to be
a mechanism underlying chronic weakness. This suggests
that there may be an evolution of mechanisms contributing
to weakness such that mechanisms underlying acute weak-
ness (initially and within a few days) differ from those con-
tributing to weakness during the ongoing course of critical
illness (e.g., within weeks of critical illness). In particular,
there may also be phases of various pathophysiological
mechanisms contributing to the development of subsequent
mechanisms, e.g., membrane dysfunction and depolariza-
tion triggering Ca2⫹ imbalance, metabolic dysregulation
which may lead to atrophy and preferential myosin loss
(FIGURE 2). Determining whether mechanisms contributing
to weakness evolve over time will require longitudinal use
of both electrophysiology and pathology studies and clearly
represents a challenge for future clinical and animal studies.
IV. INTRODUCTION TO
PATHOPHYSIOLOGICAL MECHANISMS
Multiple mechanisms contribute to development of weak-
ness during critical illness. There seem to be numerous,
either independent or interacting, mechanisms that have
been identified that contribute to muscular weakness trig-
gered by critical illness (FIGURE 2) of which some are 1)
reduced excitability of muscle and nerve, 2) altered Ca2⫹
homeostasis, 3) myosin loss following mechanical silencing,
4) atrophy of muscle, 5) death of axons, 6) death of muscle
fibers, 7) disturbed anabolism-to-catabolism ratio, 8) bio-
energetic failure, and 9) failure of neuromuscular transmis-
sion, to name only some that are explained in more detail in
the subsequent sections. These will predominantly also fo-
cus on the myopathy aspect of critical illness. It is not
known whether myopathic mechanisms develop simultane-
ously or independently, and there may be distinct phases
underlying the clinical phenotype of “myopathy” that are
inherent to different pathophysiological mechanisms (FIG-
URE 2). To develop effective therapy, it may be necessary to
prevent multiple contributors to weakness. If all the mech-
anisms underlying weakness were triggered by the same
signal, development of therapy would be straightforward,
1035
 FRIEDRICH ET AL.

early phases late phases

motorprotein actomyosin
atrophy hyperproteolysis
muscle membrane dysfunction of myosin (‘ghost sarcomeres‘)
ICU stay Ca2+
critical illness hypoexcitability imbalance +
‘silent muscle‘ deficient autophagy, myofiber
bioenergetic vacuolization
failure etc.

1-2 5 >5-10 days

Immobilization, muscle unloading, patient mobilization,
mechanical ventilation respirator weaning

FIGURE 2. Specific pathophysiological mechanisms in ICUAW may either evolve in time independently or
trigger subsequent pathways to present with phases of myopathy during critical illness. Early phases may begin
as early as from 24 h of ICU treatment and are characterized by a dysfunction of membrane excitability
(hypoexcitability), followed by subcellular putative alterations in Ca2⫹ homeostasis, bioenergetics, and motor
protein function, whereas later phases after several days to 1 wk are marked by hyperproteolysis of myofibrillar
proteins (atrophy) and/or preferential myosin loss. Severe loss of sarcomeric proteins may also be responsible
for the structural fixation of the disease seen as altered cytoarchitecture and loss of contractile filaments that are
only slowly regenerated over months. Note that each mechanism is not limited to a particular phase, and
mechanisms may coexist at late stages (i.e., membrane hypoexcitability, myosin loss, impaired autophagy, etc.).

but if mechanisms underlying weakness were triggered in- plasma cytokine levels might correlate with illness severity
dependently by different signals, multiple interventions or mortality rate in septic children. They found that plasma
would be necessary. TNF-␣, IL-1, and IL-6 levels were elevated in patients. Cy-
tokine levels correlated with mortality rate; all three cyto-
kines were higher in nonsurvivors than in patients who
V. INFLAMMATORY CYTOKINES IN
survived. Damas et al. (140) measured TNF-␣, IL-1␤, and
CRITICAL ILLNESS
IL-6 levels in 40 critically ill surgical patients where IL-6
was a robust marker of illness, correlating with both
A. Cytokine Elevation in Critical Illness APACHE II score and mortality.

A half-century of research implicates proinflammatory Subsequent refinements in immunoassay technology have

cytokines as potential mediators of critical illness. This
concept originally emerged in animal studies designed to
characterize individual cytokines. For example, circulat-
ing interferon (IFN) levels were markedly increased in
mice following endotoxin administration or bacterial in-
fection (663) or in guinea pigs subjected to burn injury
(709). In discovering tumor necrosis factor-␣ (TNF-␣),
Carswell et al. (106) found that plasma TNF-␣ levels
were increased by administering endotoxin to mice, a
finding later extended to rats and rabbits (521). Although
these early reports were limited in scope and narrowly
focused, they laid the foundation for an explosion of
basic science research in the field. It became clear that
IFN, TNF-␣, members of the interleukin (IL) family, and
other cytokine mediators are highly sensitive to experi-
mental conditions that are related to critical illness. A
partial listing with representative references includes sep-
sis (241, 328), mechanical trauma (246), surgery (670,
802), pneumonia (71, 527), drug-induced organ failure
(660), thermal injury (484, 743), and peritonitis (36).
Studies of critically ill patients provide more-specific infor-
mation on cytokine regulation in the clinical setting. An
early study by Sullivan et al. (669) tested the hypothesis that
enabled broader documentation of cytokine profiles in the
clinical setting. Sepsis severity, the evolution of organ fail-
ure, and patient death were associated with distinct multi-
cytokine profiles. Hranjec et al. (326) evaluated blood levels
of IL-1, -2, -4, -5, -6, -8, -10, and -12, IFN-␥, TNF-␣ and
granulocyte-macrophage colony-stimulating factor (GM-
CSF) within 48 h of admission to the ICU in a large patient
number. Patients were subclassified based on evidence of
infection or trauma. On admission to ICU, specific cytokine
profiles were associated with three patient subgroups: pa-
tients who lacked infection or trauma (IL-6, -8, -10), in-
fected patients who died (IL-2, -8, -10, GM-CSF), and
trauma patients who died (IL-4, -6, -8, TNF-␣). Elevation of
individual cytokines predicted death in trauma patients
(IL-4) and patients with neither trauma nor infection
(IL-8) but not in patients with infection. It is interesting
to note that in this study, ⬃10% of patients in all groups
were not mechanically ventilated. However, mechanical
ventilation was not separated as an independent variable
in the analysis of cytokine profiles. A more targeted study
measured circulating cytokines during the first week after
admission in 30 septic patients (480). They found that
early elevation of IL-8 and monocyte chemoattractant
protein (MCP-1) predicted mortality, whereas specific

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 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL

multi-cytokine profiles were associated with either organ
failure or shock. Proinflammatory cytokines are sug-
gested to promote muscle atrophy and weakness in crit-
ically ill patients (780). Not all cytokines are implicated.
Rather, a subset of cytokines has been linked to protein
loss or muscle dysfunction in critically ill patients. As
outlined in TABLE 5, these clinical associations were
strengthened by mechanistic studies using animal mod-
els, isolated tissue preparations, and cell culture systems.
Over the past four decades, this vertically integrated ap-
proach has generated substantial evidence that cytokines
can compromise skeletal muscle performance. The fol-
lowing sections highlight information on three cytokines
that are best understood in this context.
B. TNF-␣, Muscle Atrophy, and Contractile
Dysfunction
TNF-␣ is the proinflammatory cytokine that has been stud-
ied most extensively for effects in skeletal muscle. The pro-

Table 5. Inflammatory mediators associated with critical illness and effects in muscle
Inflammatory Mediator Molecular Mass, kDa Effects in Skeletal Muscle

TNF-␣ (cachectin) 26 (mature secreted form: Also expressed in type II muscle fibers (550)
17)
Depolarization of plasma membrane (712)
Na⫹-current inhibition, left shift of Na⫹ channel activation and inactivation
(274)
Activation of PKC-mediated Na⫹ channel phosphorylation (148)
Induces muscle proteolysis and atrophy (148)
Alters resting Ca2⫹ levels (decrease in myotubes) (741)
No change in tetanic Ca2⫹ amplitudes in muscle fibers (741)
Decreases Ca2⫹ transient amplitudes by 50% (in myotubes) (741)
Depresses tetanic force production in limb and diaphragm muscle (571)
Activates ubiquitin-proteasome pathway (227,428)
Increase major histocompatibility complex II surface expression (in
combination with IFN-␥) in human muscle cells (359)
Activation of NF-␬B (573)
Downregulation of MyoD inhibits myogenic differentiation (280)
Induces insulin resistance in muscle (248)
IL-1 13–17 (precursors: 33) Produced by activated macrophages; also expressed in muscle fibers in health
(619), following exercise (101), and in inflammatory myopathies (26)
IL-1␣: primarily Associates with RyR1, blocks SR Ca2⫹-release, and decreases SR Ca2⫹ leak
membrane-bound in muscle fibers (220)
IL-1␤: secreted form Upregulates iNOS expression (4)
Induces skeletal muscle proteolysis [IL-1␣ (785), but maybe not IL-1␤ (228)]
Stimulates IL-6 production in skeletal muscle cells (IL-1␤) (445)
Stimulates prostaglandin E2 (PGE2) production and proteolysis (250)
Ubiquitin gene expression 1 (437) or % (228)
Inhibition of protein synthesis (132)
IL-6 23–30 (glycosylation diversity) Produced by activated macrophages and T-cells, tumor cells, but also
produced by muscle fibers (type I ⬎ type II) (550)
No effect on ubiquitin expression (437)
Promotes infiltration of myocytes with prostaglandins (780)
Both pro- and anti-inflammatory actions in critical illness (24)
Induces skeletal muscle protein breakdown (in rats) (259)
Reduces insulin-stimulated glucose uptake in muscle (364)
IL-10 18 (unglycosylated in humans) Anti-inflammatory cytokine (780)
Prevents skeletal muscle from IL-6-induced defects in insulin action (364)
IFN-␥ 20–25 Produced by activated T-cells and natural killer cells but also in muscle fibers
following muscle injury (118)
Required for muscle regeneration (118)
Inhibits protein translation in muscle by stimulating NO synthase activity (223)
Modulator of TNF-␣ signaling in muscle (myotubes: downregulation of TNF-R2
and increased NF-␬B activity) (710)
Ubiquitin gene expression 1 (437)

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 FRIEDRICH ET AL.
tein is synthesized as a 26-kDa parent molecule that is
cleaved upon cellular release to form a 17-kDa polypeptide
that promotes anti-tumor and immune responses. This mol-
ecule was originally named “cachectin” to acknowledge its
association with catabolic states of cachexia. Circulating
TNF-␣ concentrations are commonly elevated in critically
ill patients (see above) and in animal models of critical
illness, e.g., lipopolysaccharide administration (636), peri-
tonitis (507), trauma (539), heart failure (20), and burn
injury (799). Increases in TNF-␣ promote muscle weakness
via two general mechanisms: 1) promotion of atrophy and
2) induction of contractile dysfunction.
1. TNF-␣ promotes muscle atrophy
This was first demonstrated in animal studies where sys-
temic administration of exogenous TNF-␣ decreased mus-
cle mass and muscle fiber cross-section (83, 226). Initially,
TNF-␣ was thought to be an indirect actor, e.g., via an-
orexia (485) or glucocorticoid elevation (472), since direct
exposure to TNF-␣ for up to 3 h did not stimulate protein
loss in excised muscle preparations (229, 251, 591). How-
ever, Li and colleagues (420, 421) later showed a direct
catabolic action of TNF-␣ on differentiated muscle cells.
Incubation of cultured myotubes with a clinically relevant
TNF-␣ concentration caused progressive reductions in total
protein content, muscle-specific protein levels, and myo-
tube diameter over several days. These changes mimic the
response of intact skeletal muscle to critical illness, support-
ing a potential role for TNF-␣. At the cellular level, TNF-␣
stimulates protein loss via receptor-mediated signaling
events that alter muscle gene expression. Skeletal muscle
constitutively expresses TNF-␣ receptor subtype 1
(TNFR1) and subtype 2 (TNFR2). Llovera and associates
(438, 439) have shown that TNF-␣ acts via TNFR1 (and
not TNFR2) to stimulate catabolism. In muscle, TNF-␣
exposure rapidly activates the transcription factor nuclear
factor-␬B (NF-␬B) which is essential for loss of muscle pro-
tein (421). The canonical pathway for NF-␬B activation is
mediated by the I-␬B kinase (IKK) complex (546) and is
redox sensitive during TNF-␣ stimulation. NF-␬B activa-
tion is positively modulated by a transient rise in muscle-
derived reactive oxygen species (ROS), which function as
second messengers for TNF-␣ (421), and is negatively mod-
ulated by the glutathione cycle (626). TNF-␣ also rapidly
activates the mitogen-activated protein kinases (MAPKs)
including p38MAPK, extracellular signal-regulated kinases
1 and 2 (ERK1/2), and c-Jun NH2-terminal kinase (JNK) in
differentiated myotubes (418).
In muscle cells, these signaling events stimulate the expres-
sion of genes that regulate the ubiquitin-proteasome path-
way. TNF-␣ signaling via NF-␬B increases mRNA levels for
E2-20k, a ubiquitin carrier protein and murine homolog of
human UbcH2 (419). In parallel, TNF/p38MAPK signaling
increases the expression of atrogin1/MAFbx, a ubiquitin
ligase that mediates muscle atrophy in a variety of catabolic
1038 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
states (418). These changes are associated with TNF-stim-
ulated increases in functional activity of the ubiquitin con-
jugating pathway. This is the major pathway for regulated
degradation of muscle protein via the 26S proteasome. In
muscle cells, the rise in ubiquitin conjugating activity is
abolished by selective inhibition of p38MAPK (418),
NF-␬B (421), or E2-20k (419), demonstrating that each of
these elements is essential for integrity of the response.
Moreover, selective inhibition of NF-␬B prevents loss of
muscle protein stimulated by TNF (421), identifying NF-␬B
as a critical regulator of catabolism in response to this cy-
tokine (see also sect. XI).
2. TNF-␣ and contractile dysfunction
TNF-␣ also depresses the force of muscle contraction in the
absence of atrophy. This was first observed by Wilcox et al.
(773) exposing fiber bundles isolated from hamster dia-
phragm to exogenous TNF-␣ in vitro. Isometric force nor-
malized to fiber bundle cross-section (“specific force”) was
significantly depressed by TNF-␣. This was later confirmed
in fiber bundles from guinea pig diaphragm (14), mouse
diaphragm (423), and mouse flexor digitorum brevis (571).
Contractile dysfunction is not simply an artifact of TNF-␣
exposure in vitro. Li et al. (423) observed a similar decre-
ment in specific force of diaphragm fiber bundles isolated
from transgenic mice engineered for cardiac-specific over-
expression of TNF-␣. In this case, the muscle was exposed
to TNF-␣ in vivo (serum concentration 250 –350 pg/ml)
prior to excision; exogenous TNF-␣ was not used. Yet,
specific force was approximately half the value of wild-type
muscle for twitch and maximum tetanus. The muscle was
stimulated directly, eliminating neuromuscular activation
as a potential cause of weakness. There was no evidence of
muscle atrophy or damage. Body weight, the weights of
representative trunk and limb muscles, and the ultrastruc-
ture of limb and diaphragm muscle fibers were indistin-
guishable between transgenic and control animals. Thus
chronic exposure to low levels of circulating TNF-␣ can
profoundly weaken muscle fibers without inducing detect-
able atrophy.
Several studies have addressed the cellular mechanism of
TNF-induced dysfunction. Hardin et al. (286) used mice
deficient in TNFR1 and TNFR2 to assess the receptor sub-
type by which TNF-␣ depresses specific force. One hour
following intraperitoneal TNF-␣ by injection, diaphragm
fiber bundles showed marked depression of specific force.
TNFR1 deficiency abolished this response, but TNFR2 de-
ficiency did not. Thus, like atrophy, contractile dysfunction
is mediated via TNFR1. Studies of post-receptor signaling
have largely focused on muscle-derived oxidants as second
messengers. Within minutes, TNF-␣ exposure increases cy-
tosolic oxidant activity (286, 423, 656), which can depress
specific force (570). Consistent with this model, preincubat-
ing muscle fiber bundles with N-acetylcysteine (NAC), a
reduced thiol donor, abolished the effects of exogenous
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
TNF-␣ (423). NAC pretreatment prevented the rise in cy-
tosolic oxidant activity and preserved specific force at con-
trol levels. Similarly, pretreating mice with Trolox, a water-
soluble vitamin E analog, abolished the effects of TNF-␣
injection on cytosolic oxidant activity and specific force
(286). These studies reveal that muscle-derived oxidants
mediate TNF-␣ effects on contractile function.
But which are the exact oxidants involved? Skeletal muscle
fibers contain multiple intracellular sources of ROS includ-
ing mitochondria, NADPH oxidase, cyclooxygenase, and
xanthine oxidase. Also, muscle fibers constitutively express
two enzymatic sources of nitric oxide (NO): the neuronal-
type isoform of NO synthase (nNOS) and the endothelial-
type isoform (eNOS). Both ROS and NO derivatives are
continuously generated by skeletal muscle. Both redox cas-
cades participate in a variety of signal transduction path-
ways. And in muscle, both cascades appear to be essential
for TNF-stimulated dysfunction. Alloati et al. (14) origi-
nally reported that TNF-␣ stimulates NO production by
muscle and that pharmacological blockade of constitutive
NOS activity prevents the fall in specific force caused by
TNF-␣. These findings were confirmed by Stasko et al.
(656) who identified the nNOS isoform as the molecular
source of NO signaling stimulated by TNF-␣. In this same
study, the investigators also examined ROS involvement.
They found no evidence that TNF-␣ stimulates muscular
ROS production. However, selective depletion of ROS (su-
peroxide anions, hydrogen peroxide) in the cytosolic milieu
abolished TNF-␣ effects on specific force without disrupt-
ing TNF-␣/NO signaling. The authors concluded that
TNF-␣ stimulates NO production by nNOS but that endog-
enous ROS are obligate comediators of the signal transduc-
tion pathway that depresses specific force. The mechanism
of NO/ROS interaction was not tested, but it was specu-
lated that peroxynitrite (a reaction product of NO and
ROS) might be a downstream mediator required for con-
tractile dysfunction (656). Two lines of evidence identify
myofibrillar proteins as the target of TNF-␣/NO/ROS sig-
naling. Reid et al. (571) tested TNF-␣ effects on contractile
regulation in intact single murine limb muscle fibers and
found that TNF-␣ depressed specific force of tetanic con-
tractions without altering the magnitude or duration of in-
tracellular calcium transients. They concluded that TNF-␣
signaling acted on an intracellular target downstream of the
calcium transient, i.e., the myofibrillar lattice. This interpre-
tation was confirmed by Hardin et al. (286) in permeabil-
ized muscle fibers isolated from mice injected with either
TNF-␣ or saline. In “skinned” fibers from TNF-treated an-
imals, specific force was depressed at higher calcium con-
centrations, providing clear evidence of myofibrillar dys-
function. Interestingly, TNF-␣ effects on the calcium-force
relationship closely resemble the effects of direct peroxyni-
trite exposure (684), consistent with the postulate that per-
oxynitrite is a downstream mediator of TNF-␣ signaling.
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
C. IL-1 and Skeletal Muscle
IL-1 is commonly present at elevated concentrations in
the serum of critically ill patients, a biomarker that often
correlates with clinical outcome. The cytokine exists as
two isoforms. IL-1␣ is primarily membrane-bound,
whereas IL-1␤ is the secretory form that mediates para-
crine and endocrine effects. IL-1 is synthesized both by
activated macrophages and by nonimmune cells. These
include skeletal muscle fibers which express IL-1␤ at low
levels under basal conditions (619) and at higher levels
after exercise (101) and in inflammatory myopathies
(26). In critical illness, in particular in the context of
sepsis, the release pattern of IL-1 (alongside with other
proinflammatory cytokines) shows a distinct time course
that is summarized in FIGURE 3A.
IL-1 is a potential stimulus for the protein loss and muscle
atrophy seen in critical illness. Elevated IL-1 levels clearly
promote muscle atrophy in experimental animals. For ex-
ample, Cooney et al. (132) showed that IL-1␣ infusion for 6
days decreases muscle weight and protein content of rat
gastrocnemius. The pathophysiological relevance is evident
in animal models of sepsis where administration of an IL-1
receptor antagonist can preserve muscle mass (131). Studies
of underlying mechanisms suggest that IL-1 influences both
protein degradation and protein synthesis. Baracos et al.
(34) first reported that IL-1, then referred to as leukocytic
pyrogen, acts directly on isolated skeletal muscle prepara-
tions to increase intralysosomal proteolysis and net protein
degradation. This action was augmented at elevated muscle
temperatures, a model of fever, and appeared to be medi-
ated by a rise in prostaglandin E2 synthesis. IL-1 did not
alter protein synthesis in this preparation. The catabolic
actions of IL-1␣ were demonstrated in vivo by Zamir et al.
(795) who found that total and myofibrillar protein break-
down rates were elevated in isolated limb muscles from rats
injected with recombinant IL-1␣. Consistent with the asser-
tion that IL-1 promotes proteolysis, intravenous adminis-
tration of this cytokine is reported to increase ubiquitin
expression in rodent muscle (437), although ubiquitin up-
regulation is not always observed (228). IL-1 effects on
synthesis pathways also promote net loss of muscle protein.
Cooney et al. (132) showed that IL-1␣ infusion depressed
protein synthesis rates in rat gastrocnemius, a muscle com-
posed primarily of fast fibers, whereas soleus muscle (pri-
marily slow fibers) and the heart were unaffected. This find-
ing is consistent with earlier observations that amino acid
uptake was depressed in limb muscles of rats treated with
IL-1␣ (794).
Less is known about IL-1 effects on skeletal muscle contrac-
tion. However, a recent report on IL-1␣ effects on calcium
release from the sarcoplasmic reticulum (SR) raises intrigu-
ing possibilities (220). With the use of permeabilized single
fibers, spontaneous colocalization of exogenously applied
IL-1␣ with the RyR1 was found (220). IL-1␣ exerted revers-
1039
 FRIEDRICH ET AL.

A
Pro-inflammatory Anti-inflammatory

Sepsis: + Liver macrophages Serum

IL-6 Exercise:

Cytokine expression
TNF-α IL-6
IL-1α

Cytokine levels
IL-10
IL-1β
IL-1 TNF-α
sTNF-R TNF-α
IL-1RA IL-1

0 5 10 15 20 0 5 10 15 20
Time (hrs) Time (hrs)
Time
B
Non-muscle tissue Systemic Local (muscle)
(e.g., tissue macrophages, liver, Liver
adipocytes, glia cells, etc.) CRP, TNF-α,
IL-10, IFN-γ
Muscle
wasting ?
IL-1
IL-1 TNF-α IL-1
IL-6
TNF-α
IL-6

Macrophages IL-1RA
Monocytes –
Neutrophils
IL-10 +
IL-1 Muscle
Circulation TNF-α

Local Systemic Local

FIGURE 3. Pro- and anti-inflammatory cytokines and their role in sepsis/critical illness and the systemic
inflammation-muscle axis. A: time course of pro- and anti-inflammatory cytokines in the systemic circulation in
critical illness as best studied in the scenario of sepsis. During sepsis, pro-inflammatory IL-1 and TNF-␣ rise
early, followed by an increase in IL-1, which is then followed by a rise in anti-inflammatory mediators to initiate
the compensatory anti-inflammatory response syndrome (CARS). IL-6 both exerts pro- and anti-inflammatory
effects. For example, exercise lacks the pro-inflammatory response and is purely characterized by anti-
inflammatory response triggered by almost sole IL-6 release from exercising muscle (“myokine”; note: IL-6
amplitude in both sepsis and exercise scaled to maximum; absolute IL-6 amplitudes are much larger in
exercise). Individual time courses may vary depending on the model (e.g., CLP shown in the right panel) and
outcome. [Right panel according to data from Chensue et al. (119). Left panel modified from Petersen and
Pedersen (545).] B: systemic inflammation-muscle axis during sepsis and critical illness. Activated macro-
phages in inflamed tissue as well as monocytes and neutrophils in the blood secrete large amounts of
pro-inflammatory IL-1 and TNF-␣ that drive the pro-inflammatory systemic response. These mediators also
stimulate myokine production in skeletal muscle, of which IL-6 is the most predominant to initiate the systemic
CARS by inhibiting further IL-1/TNF-␣ release and to stimulate production of IL-10 and IL-1RA, for example.

ible effects on SR calcium release and specific force that
were strongly dependent on Mg2⫹ concentration. Long-
term IL-1␣ exposure of intact muscle fibers caused loss of
sarcolemmal integrity leading to intracellular deposition of
IL-1␣. These data suggest a novel mechanism of action by
which IL-1 might depress muscle contraction in critically ill
patients (see also sect. IX). This hypothesis has not been
tested but is consistent with several related observations: 1)
specific force of skeletal muscle is depressed by secretory
products of lipopolysaccharide-stimulated monocytes
(774), which are known to include IL-1; 2) similar to skel-
etal muscle, IL-1 alters SR calcium release by cardiac myo-
cytes (170); and 3) in the heart, IL-1 depresses the force of
myocardial contraction (321). Clearly, the effect of IL-1 on
skeletal muscle contraction is a novel topic of potential
importance in critical illness.
1. The paradox of IL-6
IL-6 is a pleiotropic cytokine with both pro- and anti-in-
flammatory properties. It is secreted by various cell types
including T cells, macrophages, smooth muscle cells, osteo-
blasts, and skeletal muscle fibers. Among muscle-derived
cytokines, IL-6 has been studied extensively. IL-6 affects
skeletal muscle myogenesis, lipid metabolism, glucose up-
take, protein synthesis, and protein degradation.

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 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
IL-6 is commonly elevated in the serum of critically ill pa-
tients (FIGURE 3A), suggesting a positive association with
the loss of muscle that occurs in these individuals. However,
the experimental data paint a more nuanced picture: on the
one hand, direct IL-6 exposure has not been shown to stim-
ulate muscle proteolysis in vitro. Incubation of rat limb
muscles with recombinant IL-6 in vitro does not alter the
rate of protein breakdown (230, 259), nor have cell culture
studies detected an effect of exogenous IL-6 on the rate of
proteolysis in rodent muscle-derived myotubes (179). In
contrast, IL-6 appears to promote protein degradation in
vivo. High concentrations of circulating IL-6 stimulate
muscle proteolysis in rats treated with the recombinant cy-
tokine (259) and in transgenic mice engineered for stable
overexpression of IL-6 (718). Conversely, inhibition of cir-
culating IL-6 has been shown to lessen muscle atrophy in an
animal model of cancer cachexia (665) and in IL-6 trans-
genic mice (719). These divergent outcomes simply may be
artifacts of experimental design, e.g., IL-6 concentration or
the duration of exposure. However, Munoz-Canoves et al.
(497) have proposed a more interesting interpretation.
They suggest that IL-6 promotes muscle atrophy in the in-
tact animal via indirect effects on insulin-like growth factor
I (IGF-I) signaling. Normally, IGF-I promotes muscle
growth. The authors reasoned that IL-6 reduces serum lev-
els of IGF-I binding-protein-3 (497) and thereby promotes
degradation of serum IGF-I, lessening IGF-I effects on mus-
cle growth. To our knowledge, only one published report
has tested the direct effect of IL-6 on contractile function.
Janssen et al. (351) incubated diaphragm muscle fiber bun-
dles with recombinant IL-6, then measured specific force
and endurance capacity. IL-6 did not alter these parameters.
Apart from a systemic action of IL-6 on muscle, muscle
itself has been recognized as an endocrine organ being able
to actively secrete several cytokines upon stimulation, e.g.,
in response to exercise or inflammation. These “myokines,”
among which IL-6 seems to be most responsive to physical
exercise (545) or electrical stimulation (89), are produced in
an ATP- and Ca2⫹-dependent manner. IL-6 has sometimes
been termed “a double-edged sword” exerting both protec-
tive and deleterious effects on skeletal muscle (497). On the
one hand, IL-6 production is stimulated by TNF-␣ and
IL-1␤ and may contribute to the proinflammatory cascade
in critical illness and sepsis (706); on the other hand, stren-
uous exercise induces a likewise marked increase in IL-6
plasma levels (up to 100-fold; Ref. 192) without the preced-
ing increase in proinflammatory TNF-␣ and IL-1 as seen in
sepsis (FIGURE 3A). The fact that the IL-6 peak is followed
by rising levels of cytokine inhibitors, i.e., IL-1RA and sol-
uble TNF-␣ receptors (sTNF-R) has cornered its role for
anti-inflammatory effect of exercise (532) but may also be
important in initiating the compensatory anti-inflammatory
response syndrome (CARS) in sepsis and eventually, during
critical illness (533). It is attractive to speculate that sys-
temic IL-6 produced in nonmuscle tissues by TNF-␣ and
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
IL-1 may contribute to proinflammatory feedback while,
once muscle secretes large amounts of IL-6 into the circula-
tion, this would shift the response towards an anti-inflam-
matory feedback. This hypothesis still awaits experimental
clarification, but at least one recent study shows that in
mechanically ventilated ICU patients who developed myop-
athy, the inflammation-induced acute phase response re-
sulted in a marked increase in IL-6 production in skeletal
muscle, and also in immobilized muscle (392). Although
this increase in inflammation-induced IL-6 myokine pro-
duction is substantially smaller than in response to strenu-
ous exercise (⬃15- vs. 100-fold, respectively; Refs. 192,
392), the results point towards a common denominator in a
“muscle-immune system” axis where skeletal muscle feeds
back to the proinflammatory response syndrome by tuning
the onset of the CARS reaction (FIGURE 3B). However, since
IL-6 also exerts potential detrimental effects on muscle such
as muscle wasting, this may even become the more promi-
nent effect in critical illness beyond a putative “tipping
point” of IL-6 production such as suggested in FIGURE 3B.
Apart from IL-6, IL-1 has recently also been shown to be
secreted by skeletal muscle in response to inflammasome
upregulation (568), and this may be in part responsible for
detrimental effects of force production in critical illness
(220). However, the role of this “myokine” in regulating
systemic immune response on top of the already increased
circulating systemic IL-1 is not known.
FIGURE 3B summarizes the local (muscle) and systemic in-
teraction of cytokines.
VI. BIOMECHANICS,
MECHANOSENSATION, AND
TENSEGRITY IN CRITICAL ILLNESS
In this section, the mechanical activation of skeletal muscle
and its pathways that are significantly affected by the ICU
condition are discussed in more detail. Mechanical external
stimuli may not only influence immediate signaling events,
e.g., SR Ca2⫹ release, via mechanosensitive channels (697)
but also influence the shape and growth of all cells via direct
effects on protein synthesis and degradation. However, our
knowledge of the mechanisms on how mechanical signals,
i.e., mechanosensation or “tensegrity” (339 –343), are
transduced to influence transcriptional regulation and in-
tracellular biochemistry is far from complete. Tensegrity or
“tensional integrity,” a term derived from architecture, de-
scribes the interaction between isolated components within
a system under mechanical compression or tension and re-
sulting structure. It has been introduced to muscle biology
to summarize cellular functional and structural responses to
mechanical stimuli (574). For example, mechanical signals
may induce increased protein synthesis, satellite cell activa-
tion, and release of growth factors and may overlap with met-
abolic, action potential-induced, and oxidative signaling
1041
 FRIEDRICH ET AL.
(576). Different major signaling cascades such as PI-3K,
MAPKs, Ca2⫹-calmodulin-calcineurin-NFAT, glycogen
synthase kinase (GSK), and AMP activated kinase (AMPK)
are downstream effectors of mechanotransduction (86)
(FIGURE 4). Mechanosensing in skeletal muscle involves
multiple components and spans from integrins, focal
adhesion complexes (FAC), stretch-activated calcium- and
sodium-permeable membrane ion channels, caveolin-3 and
the caveolin-3-associated nNOS, the sarcodystroglycan
complex, intermediate filaments, and a number of mecha-
nosensitive sarcomeric proteins, as well as mechanosignal-
ing via the IGF-I growth factor (76, 86, 346, 390, 391, 641,
652, 686, 687, 754) signaling (FIGURE 4). In addition, ex-
ternal forces on surface membrane receptors, such as integ-
rins and cadherins, might act at distance and promote co-
ordinated changes in nuclear structures via a hard-wired
network including structural actin and specialized nuclear
anchoring structures (349, 754). This direct and fast mecha-
notransduction from the cell surface to the nucleus induces
an ion flux through the nuclear membrane and the intranu-
clear acto-myosin complex may contribute to nuclear pre-
stress and nuclear mechanosensation affecting gene regula-
tion via various mechanisms (754) (FIGURE 4).
The communication between transcription factors and
transcriptional modifiers in the sarcomere has recently been
reviewed (76). Multiple mechanosensors are embedded in
the sarcomere. In the Z-disk, several mechanosensitive ele-
ments have been identified with direct transcriptional links
to the nucleus, such as MYOZ2 (negative regulator of cal-
cineurin), MLP, and CLOCK, shuttling to the nucleus in
response to mechanical strain, and CBF␤ (involved in
JUNB-mediated gene expression) (FIGURE 4). In the I-band,
different stretch-sensitive muscle ankyrin repeat proteins
(MARPs) form complexes with titin and myopallidum/cal-
pain-3 and have been suggested to sense passive stress on
the sarcomere (76). At the M-band, the titin kinase interacts
with a complex of atrogenes which during mechanical ar-
rest dissociates and translocates to the cytoplasm and nu-
cleus (NBR1, SQSTM1, and MuRFs) (391, 559). These
atrogenes are believed to act as transcriptional repressors
amplifying the atrophy program affecting both protein syn-
thesis and different degradation pathways (see Ref. 76) (FIG-
URE 4).
Different experimental and clinical models have been used
to study the effects of immobilization on skeletal muscle
structure and function, such as hindlimb unloading, micro-
gravity, bed rest, joint immobilization in plaster (or other
types of fixation), denervation, etc. All these models are
associated with altered mechanosensing, but effects on pro-
tein synthesis and degradation are dependent on type of
mechanical load. The mechanical load induced by weight
bearing, passive stretch, or shear stress in the sarcomere
caused by activation of contractile proteins and the level
and type of activation of contractile proteins will involve
1042 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
different mechanosensors targeting specific intracellular
signaling pathways with consequences for myofibrillar pro-
tein synthesis and degradation. It is accordingly not surpris-
ing that the effects of hindlimb unloading, denervation, and
immobilization will have different effects on myofibrillar
protein expression despite the fact that all are characterized
by a decline in muscle mass and force. For instance, strict
bed rest for 6 mo results in mild muscle fiber atrophy due to
a general loss of contractile proteins that is larger than the
loss in muscle fiber size, resulting in decreased single muscle
fiber specific force (398). During muscle unloading by
hindlimb suspension or microgravity, the loss of muscle
mass and function has been reported to be associated with a
preferential actin loss (203, 204, 585) and slow-oxidative
(type I) to fast-glycolytic (type II) fiber types switching
(493). In limb suspension, microgravity, and bed rest mod-
els, weight bearing has been removed, but there is still in-
ternal strain related to activation of contractile proteins. In
immobilization models with joint fixation by, e.g., plaster,
weight bearing is typically intact and activation of contrac-
tile proteins has not been eliminated, although contractions
are mainly isometric. In denervation atrophy, muscles are
still passively loaded due to weight bearing or activation of
agonists/antagonists. This also applies to spinal cord injury
where marked fiber atrophy and slow-to-fast fiber transi-
tion occurs with a larger extent in humans compared with
rodents (266). In deeply sedated mechanically ventilated
ICU patients, with or without neuromuscular blockade,
both external (weight bearing or passive movement induced
by activation of agonists or antagonists) and internal me-
chanical load (activation of contractile proteins) have been
removed. This complete “mechanical silencing” in ICU pa-
tients is, to our knowledge, unique for ICU patients with
significant consequences for gene and protein expression
and different from the other unloading conditions listed
above.
The preferential loss of the molecular motor protein myosin
and myosin-associated proteins and maintained expression
of thin filament proteins are a hallmark of CIM in ICU
patients (396, 397, 399, 400, 519, 662). Neuromuscular
blockade, systemic administration of glucocorticosteroids,
and sepsis have been forwarded as important factors trig-
gering this type of acquired myopathy, but preferential my-
osin loss in ICU patients has been reported in the absence of
any of these factors (399). Instead, all ICU patients who
develop CIM have been exposed to long-term mechanical
ventilation and mechanical silencing (396, 519). Further-
more, both experimental and clinical studies have shown
that long-term mechanical ventilation and “mechanical si-
lencing” with or without neuromuscular blockade and
without both sepsis and systemic steroid administration in-
duce the preferential myosin loss observed in patients with
CIM (396, 435, 517, 519). Thus mechanosensation plays
an integral role in the complex development of CIM in
long-term immobilized and mechanically ventilated ICU
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL

SACT LIF IGF-I rp-vl Integrins

FAK DSG
ILK
Ca2+ Caveolae
Na+
Ca2+
PI3K
nNOS

AKT F-actin

Downstream effectors of
mechanotransduction:
p70S6K • PI-3K
mTOR • MAPKs
4EBP Nucleus
• Calmodulin
• Calcineurin
Telethonin • Glycogen synthase kinase
MLP • AMP activated kinase
CLOCK • AKT/mTOR
CBFβ MARPs Titin kinase:
MYOZ2 • SQSTMI
α-actinin • NBRI Protein synthesis/
abscurin • MuRF degradation
• Pb2
Titin Myosin Actin

Z-line M-band Z-line

FIGURE 4. Mechanosignaling in skeletal muscle. Mechanosignaling represents an emerging and dynamic

field in biomedical science, but the complexity of the different pathways involved, and how they are interrelated,
is not fully resolved. Different pathways involved in mechanosensing and tensegrity in skeletal muscle are briefly
summarized, and those reported to be altered in CIM are highlighted in red. However, mechanosignaling has
only recently been forwarded as a factor triggering CIM, and the mechanosensing pathways are most probably
far more complex than those indicated in red. Multiple signaling pathways influence protein synthesis and
degradation in the muscle fiber spanning from the muscle membrane and extracellular matrix to the M-band
in the center of the sarcomere. Insulin-like growth factor I (IGF-I) has been suggested to play an important role
for the muscle hypertrophy induced by mechanical overload, but a maintained hypertrophy response has been
reported in transgenic mice with an IGF-I receptor lacking the ability to bind IGF-I, suggesting multiple other
mechanosensitive pathways (651). Calcium- and sodium-permeable stretch-activated channels (SAC) respond
to mechanical stimuli and various intracellular signaling cascades. In addition, membrane invaginations, i.e.,
caveolae, respond to cell stress and stretch-induced signaling, and many different proteins involved in cell
signaling bind to caveolins, such as neural nitric oxide synthase (nNOS), G protein subunits, tyrosine kinases,
small GTPases, and growth receptors (240, 641). The cytokine leukemia inhibitory factor (LIF) plays an
important role in muscle hypertrophy in response to mechanical loading (651). Integrins spanning from the
extacellular matrix to the interior of the muscle cell, linked to cytoskeletal actin, directly connect to the nuclei
and mitochondria, thus allowing a “hard-wired” and rapid signal propagation to nuclear and mitochondrial DNA
(754). The subsarcolemmal dystrophin sarcoglycan complex (DSG) is involved in mechanosensing, and a
deficiency in this complex is a feature of muscular dystrophies with defects in the signaling related to
mechanical load, resulting in muscle degeneration (793). A number of sarcomeric proteins are involved in
mechanosensing, and there is emerging evidence of a very dynamic exchange of multiple sarcomeric proteins
to the cytoplasmic pool affecting muscle gene expression in response to mechanical load from the Z-line to the
center of the sarcomere in the M-band (76, 234, 390). Multiple major signaling cascades are downstream
effectors of mechanosensing, such as PI-3K, MAPKs, calmodulin, calcineurin, glycogen synthase kinase, AMP
activated kinase, and AKT/mTOR (86).

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 FRIEDRICH ET AL.
patients that distinguishes it from other myopathies under
the ICUAW umbrella (FIGURE 1B).
In pioneering work by Griffiths et al. (269), it was demon-
strated that passive mechanical loading 9 h/day for 7 days
had a significant positive effect on skeletal muscle in me-
chanically ventilated ICU patients treated with nondepolar-
izing neuromuscular blocking agents. In an experimental
study using a novel rat ICU model where animals were
exposed to neuromuscular blockade and mechanical venti-
lation for durations varying from ⬍1 day to 14 days, it was
confirmed that unilateral loading 12 h/day had a positive
effect on skeletal muscle structure and function (574). That
is, both the loss of muscle fiber size and specific force at the
single muscle fiber level were significantly attenuated in re-
sponse to passive loading, resulting in a doubling of the
functional capacity on the loaded versus the unloaded side
(574). The mechanisms underlying the loading effects
showed a complex temporal pattern involving oxidative
stress, posttranslational protein modifications, transcrip-
tional regulation of myosin synthesis, protein degradation
via the E3 ligase MuRF1, and extracellular matrix/cell ad-
hesion proteins (574). Similar effects were observed in both
fast- and slow-twitch limb muscles, but the effects of load-
ing were typically more pronounced in slow- versus fast-
twitch muscles. In a follow-up clinical study, unilateral an-
kle joint flexion-extensions 10 h per day for 9 days in se-
dated, but not pharmacologically paralyzed, neurointensive
care patients showed a significant positive effect on single
muscle fiber force generation capacity (specific force; Ref.
435). Furthermore, nNOS which is associated with the
mechanosensitive caveolin-3 in the muscle membrane was
translocated to the cytoplasm in response to the clinical ICU
condition, i.e., in a similar fashion as reported in response
to hindlimb suspension (687), and was suggested to play a
role in the posttranslational deamidation modifications of
the myosin motor domain on both the loaded and unloaded
side (435). A significant preferential myosin loss, the hall-
mark of CIM, was observed in response to long-term im-
mobilization and mechanical ventilation in the ICU patients
in the absence of neuromuscular blockade, suggesting that
the mechanical silencing may play a significantly more im-
portant etiological role in triggering CIM than neuromus-
cular blockers (32, 435). In spite of the significant positive
effect of mechanical loading on skeletal muscle structure
and function, it did not abolish the negative effects of the
ICU condition, suggesting that this mild type of mechanical
loading did not impact on all mechanosensitive signaling
pathways or that other yet unidentified factors, in addition
to mechanosensation, may play an important etiological
role. The latter statement is supported by the fact that most
CIM patients recover from the muscle paralysis while still
mechanically ventilated and immobilized in the ICU. One
key difference between passive loading and normal activa-
tion of muscle contraction is that during passive loading,
muscle action potentials are not occurring. This difference
1044 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
may explain why passive loading does not prevent all the
changes triggered by muscle inactivity. In particular, muscle
excitation significantly contributes to transcription in a pro-
cess called excitation-transcription coupling (276, 724).
The significant positive effects of passive loading of skeletal
muscle in experimental and clinical CIM intervention stud-
ies support the early physical therapy and mobilization of
deeply sedated or pharmacologically paralyzed mechani-
cally ventilated ICU patients that has been shown to shorten
ventilator- and ICU-days, to reduce health care costs as well
as to improve prognosis and quality of life (88, 146, 495,
505, 623).
VII. NEUROMUSCULAR TRANSMISSION IN
CRITICAL ILLNESS
Nondepolarizing neuromuscular blocking agents are used
to facilitate mechanical ventilation (536). In the 1980s, it
was first reported that following prolonged use of neuro-
muscular blocking agents, some patients developed persis-
tent weakness (529). Subsequent studies identified the
mechanism underlying weakness as prolonged neuromus-
cular blockade (37, 386, 538, 596, 624, 625). Development
of prolonged weakness was due to slow clearance of block-
ing agents or their metabolites and was often associated
with renal and/or hepatic failure (37, 386, 624, 625). Be-
cause of concerns regarding prolonged weakness, neuro-
muscular blocking agents are now less frequently used and
for as short a period as possible such that prolonged neuro-
muscular blockade is primarily of historical interest.
At the time of many of the initial reports of prolonged
neuromuscular blockade, the role of myopathy as a contrib-
utor to development of weakness in critical illness was not
yet well recognized. Thus studies generally did not perform
muscle biopsies or EMG analysis of motor unit recruitment
to look for co-occurrence of myopathy. It was only later
proposed that use of neuromuscular blocking agents is a
risk factor for the development of ICUAW (141, 255, 256).
CIM was likely a contributor to weakness in some patients
reported to have weakness due to prolonged neuromuscular
blockade (37, 255), but it was not clear whether neuromus-
cular blockade itself would produce the full-blown picture
of CIM. With increased awareness of CIM as a cause of
weakness in critically ill patients following the additional
use of neuromuscular blocking agents, and more cautious
use of neuromuscular blocking agents, most patients with
pure motor deficits have been found to have CIM rather
than prolonged neuromuscular block as the etiology of
weakness, in particular since those patients were always
also mechanically ventilated and completely immobilized.
Some speculations for neuromuscular blocking agents to
trigger myopathy in ICU patients, and in particular CIM,
point towards their potential to induce functional denerva-
tion and subsequent denervation atrophy during prolonged
usage (64, 625).
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
A. Microcirculation-Induced Denervation
Disturbances of the microcirculation are seen in sepsis and
critical illness. Transmigration of immune cells out of blood
vessels and cellular infiltration of the tissue may provide the
grounds for the specific aberrant effects of inflammatory
mediators to both muscle and nerve (149, 193). Addition-
ally, tissue edema, seen in sepsis and critical illness, may
also represent a nonspecific compression damage factor to
the muscle-nerve compartment, especially since the distal
motor axons are located within the muscle fascia and can be
prone to compression. In a histochemical and ultrastruc-
tural study of skeletal muscle biopsies from several patients
with sepsis and multiorgan failure (all being mechanically
ventilated), five of which also presented with muscle weak-
ness, ultrastructure showed fiber atrophies and altered cap-
illaries with edema, infiltrates, and segmental necrosis
(158). A similar observation was noted in a porcine septic
shock model where after 18 and 48 h of septic shock in-
duced by endotoxin injection (no mechanical ventilation or
immobilization of animals), endothelial cell damage with
endomysial edema and mitochondrial swelling in muscle
fibers were detected (293). Endomysial edema increased
during the time course of septic shock, and plasma TNF-␣
levels were significantly increased. However, whether the
muscle damage seen was therefore primarily due to edema-
induced damage or more directly due to either endotoxin or
TNF-␣, or both, could not be assessed. Other studies
seemed to exclude a role for edema to induce muscle weak-
ness in septic patients. In a clinical study assessing muscle
force and edema in 18 septic ICU patients, tissue edema was
not associated with skeletal muscle weakness (245). More
support to question the direct involvement of tissue edema
in the pathophysiological mechanism of ICUAW came from
a rat CLP study where EDL muscle microcirculation was
observed with intravital microscopy 6 – 48 h after sepsis
induction (549). In septic animals, the number of stopped-
flow capillaries was significantly increased but not related
to an increase in tissue wet-to-dry weight ratio, indicating
that extrinsic compression of capillaries by tissue edema
was not a primary cause of interstitial hypoperfusion to
induce damage to nerve and muscle. In a recent experimen-
tal study on septic nonventilated rats, animals showed
marked signs of axonal neuropathy already from day 2 after
sepsis induction despite a normal morphology of nerve sec-
tions arguing against a major nerve compression by edema
(515). Nevertheless, even without compression as the pri-
mary cause of tissue hypoperfusion, the latter may contrib-
ute to the chronic membrane depolarization of terminal
motor axons as concluded from a clinical study on patients
with “electrophysiologically proven CIP” who showed re-
duced nerve superexcitability and increased accommoda-
tion to depolarizing and hyperpolarizing currents (800).
That the terminal motor axonopathy seen in critical illness-
induced weakness also extends further to the neuromuscu-
lar transmission was inferred from a clinical study perform-
ing nerve conduction studies, electromyography and, in
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
particular, single-fiber electromyography (SFEMG) in several
patients with CIP, both before they developed spontaneous
muscle electrical activity and during follow-up (621). In par-
ticular, the latter technique allows assessing a measure for
neuromuscular transmission through quantification of the jit-
ter between “just suprathreshold excitation” and action po-
tential recording, since a jitter ⬍10 ␮s usually reflects a direct
stimulation of fibers (621, 655). Interestingly, patients who
developed spontaneous activity in muscles during the study
course also had significantly increased jitter time, indicating a
delay in neuromuscular transmission.
B. Neuromuscular Transmission in Sepsis
and Systemic Inflammation
As sepsis (501, 502, 508, 711) and nonseptic critical illness,
i.e., thermal injury and burns (180, 454, 462, 463), have
been reported to attenuate the action of nondepolarizing
blocking agents, such as d-tubocurarine or rocuronium, a
series of studies were performed to determine the underly-
ing mechanisms of this rather unexpected facilitation of
neuromuscular transmission in animal models of experi-
mental sepsis, with sepsis as the only confounding condition
inducing muscle weakness. Direct exposure of frog sarto-
rius muscle to Escherichia coli endotoxin (10 ␮g/ml) re-
sulted in elevations of miniature-endplate potential (MEPP)
frequencies without changing MEPP amplitudes. These
changes were abrogated in Ca2⫹-free solutions and antag-
onized by elevating extracellular K⫹, indicating endotoxin-
induced alterations of the presynaptic terminal membrane
ion conductances, in particular for Ca2⫹ (544). In an at-
tempt to better assign neuromuscular transmission changes
and neuromuscular blocking action to the stage of sepsis,
Narimatsu et al. (502) investigated phrenic nerve-induced
twitch-tension responses in hemidiaphragm preparations
from rats with early (9 h post CLP) and late (18 h post CLP)
acute panperitonitis sepsis. Those represent the bimodal
time course of the “hyperdynamic and hypermetabolic”
and “hypodynamic and hypometabolic” phases of CLP-
induced sepsis in this model (117, 755). Indirect (nerve) and
direct (muscle) twitch stimulation produced similar decre-
ments in isometric twitch-tension but much more pro-
nounced in late sepsis (⬃65% decrement) compared with
early sepsis (⬃35% decrement). The dose-response curves
of twitch tension for rocuronium, pancuronium, and d-tu-
bocurarine were consistently shifted towards higher con-
centrations by sepsis with an additionally marked increase
from early to late sepsis throughout (502). Since these re-
sults were obtained under a low stimulation-frequency re-
gime (0.1 Hz), the NMBA-induced twitch depression pre-
dominantly reflects competitive blocking of postjunctional
acetylcholine receptors, and it was speculated that hyposen-
sitivity to neuromuscular blockade during sepsis may orig-
inate from upregulation of postjunctional nicotinic AChR
rather than a decrease in drug-receptor affinity (502), sim-
ilar as seen in a rat burn injury model (363). In a follow-up
1045
 FRIEDRICH ET AL.
study, Niiya et al. (508) focused on elucidating the exact
mechanisms underlying changes in neuromuscular trans-
mission during “acute late” sepsis (⬃18 h post CLP). This
was because results from chronic sepsis either in nonlethal
panperitonitis CLP models or intraperitoneal endotoxin-
induced sepsis in animals were inconclusive, showing ei-
ther hyper- or hyposensitivity to d-tubocurarine, or a
decrease or no change at all in AChR number (313, 595,
720). Acute late sepsis (⬃18 h post CLP) induced a sig-
nificant increase in endplate potential (EPP; postjunc-
tional potential induced by quantal release of acetylcho-
line from the motor nerve bouton in response to electric
stimulation) amplitudes and EPP quantal content, indi-
cating a facilitation of EPPs and excitability of muscle
(508). The authors also measured acetylcholine poten-
tials (AChP; postjunctional potential induced by ionto-
phoretic acetylcholine application), electrotonic poten-
tials (EP; sequential muscle membrane potential changes
to direct current applications), spontaneous miniature
endplate potentials (MEPP; spontaneous and quantal re-
lease of acetylcholine from the motor nerve bouton), and
resting membrane potentials (RMP). With the use of this
series of techniques, prejunctional effects of sepsis could
be dissected from postjunctional ones. Prejunctional ef-
fects included an increase in quantal content of EPPs
through increased release probability (reflected by an in-
creased MEPP frequency), probably mediated by a sepsis-
induced increase in intracellular Ca2⫹ concentrations to
facilitate transmitter release (508). Postjunctionally, ace-
tylcholine-potential analysis revealed a significant de-
crease in acetylcholine sensitivity during acute late sepsis
pointing towards a reduced function/density of AChR
and/or increased acetylcholinesterase activity (508).
Since previous studies reported an inhibition of the latter
in conjunction with inflammation (46, 142), thus expect-
ing an increase in acetylcholine sensitivity, it was con-
cluded that decreased postjunctional nAChR density
(720) explained the observed reduced acetylcholine sen-
sitivity by overcoming inhibited acetylcholinesterase ac-
tivity in acute late sepsis (508). On the other side, also
acetylcholine sensitivity in extrajunctional areas might
need to be considered because sepsis was shown to induce
spread of AChRs along the sarcolemma (461), a condi-
tion which would be expected to increase acetylcholine
sensitivity rather than decrease it.
The issue of altered AChR expression numbers as well as
shifts in expression profiles towards embryonic isoforms
(464) in myopathy in critical illness is still puzzling with
studies showing upregulation (214, 460, 639), down-
regulation (508), or no change at all (213, 337), depend-
ing on the experimental model of critical illness (464).
This is possibly due to the relative contribution of the
isolated effects of systemic inflammation and sepsis, im-
mobilization and denervation to the resulting overall
AChR expression in each model. For instance, denerva-
1046 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
tion is expected to increase expression of AChR of im-
mature isoforms (788). Immobilization, as a contributing
correlate to ICUAW (214), either resulted in increased
(214, 461) or unaltered receptor expression (337) in the
immobilized limb. Finally, the condition “critical illness”
also produced differential outcomes: upregulated (362,
758) or unaltered (455) AChRs in thermal injury animal
models, as well as in sepsis animal studies, depending on
whether a panperitonitis CLP model [concluded down-
regulation at the neuromuscular endplate region (508);
no change in AChR (595)] or chronic intravenous E. coli
infection model (no upregulation of AChRs, Ref. 213)
was employed. The difference in the CLP studies may be
attributed to the stage of sepsis investigated, but this
requires further confirmation studies. It should be noted
that none of those animal models involved to induce
myopathy in sepsis (“sepsis-induced myopathy”) con-
ducted any kind of mechanical ventilation and/or immo-
bilization and did not assess preferential myosin loss, and
although being sometimes termed so in the literature,
may not be considered as CIM per se (FIGURE 1B). Inter-
estingly, to date, there does not seem to be a single study
that dissected the effects of sepsis and immobilization in
critical illness patients (which strictly means including
mechanical ventilation). This could experimentally be
overcome in future animal studies combining a pure sep-
sis animal model with a continuous passive mechanical
loading protocol, similar as reported in two clinical stud-
ies where passive motion in mechanically ventilated ICU
patients without sepsis (435) was able to preserve specific
force (435) and prevent fiber atrophy (269).
Taken together, even though presynaptic facilitation of
transmission is a common finding in critical illness, the
overall loss-of-function aspect of muscle performance
seems to be represented by postsynaptic alterations from
the neuromuscular junction (this section) to downstream
mechanisms (following sections). This ultimately outweighs
a facilitated presynaptic component of muscle activation in
ICU-related myopathies. FIGURE 5 summarizes the mecha-
nisms discussed in this chapter.
VIII. MEMBRANE AND ION CHANNEL
FUNCTION IN CRITICAL ILLNESS
A. Sodium Channels Determine Membrane
Excitability in Skeletal Muscle
Voltage-gated sodium channels in the adult skeletal mus-
cle (Nav1.4) determine the membrane excitability of the
muscle fiber sarcolemma (599) and are important to ini-
tiate the upstroke phase of the action potential upon
crossing a certain membrane potential threshold for
channel opening during membrane depolarization. This
potential threshold is mainly set by the steady-state inac-
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL

Extrajunctional
spread

ACh in
AChR
secretory
vesicles
ACh Motor nerve
terminal
AChR

CIM

Inflammation/
Denervation Immobilization
sepsis
Embryonic
Em
mbryoni
bryonic
y
ACh release AChR
AC
AChR
ChR
Acute
late
Embryonic AChR

? N le
Nucleus
e
AChR density

Acute Chronic
late
Extrajunctional spread

?
ACh sensitivity
Acute
late
FIGURE 5. Alterations at the level of neuromuscular transmission contributing to ICU-acquired weak-
ness. ICUAW is usually a mixed syndrome of either neuropathy- or myopathy-induced weakness during
critical illness either due to sepsis (or even sepsis-unrelated conditions, e.g., burns), immobilization, and
eventual denervation contributing to alterations to neuromuscular function. Typical effects on either
presynaptic (neuropathy) or postsynaptic (myopathy) functions are shown and, where available from
literature, dissected into the single confounding conditions where pure immobilization or denervation
studies were performed. See text for details. For pure denervation and immobilization, data were also
extracted from References 375, 668, and 782.

tivation of the channels (253, 270). Both changes in
steady-state activation and inactivation modulate excit-
ability and action potential properties in skeletal muscle
(219) and are thus of special interest in many diseases
associated with channelopathies (e.g., Refs. 104, 380).
Nav1.4 channels are unevenly distributed over the muscle
fiber membrane with highest densities near the neuro-
muscular junction and dropping towards the ends (15).
They are also located in high densities in the t-system to
warrant fast and even spread of action potentials from
the surface membrane to the triad junctions to trigger
excitation-contraction coupling. Detailed information
on normal Na⫹ channel function and membrane excita-
tion is reviewed elsewhere (110, 111). Na⫹ channels,
once opened and having undergone transition into their
inactivated state, have to be reactivated by repolarizing
the membrane potential well below their activation
threshold. This is primarily achieved by K⫹ efflux
through voltage-gated K⫹ channels. The resting mem-
brane potential in particular is set by the electrochemical
diffusion equilibrium of K⫹, and any changes towards
the relative resting permeabilities of other ions (e.g.,
Na⫹) over K⫹ can markedly shift the resting membrane
potential and impair action potential generation and
spread. Furthermore, skeletal muscle has a severalfold
higher Cl⫺ permeability within the tubular membranes
over the sarcolemma (168). This larger tubular conduc-
tance is required to maintain excitability during bouts of
muscle activation where tubular K⫹ accumulation would
otherwise depolarize the tubular potential to either facil-
itate uncontrolled spontaneous myogenic contractions or
lock Na⫹ channels in an inactivated state, depending on
the level of depolarization (173). From this, it is clear that
any plasma ionic imbalance caused by critical illness

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 FRIEDRICH ET AL.
would have greater effects in the t-system over the sarco-
lemma due to larger concentration gradients present in
this diffusion-restricted space.
B. “Sodium Channelopathy” in Muscle in
Critical Illness
The first indication that there might be an ion channelopa-
thy in critically ill patients came from studies showing that
muscle was electrically unexcitable in the acute phase of
severe weakness (577, 583). Subsequently, there have been
a number of studies demonstrating reduced muscle excit-
ability that manifests as reduction of muscle fiber conduc-
tion velocity, increased relative refractory period, and re-
duced excitability of fibers in response to direct muscle stim-
ulation (12, 59, 413, 613, 614, 764, 801). Reduction in
muscle fiber conduction velocity likely underlies prolonga-
tion of compound muscle action potential duration that is
seen in patients with CIM (257).
Studies of mechanisms underlying loss of muscle excitabil-
ity in CIM have been performed in a rat model of the dis-
order. To simulate CIM in rats, denervation of muscle was
combined with corticosteroid treatment (see sect. XII). In
steroid-treated, denervated rat muscle, it was found that a
combination of depolarization of the resting potential and a
hyperpolarized shift in the voltage dependence of sodium
channel inactivation resulted in unexcitability of the major-
ity of muscle fibers (196, 580 –582). The voltage depen-
dence of sodium channel inactivation was also found to be
shifted in the hyperpolarized direction by pure sepsis in the
rat (594). These data suggest that increased inactivation of
sodium channels is a major contributor to reduced excit-
ability. As the above studies were performed on muscle
removed from rats and perfused in Ringer solution, the
hyperpolarized shift cannot be accounted for by the pres-
ence of a circulating factor acting on the sodium channel.
However, there is a study suggesting that circulating factors
may contribute to modulation of sodium channel gating.
When murine muscle fibers were exposed to serum fractions
from septic patients for up to 80 min (1:10 dilutions in
standardized external solutions), there was a depolarized
shift in the voltage dependence of sodium channel inactiva-
tion (218) (FIGURE 6). Thus, if a circulating factor contrib-
utes to altered membrane excitability, its acute effect is
opposite to the effect triggered by long-term exposure.
One way in which the voltage dependence of sodium chan-
nel inactivation might be shifted in the hyperpolarized di-
rection is via expression of different sodium channel iso-
forms which inactivate at more hyperpolarized potentials.
In innervated mature skeletal muscle, only the Nav1.4 so-
dium channel isoform is expressed. After denervation, ste-
roid treatment, or sepsis, there is upregulation of the Nav1.5
isoform (578, 594, 789). Normally, the Nav1.5 isoform is
expressed in embryonic skeletal muscle but is downregu-
1048 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
lated during development (790). In experiments done in
vitro, it has been found that the Nav1.5 isoform activates
and inactivates at potentials 15–20 mV more hyperpolar-
ized than Nav1.4 (753, 804). Thus upregulation of Nav1.5
might cause a hyperpolarized shift in inactivation of the
total sodium current. There is marked upregulation of
Nav1.5 mRNA in steroid-denervated muscle beyond that
seen in either denervated or steroid-treated muscle alone
(578). However, when ␮-conotoxins (GIIIB) were used to
selectively block Nav1.4 sodium channels in steroid-dener-
vated muscle, little sodium current remained, and the cur-
rent that remained was inactivated with similar voltage de-
pendence as the total current (196). These data, as well as
more recent protein measurements, indicate that Nav1.4 is
the primary sodium channel in both control and steroid-
denervated muscle (376). The conotoxin data further sug-
gest that the voltage dependence of both Nav1.4 and Nav1.5
was shifted in the hyperpolarized direction in this rat model
of steroid-denervation myopathy (SDM; FIGURE 1B) that
seems to reproduce key symptoms found in CIM muscle
(196). Thus, despite in vitro data suggesting that Nav1.5
inactivates at more hyperpolarized potentials than Nav1.4,
this may not be the case in vivo. These data suggested that
the primary cause of hypoexcitability of steroid-denervated
fibers was a hyperpolarized shift in the voltage dependence
of inactivation of Nav1.4 (196) (FIGURE 6).
A recent study of covalent modifications of Nav1.4 found
reduced glycosylation (376). However, as previous work
found that removal of sialic acid from sodium channels
shifts inactivation gating in a depolarizing direction (47, 48,
492), the reduction in glycosylation is likely to be compen-
satory rather than causative for the hyperpolarized shift in
inactivation. One finding that may account for the hyper-
polarized shift in inactivation is increased association of
sodium channels with proteins of the dystrophin-associated
protein complex (376). In particular, there is increased as-
sociation with nNOS. In mice lacking nNOS, denervation-
induced loss of excitability was lessened (376). One way
NO might trigger hyperpolarized inactivation is through
phosphorylation of Nav1.4; however, global levels of so-
dium channel phosphorylation were unaltered following
denervation and steroid treatment (376). The finding that
nNOS is involved in regulation of excitability following
denervation adds to earlier findings that implicate NO in
the response of skeletal muscle to denervation. Previously, it
has been shown that inhibition of nNOS lessens muscle
atrophy triggered by denervation (687). Since dramatic
muscle atrophy occurs in CIM, this raised the possibility
that nNOS signaling plays a role in triggering both electrical
hypoexcitability and atrophy of fibers.
In an in vitro TNF-␣ challenge of isolated muscle fibers,
TNF-␣ induced a reversible dose- and time-dependent inhi-
bition of Na⫹ currents of up to ⬃75% of control currents
(275). Steady-state activation and inactivation curves were
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL

Steroid-denervation animal model

Nav+-channels:
Control RP Control inactivation
Control Excitable Inexcitable
• Reduced INa amplitudes 40 100 Excitable inactivation

Normalized current (%)

SD SD
(SD-model, chronic CLP-sepsis) Inexcitable inactivation
20 80
• Acute INa increase
0
(septic serum challenge) 60

mV
–20 13.5 mV
• Increased expression of Nav1.5 Excitable RP
–40 40
(embryonic isoform)
–60 20 Inexcitable RP
• Hyperpolarizing shift of steady-state inactivation
(chronic CLP-sepsis, SD-model) –80 10 ms
0
–100 –90 –80 –70 –60 –50
Voltage (mV)

DHPR Acute septic serum challenge

(heart) 100

Normalized current (%)

Nav1.4 Nav1.5 75

50
DHPR
25 CS 30 kDa
CIM 30 kDa

0
–100 –80 –60 –40
Pre-pulse potential [mV]
Chronic sepsis (CLP)
100

Normalized current (%)

INa
Other channels, membrane parameters: 75
• Membrane depolarization in all sepsis models
Septic –2.5 nA 50
• L-type channel function impaired Septic Control
• Cl– conductance reduced
25
Control –6.5 nA
0
–150 –100 –50 0 50
Pre-pulse potential (mV)
FIGURE 6. Alterations of ion channels in models of ICU-related myopathies. Graphical summary of docu-
mented mechanisms contributing to altered membrane excitability through ion channel dysfunction in ICU-
related myopathies. Most research performed points towards reduction in ion current densities, e.g., for Na⫹,
Ca2⫹, and chloride conductances. For voltage-gated Na⫹ channels, a hyperpolarizing shift of inactivation curves
is induced in chronic sepsis and steroid-denervation models of critical illness, thus reducing availability of Na⫹
channels for action potential generation at resting potentials, which is even worsened by additional membrane
depolarizations. Results shown are taken from References 218, 581, 594, and 696. [Top middle and right
panels from Rich and Pinter (580). Copyright John Wiley and Sons. Middle right panel from Friedrich et al.
(218). Copyright Springer Science ⫹ Business Media.]

left-shifted approximately ⫺20 mV towards more negative
potentials by TNF-␣ (TABLE 5). The time course of current
block was almost complete at its maximum potency from
15 min post-exposure for larger concentrations tested (⬎10
ng/ml) and even earlier for lower concentrations (⬃5 min
for 2.5 ng/ml) and can be considered an acute effect during
sepsis (274), probably also in nonseptic critical illness con-
ditions associated with increase in pro-inflammatory mi-
lieu. The lower concentrations for which ⬃5% Na⫹ current
(INa) block was observed have been correlated with serum
plasma levels found in septic patients with multiple organ
failures (548) and lipopolysaccharide (LPS)-induced sepsis
in rats (221), although vast variations can be found in the
literature with even 100-fold lower concentrations in sepsis
(249, 355). Another error variable may stem from the fact
that most studies on septic patients do not give further
details whether and how patients were subjected to analgo-
sedation (i.e., use of fentanyl or related analgo-sedatives to
maintain intubation; Ref. 695) and mechanical ventilation
and silencing that could further contribute to pro-inflam-
matory cytokine production. Since interstitial TNF-␣ con-
centrations might be substantially higher in LPS-stimulated
muscle (known to additionally secrete TNF-␣; Ref. 471), a
maximum block of INa of ⬃75% as assessed by Guillouet et
al. (274) might be a realistic scenario. Since the TNF-␣
effect was complete within minutes, a transcriptional mod-
ification like channel numbers or channel isoform, espe-
cially a shift towards the embryonic Nav1.5 isoform, seems
unlikely in the acute TNF-␣ challenge model. Moreover, the
authors observed a most intriguing effect of blocking PKC-
mediated phosphorylation by pretreatment of fibers with
chelerythrine (274), a blocker of protein kinase C (761).

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 FRIEDRICH ET AL.
This suggests a specific PKC-mediated change in Na⫹ chan-
nel gating through phosphorylation, probably between do-
mains III and IV (45) by TNF-␣ in skeletal muscle, similar to
what has been found in neurons (139). Whether TNF-␣
does so in muscle primarily by either the A2 phospholipase,
phospholipase C, or protein kinase A pathways or combi-
nation of those, all of which stimulate PKC (593), remains
to be determined. Interestingly, the hyperpolarizing shift of
Nav1.4 inactivation of about ⫺20 mV is also reproduced in
human voltage-gated Nav1.4 channels expressed in human
embryonic kidney cells following acute application of lipo-
polysaccharides at ⬎50 ng/ml (283), pointing towards an
acute acquired channelopathy by LPS or TNF-␣ similar to
that seen in critical illness and sepsis (594) (FIGURE 6).
1. Transferability to patients
Although the muscle membrane hypoexcitability is a hallmark
in CIM patients, the presence of the same biophysical changes
to Na⫹ channels as detailed above in animal models also in
patients has never been proven to date and is clearly a chal-
lenge for future research directions. As detailed later in section
XII, those animal models are adequate to reproduce the mus-
cle phenotype of CIM patients; thus a similar Na⫹ channelo-
pathy in CIM patients is probable. Clearly, in the critically ill
patients who succumbed to one of the varieties of the ICU
syndrome, many systems will be altered, such as the ionic
balance of potassium, sodium and chloride in the plasma, cal-
cium in the plasma, and the osmotic strength of the extracel-
lular fluid bathing the muscle fibers. All of these will have a
significant effect on the function of nerve and muscle. How-
ever, clinical data on this are extremely scarce. For example,
plasma Ca2⫹ concentration changes have been associated with
CIPNM in ICU patients; however, this was true both for hypo-
and hypercalcemia (17). Studies on plasma Na⫹, K⫹, Cl⫺, and
osmolarity in diagnosed CIM patients seem not to be available
and are clearly needed.
C. Membrane Depolarization in Muscle in
Critical Illness
A consistent finding in skeletal muscle from animal models
and patients with critical illness conditions (sepsis, mechanical
ventilation, immobilization, steroid-denervation, etc.) is a sub-
stantial membrane depolarization that limits excitability of
muscle (138, 178). However, unlike for sepsis or steroid-de-
nervation, for pure mechanical ventilation and/or immobiliza-
tion, membrane depolarization is much less well documented,
both for patients and for animal models, except for one study
reporting slight depolarizations (⬃5 mV) in a rat limb muscle
immobilization model (surgical muscle shortening) (798).
There are plenty potential mechanisms to explain depolar-
ized membrane potentials, e.g., changes in Nernst poten-
tials of respective ion species due to concentration changes
(i.e., changes in plasma concentrations of Na⫹, K⫹, or Cl⫺),
1050 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
membrane resistance and conductance changes, as well as
energy depletion of ATP stocks that feed electrogenic
pumps to maintain negative membrane potentials, i.e.,
Na⫹-K⫹-ATPase. In early studies on skeletal muscles from
primates with septic shock, the depolarized membrane po-
tential was associated with increased intracellular sodium
chloride content and marked depletion of extracellular con-
tent (717). In dogs and rabbits during E. coli-induced bac-
teremia (338, 635), a marked membrane depolarization of
skeletal muscle was also noted. Cellular injury as a result of
cell swelling in E. coli-induced sepsis in a rabbit model was
used to explain membrane depolarization in muscles before
the onset of septic shock (338). The selective increase in
Na⫹ and Cl⫺ concentrations in hindlimb adductor muscle
was also confirmed in a dog sepsis model 48 h after infusion
of E. coli, without any change to K⫹ concentrations (635).
The increase in Na⫹ permeability of the membrane was
sufficient to explain the observed ⬃10 mV depolarization
which was also supported by the significant decrease in ATP
concentration in those muscles (635). However, another
study in rats with subacute E. coli-induced sepsis showed a
different scenario: an increased Na⫹-K⫹-ATPase activity
and unaltered ATP and phosphocreatine levels. The pre-
served ATP content and increased pump activity were ex-
plained by sepsis-induced hyperlactatemia and increased
muscle content of lactate, a known stimulator of Na⫹-K⫹-
ATPase, that even led to decreased intracellular Na⫹ con-
centrations (469). Unfortunately, membrane potentials
were not recorded in that study. Similar observations were
made in a rat CLP model (347). In another mouse LPS-
induced sepsis model, Liu et al. (432) observed a marked
depolarization in the diaphragm and increased input resis-
tance due to an endotoxin-induced shutdown of sarcolem-
mal chloride conductance while K⫹ conductance was unal-
tered. NO synthase (NOS) inhibitors reversed the observed
effects arguing in favor of an NO-mediated alteration of
chloride conductance that was also confirmed by the fact
that in vitro application of LPS by itself to diaphragm was
not able to reproduce the membrane effects seen in the
septic mouse, whereas addition of an NO donor was (432).
In the CIM model of steroid denervation (SD), a downregu-
lation of Cl⫺ conductance was not seen with SD but only
following denervation alone (582).
In several studies, a circulating factor was postulated to be
responsible for fast membrane depolarization in the ap-
proximately minute range (178, 218). For instance, plasma
samples from sheep or pigs in shock were assayed for depo-
larizing activity when applied to rat diaphragm in vitro
(90). The depolarizing effect of a so-called “circulating de-
polarizing factor” (CDF) was similar as the membrane po-
tentials found in the muscles “in situ” in the original ani-
mals in shock the plasma came from (90). Given that sepsis
is associated with membrane depolarization, increased Na⫹
permeability and Na⫹ content (121, 244, 614), one of the
potential mechanisms that contribute to the maintenance of
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
increased [Ca2⫹]i in septic muscle may be reflected by an
increased activity of the Na⫹/Ca2⫹ exchanger (NCX) to
import Ca2⫹ for the extrusion of subsarcolemmally ele-
vated Na⫹. In a rat endotoxemia sepsis model, expression
levels for NCX were found increased in the early course of
sepsis (4 h) in cardiomyocytes and then declined at later
stages (30). However, for skeletal muscle, such recordings
are not yet available. The increased Ca2⫹ uptake as a re-
sponse to enhanced depolarization is not only a mechanism
in pathophysiology of septic myopathy but also visible in
exercising muscle where bouts of tetanic stimuli can cause
depolarization and Ca2⫹ uptake (447, 541).
Although much evidence is in favor of the sepsis-induced de-
polarization hypothesis, isolated inflammatory cytokines, i.e.,
TNF-␣, also produced controversial results. For instance,
while Tracey et al. (712) reported a depolarization in single
fibers during whole muscle impalements, another study
showed a dose-dependent hyperpolarization of membrane po-
tentials by TNF-␣ in enzymatically isolated peroneus longus
fibers (274). However, since those authors used a vigorous
collagenase isolation procedure (3 mg/ml collagenase for 2 h at
37°C), their control Em values were already somewhat depo-
larized (approximately ⫺60 mV) and repolarized by TNF-␣,
presumably by stimulating the Na⫹-K⫹-ATPase (274). Yet,
another in vitro study in whole EDL muscles from guinea pigs
treated with TNF-␣ (5 and 10 ng/l for 30 min) showed no
effect at all on resting membrane potentials (14).
Although the relationship between sepsis, systemic inflamma-
tion, and inflammatory cytokines on the one side and mem-
brane depolarization in skeletal muscle seems well established,
it is 1) not yet established that this sepsis-induced myopathy
(SIM) is equivalent to CIM since no study yet convincingly has
demonstrated the preferential myosin loss in long-term sepsis
[on top of the severe atrophy in experimental sepsis affecting
both actin and myosin equally seen as a general myofilament
release, see below and Williams et al. (776)] and also 2)
whether membrane depolarization is indeed present in pa-
tients with CIM. Although critically ill patients with clinically
diagnosed CIM show reduced muscle membrane excitability,
direct in vivo recordings of resting membrane potentials in
CIM patients are not available except for one early study that
showed substantial resting transmembrane potential depolar-
ization in severely critically ill patients in vivo (138). Unfortu-
nately, details about whether these patients were mechanically
ventilated or septic were not reported. This limits our under-
standing of membrane depolarization in CIM to direct proof
from the SD rat animal models of CIM (377, 581) but not yet
for mechanical ventilation and immobilization models (517).
D. Membrane Ca2ⴙ Channels in ICU-Related
Myopathies
Voltage-gated Ca2⫹ channels, surprisingly, have only been
very modestly studied in conjunction with sepsis and critical
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
illness in muscle. In the SD model of critical illness myop-
athy, Kraner et al. (377) observed an elevation of RyR1 and
CaV1.1 from immunostaining of single fibers that especially
were severely atrophic and had disorganized sarcomeres. It
was thus concluded that increased Ca2⫹ release from the SR
may contribute to the pathology in CIM. However, SR
Ca2⫹ release was not directly assessed, nor was dihydropyr-
idine receptor (DHPR) function. At least in the heart, stud-
ies have pointed towards an impaired SR Ca2⫹ release
through the ryanodine receptor during the hypodynamic
phase of sepsis (162, 163), and a decrease in ryanodine
receptors was detected in endotoxin shock in the heart (430,
787). L-type Ca2⫹ currents recorded in single ventricular
cardiomyocytes isolated from pigs with early phase hyper-
dynamic septic shock revealed a significant decrease in
Ca2⫹ current densities (⬃25%) with a consistent shift of
both activation and inactivation curves ⬃5–10 mV towards
more negative potentials (659). TNF-␣ did not induce any
further changes to the current properties (659). A similar
reduction of L-type Ca2⫹ currents in ventricular cardiomy-
ocytes from septic guinea pigs 4 h after E. coli LPS injection
was found that was, however, unrelated to any changes in
steady-state activation or inactivation (810). L-type chan-
nel function in skeletal muscle in conjunction with critical
illness myopathy has so far only been addressed in one
study using the acute serum challenge from CIM patients to
normal muscle fibers (cf. sect. XII). Serum fractions from
septic and mechanically ventilated critically ill patients
acutely reduced Ca2⫹ current amplitudes when applied to
murine normal mouse single fibers without any shifts in
steady-state activation and inactivation curves (217). This
was interpreted as an acute reduction of the fraction of
functional L-type channels by a putative low-molecular-
weight factor (218, 290, 318, 759).
In summary, ion channels other than Na⫹ channels still
have only scarcely been addressed but are certainly an in-
teresting field to highlight in future studies involving critical
illness myopathies.
1. Are electrically active tissues other than skeletal
muscle affected?
One of the major problems triggered by critical illness is
multisystem organ failure. The mechanisms underlying or-
gan failure remain poorly understood. The finding that so-
dium channel dysfunction contributes to failure in force
generation in skeletal muscle demonstrates that a novel
form of acquired channelopathy may be present during the
acute phase of critical illness. If channelopathy affects other
electrically active tissues, it could provide a mechanism to
account for failure of a number of different organ systems.
It is well established that critical illness can induce neurop-
athy. The first indication that neuropathy in critically ill
patients might not be entirely accounted for by axon degen-
eration came from a study in which nerve and muscle biop-
1051
 FRIEDRICH ET AL.
sies were taken in patients with severe critical illness poly-
neuropathy and myopathy. Nerve biopsy in many patients
with electrophysiological evidence of neuropathy was nor-
mal (403). This finding suggested there was a functional
deficit in nerves of affected patients that did not have a
pathological correlate. More recently, it was found that
nerve excitability was reduced in patients with critical ill-
ness polyneuropathy (800). The presence of a functional
deficit in the acute phase of critical illness polyneuropathy
raised the possibility of rapid recovery since restoration of
excitability could occur more rapidly than regrowth of ax-
ons. Rapid improvement has been reported in some patients
with critical illness polyneuropathy (515).
In studies of septic rats, peripheral nerves revealed reduced
excitability that could not be accounted for by changes in
input resistance or resting potential excitability (515). Instead,
restoration of normal excitability following brief hyperpolar-
ization of axons suggested that a hyperpolarized shift in the
voltage dependence of sodium channel inactivation was the
mechanism underlying reduced excitability (515). These data
suggest that a sodium channel dysfunction similar to the one in
skeletal muscle also occurs in peripheral nerve.
The presence of sodium channelopathy in both muscle and
nerve might provide a mechanism to explain why critical
illness myopathy and critical illness neuropathy often coex-
ist (43, 44, 64, 147, 361, 403, 413, 528, 614). When pa-
tients with co-occurrence of neuropathy and myopathy are
studied longitudinally, many evolve into either CIP or CIM
(43, 273, 361). This raises the possibility that sodium chan-
nelopathy is present at early stages. If reduced excitability of
peripheral nerve and muscle is due to sodium channelopa-
thy, the channelopathy would have to affect multiple so-
dium channel isoforms. In the rat steroid-denervation
model of critical illness myopathy, the sodium channel iso-
forms present in skeletal muscle are Nav1.4 and Nav1.5
(578). In dorsal root axons, Nav 1.6 as well as other sodium
channel isoforms are expressed (19, 92).
There is evidence consistent with sodium channelopathy in
the heart during sepsis. ECG amplitude is reduced during
the acute phase of sepsis (579). One interpretation of this is
that there is reduced excitability of myocardium. To di-
rectly measure myocardial excitability, a recent study in
CLP-induced sepsis in rats measured properties of papillary
muscle action potentials with microelectrodes. Although
resting potential was not altered, action potential amplitude
was reduced and threshold was elevated 24 h after sepsis
induction (371). Reduction in the rate of action potential
rise suggested the etiology of reduced cardiac excitability
was a reduction in sodium current. The in vivo data fit well
with an earlier in vitro study in which application of LPS to
mouse cardiomyocytes reduced excitability (785). Al-
though the mechanism underlying the reduction in sodium
current is not known, these data are consistent with an ac-
1052 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
quired sodium channelopathy in heart that affects the Nav1.5
Na⫹ channel isoform. The presence of Na⫹ channelopathy in
heart may contribute to the reduced contractility of heart that
occurs during sepsis (481). Partial block of Na⫹ current in
heart with the Na⫹ channel specific blocker tetrodotoxin
mimicked changes in excitability that occurred during sepsis,
i.e., reduced excitability and greatly reduced cardiac contrac-
tility (371). These data suggest that reduction of Na⫹ current
might contribute to reduction in both cardiac excitability and
cardiac contractility during sepsis.
Motoneuron excitability is also significantly reduced within
24 h of sepsis induction in rats, in particular during repetitive
firing of action potentials (500). Any reduction in motoneuron
excitability will reduce motor unit recruitment and thus con-
tribute to weakness. Motoneurons execute their role in mod-
ulating force output by converting the synaptic current deliv-
ered to the soma into a firing rate that determines muscle force
output. The finding of reduced motoneuron excitability raises
the possibility that channelopathy within the central nervous
system also contributes to weakness.
To summarize, studies to date in skeletal muscle, peripheral
nerve, heart, and spinal cord are all suggestive of some
acquired channelopathy that is triggered by critical illness.
No studies to date have examined excitability of neurons
within the brain. Septic encephalopathy is one of the most
common and troubling complications of critical illness
(564). Despite a number of studies, the mechanism under-
lying septic encephalopathy remains a mystery. Presence of
channelopathy in multiple tissues raises the possibility that
reduced excitability of neurons within the CNS might un-
derlie septic encephalopathy. If this was the case, a single
therapy to improve excitability might treat failure of a num-
ber of electrically active tissues.
Why might sodium currents be reduced in multiple tissues
during sepsis? One possibility is that Na⫹ currents are es-
pecially sensitive to cell sickness/injury. In studies in both
skeletal muscle and axons, it appears that damage triggers a
hyperpolarized shift in the voltage dependence of the Na⫹
current activation and inactivation as well as a reduction in
maximal current density (72, 195, 494). In injured cells
with a depolarized resting potential, a hyperpolarized shift
in the voltage dependence of inactivation would result in
increased channel inactivation to reduce excitability. De-
creased cell excitability might even serve to increase survival
of the injured cell by shutting down a Na⫹ “window” cur-
rent that is triggered by depolarization of the resting poten-
tial (547). The Na⫹ window current might further depolar-
ize the cell, to cause elevation of intracellular Ca2⫹ (252,
547) and cell death. One way to prevent this cascade of
events is to shut down Na⫹ current. This has the cost of
reducing excitability and, thus, temporarily worsening cell
function, but might promote survival. Reduction of Na⫹
current might serve a similar purpose to the use of barbitu-
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
rate coma in patients with acute neurologic injury: by de-
creasing metabolic demand during a period of cell stress, it
might increase cell survival to improve long-term outcome
(319, 432, 604).
IX. EXCITATION-CONTRACTION COUPLING,
Ca2ⴙ HOMEOSTASIS, AND MOTOR
PROTEINS IN CRITICAL ILLNESS
A. The Normal Electromechanical Signaling
Cascade in Muscle
Force output in skeletal muscle is the result of a complex
cascade of mechanisms that convey electrical stimulation of
the surface and tubular membranes to an intracellular
chemical response (rise in myoplasmic Ca2⫹ concentration)
followed by a mechanical contractile response (50, 151,
477). Ca2⫹ ions are released from the sarcoplasmic reticu-
lum (SR) in response to a tubular action potential (388) in a
process called excitation-contraction coupling (EC cou-
pling). Ca2⫹ ions then quickly diffuse within the myoplasm
(41, 151) to bind to troponin C that acts as a Ca2⫹ switch of
the thin filaments of the contractile apparatus (412, 671).
This initiates the cross-bridge cycle to recruit weakly or
strongly bound cross-bridges, depending on the imposed
load (516a). This results in contractile power, either as iso-
metric, isotonic, or a mixed contraction. After the excita-
tion ceases, Ca2⫹ ions are redistributed into the SR via a
sequential buffering to low-affinity buffer proteins (e.g.,
parvalbumin, etc.) and the SR Ca2⫹-ATPase pump activity
(SERCA) (50, 354, 478). The release machinery at the level
of the SR ryanodine receptor (RyR1 in muscle) is a tightly
controlled and diversely modulated molecular release gate
(169, 281, 558, 813). The mechanical output of the motor
proteins is mainly determined by the myosin heavy chain
expression which varies from muscle to muscle and is also
subject to a high degree of plasticity in health and disease
(287). Additional determinants are also the light chain iso-
forms and their respective phosphorylation (264) that can
be affected downstream to many signaling pathways and
stimuli, e.g., hormones (422) or weight-bearing function
(398). It is apparent that disturbances at any step of the
contractile cascade can induce or sustain some of the pa-
thology in all forms of ICU-related myopathies (FIGURE 1B).
B. Altered Global Muscle Ca2ⴙ Homeostasis
in Critical Illness
Early studies in septic rats (bacterial peritonitis; no mechan-
ical ventilation) already pointed towards impaired intracel-
lular Ca2⫹ regulation: a significant Ca2⫹ uptake was found
in soleus muscle at days 1–3 of sepsis induction that was
abolished by the L-type calcium channel blocker diltiazem
(57). 45Ca fluxes in septic muscles were ⬃25% larger com-
pared with mock treated animals. Diltiazem reduced Ca2⫹
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
flux both in septic and control animals, however, to much
larger extent in the septic muscle group (57) (FIGURE 7B).
Treatment of normal muscle with the Ca2⫹ ionophore iono-
mycin induced a similar increase in Ca2⫹ flux as seen in the
septic rat muscles. The increase in Ca2⫹ flux was paralleled
by an increase in tyrosine release linking increased Ca2⫹ to
a higher proteolysis rate (57, 613). Similar results were
obtained after a single intraperitoneal E. coli injection to
male rats in soleus muscles 10 h after inoculation (771).
Another study using the CLP septic rat model also showed
an increased Ca2⫹ content by 50% in soleus muscle and by
10% in extensor digitorum longus (EDL) muscle when
bathed in different Ca2⫹ solutions for up to 120 min (49).
Since 45Ca flux measurements or total Ca2⫹ content do not
reflect free myoplasmic Ca2⫹ concentrations, Fischer et al.
(202) took the next step and measured approximately
threefold increased resting fura-2 Ca2⫹ levels in whole EDL
muscles from septic rats 16 h after CLP induction (⬃1 ␮M
vs. ⬃350 nM in untreated rats) (FIGURE 7C). Although these
control values seem somewhat elevated compared with sin-
gle fiber Ca2⫹ determinations (40 –100 nM; Refs. 208, 296,
777), they are similar to other studies using fura-2 calcium
fluorescence recordings in total muscle (447), probably re-
flecting some inhomogeneity contributions from dye cap-
tured in the intercellular space or contributions from endo-
thelial, vascular smooth muscle cells, or immune cells resid-
ing in the muscle tissue. Surprisingly, direct recordings of
resting Ca2⫹ levels in single muscle fibers following septic
challenge are still missing. Specifically, most studies on al-
tered Ca2⫹ homeostasis in sepsis models have been per-
formed in cardiomyocytes because cardiomyopathy is also
a complication in sepsis. In rat models of sepsis, either CLP-
(807) or LPS-induced (292), a decreased fraction of cardiac
shortening was explained by a significant reduction in Ca2⫹
transient amplitudes 48 h after CLP (807) or 4 h after LPS
(292). Reduced SR Ca2⫹ content of ⬃380 nM (LPS) vs. 560
nM (control) was subsequently explained by a significantly
compromised SR Ca2⫹ uptake and increased SR Ca2⫹ leak
in SR vesicles (292) and from largely increased Ca2⫹ spark
frequencies in intact cardiomyocytes (807). Dantrolene, a
blocker of the ryanodine receptor, normalized the SR Ca2⫹
leak in SR cardiac vesicle preparations from LPS-treated
rats (292) and significantly reduced elevated resting Ca2⫹
levels in LPS-treated guinea pig cardiomyocytes (⬃230 nM)
to control values (⬃150 nM) (702). More importantly,
Thr-17 phosphorylation of phospholamban was 30% re-
duced, explaining the compromised SR Ca2⫹ uptake in sep-
tic cardiomyocytes (292). Interestingly, the contractile ap-
paratus properties so far present a diverse picture. In an
endotoxemia-induced myocardial dysfunction model in
guinea pigs, Ca2⫹ sensitivity of the myofilaments was unal-
tered 4 h after LPS induction in chemically skinned cardio-
myocytes, although maximum CSA-normalized tension
generated was significantly reduced, an effect that was re-
voked in the presence of protease inhibitors (584). How-
ever, another study in endotoxin-treated rabbits showed
1053
 FRIEDRICH ET AL.

A B C
- diltiazem + diltiazem

Ca2+ Flux: nmol/(g x 0.5hr)

250 (6) 1.5 - dantrolene
(22) P < 0.05
200 (10)
+ dantrolene

[Ca2+]i (μM)
(6) (8) (8)
(5) 1.0
(7) (6)
150 (15)

100
0.5
50

0 0
Control Sterile Septic Sterile Septic
control LPS sepsis
0 1 2
Days Post - Implantaion

D E F
diaphragm
25
M. soleus

membrane damage (%)

25 IL-1
20
depolarization (mV)

control
Muscle fibre
20 low Mg2+
15
15 low Mg2+
10 10

wash

0.5 (a.u.)
5

0.5 (a.u.)
5
out
0
10-1 100 101 102 103 0
25 s
endotoxin (mg/l) ctrl. LPS CLP 50 s 25 s

sepsis
FIGURE 7. Key findings involved in the reconstruction of the cellular pathology related to Ca2⫹ homeostasis,
EC coupling, and motor protein function in sepsis-related myopathies. A: macrophages (CD68-positive) within
muscle tissue in a biopsy from a CIPNM patient. [From De Letter et al. (150). Copyright 2000 Elsevier.] B:
Ca2⫹ flux into soleus muscles from septic (fecal pellet implantation) and sham-operated animals either
pretreated or not with diltiazem. [From Bhattacharyya et al. (57).] C: resting fura-2 Ca2⫹ levels in whole EDL
muscles from sham or CLP-septic rats (202). D: depolarization potency of plasma from a sheep in endotoxin
shock on rat diaphragm in vitro, compared with direct E. coli LPS depolarizing effect on rat diaphragm (90). E:
membrane integrity is compromised differentially in different muscles and sepsis models. Myofiber membrane
damage allows passage of extracellular cations and small molecules into the myoplasm (427). F: force
recordings in a single skinned fiber bathed in a low Mg2⫹ (10 ␮M) environment under control conditions (no
IL-1) and in the presence of 25 ng/l IL-1 (␣ isoform). As long as IL-1 is present, no force is produced. Washing
out IL-1 while still in low Mg2⫹ environment then restores a force transient indicative of IL-1 directly stabilizing
the inhibitory Mg2⫹ site on RyR1. [From Friedrich et al. (220). Reprinted with permission of the American
Thoracic Society. Copyright 2015 American Thoracic Society.]

higher Ca50 values for half-activation of papillary muscle control values (202), suggesting a potential involvement of
isometric force (1.78 vs. 1.53 ␮M) already 4 h after a 0.5 the SR and the RyR1 in the altered Ca2⫹ homeostasis dur-
mg/kg iv endotoxin treatment, indicating a reduced myofi- ing sepsis. The increased [Ca2⫹]i is furthermore expected to
brillar Ca2⫹ sensitivity. The latter even worsened after a activate calpains for the breakdown of desmin, ␣-actinin,
higher LPS dose (1 mg/kg: Ca50 ⫽ 2.08 ␮M) and with time and other Z-disk anchoring proteins (202, 776). However,
(2.12 ␮M after 24 h) but returned to normal after 5 days the above-mentioned CLP study did not claim to establish a
(692). Treatment of control papillary muscle strips with cause-effect relationship for dantrolene to exclusively act
isoproterenol produced a reduction in myofibrillar Ca2⫹ on muscle [Ca2⫹]i, since 1) only one time point was inves-
sensitivity similar to that seen in LPS-treated preparations, tigated (16 h post CLP or sham) and 2) dantrolene also
indicating a higher degree of protein kinase A-dependent significantly reduced plasma TNF-␣ and corticosteroids
phosphorylation as a cause for the changes in Ca2⫹ sensi- levels (202). Since TNF-␣ at 10 nM levels is known to
tivity seen in septic hearts (693). depolarize resting membrane potentials in whole EDL and
soleus muscles already after short incubation (712), it can
In skeletal muscle, elevated resting cytoplasmic [Ca2⫹]i also be speculated that the associated increase seen in [Ca2⫹]i in
seems to be a major trigger for subsequent downstream sepsis 16 h post-CLP may rather be an effect of increased
proteolysis and metabolic failure events. Strikingly, the plasma TNF-␣ because membrane depolarization has been
vastly increased [Ca2⫹]i found in whole EDL muscles 16 h shown to increase the membrane permeability towards
after CLP procedure in rats was dantrolene responsive, i.e., Ca2⫹ (120, 188, 771). Since the enhanced Ca2⫹ uptake in
dantrolene completely reversed the increased [Ca2⫹]i to K⫹ depolarized skeletal muscle from septic rats was blocked

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 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
by diltiazem that blocks the dihydropyridine receptor
(DHPR) (771), it is likely that the mechanism of this Ca2⫹
entry in sepsis might be identical to the “excitation-coupled
Ca2⫹ entry” (ECCE) that requires a functional DHPR but is
independent of store depletion (33, 334, 446). The upregu-
lation of the Cav1.1-ryanodine receptor complex in a rat
model of critical illness myopathy may also point towards
this direction (377). Therefore, it is tempting to speculate
that membrane depolarization might be a first event that
initiates increased membrane Ca2⫹ permeability and rise in
[Ca2⫹]i followed by activation of Ca2⫹-dependent proteol-
ysis and, eventually, necrosis.
The above-mentioned studies mostly relate to models of
sepsis-induced myopathy; strikingly, for CIM, no study on
Ca2⫹ homeostasis is available, neither for patient muscles
nor for animal models.
C. Muscle Ca2ⴙ Stores and Ca2ⴙ Transients
in Critical Illness
Another mechanism for the Ca2⫹ entry in septic muscle may
involve a dysregulation of the Ca2⫹ store with activation of
store-operated Ca2⫹ entry (SOCE). A reduced ryanodine-
induced contracture in diaphragm from septic mice (7.5
mg/kg LPS ip) that was reversed by the LPS inhibitor poly-
myxin B confirmed the involvement of LPS signaling on the
sarcoplasmic reticulum regulation (433). This was ex-
plained by a similarly reduced SR Ca2⫹ release by LPS.
Whether this is due to a decreased SR content of releasable
Ca2⫹ as a consequence of an increased SR leak similar to
cardiac muscle (e.g., Refs. 170, 292) has not yet been ad-
dressed. If the SR content was indeed reduced in septic
skeletal muscle, SOCE could in principle be activated (254,
806). However, in a steroid-denervation rat model of CIM,
ORAI1 (Ca2⫹ release-activated Ca2⫹ channel protein 1)
expression levels were found ⬃20% reduced compared
with controls 7 days post-op (377). SR function in skeletal
muscle still has only been initially studied in a CLP murine
sepsis model by Zink et al. (809). The authors compared
“intracellular Ca2⫹ regulation” in skinned EDL muscle fi-
bers from CLP, sham-operated, and general-anaesthesia-
only mice 2–7 days post-procedure, recording caffeine-in-
duced force transients. Relative force transients were de-
creased in the surgical procedure groups from day two but
recovered in the sham group from day three while still de-
clining in the CLP group to a minimum of ⬃40% at day
three, followed by recovery to control values at day seven.
SR reloading conditions were kept identical among groups,
though with a slightly overfilled SR compared with the usu-
ally only one-third filling of fast-twitch muscles (554). Un-
fortunately, the study did not provide any mechanistic ex-
planation for the observed force reductions. A link to im-
paired Ca2⫹ homeostasis on the SR level was made from
conversion of the force responses to “apparent Ca2⫹ tran-
sients,” using the steady-state pCa-force curves. However,
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
this approach is considered qualitative, at best, and has to
be interpreted with caution. For example, their calculated
Ca2⫹ transient amplitudes in the general anesthesia group
after 10 mM caffeine were close to 2 ␮M and ⬍1 ␮M in the
CLP group (809). However, direct Ca2⫹ fluorescence re-
cordings of Ca2⫹ transients in rat EDL muscles using Mag-
fura-2 already gave twitch peak Ca2⫹ amplitudes of ⬃18
␮M (41). Therefore, a mechanistic understanding of altered
Ca2⫹ homeostasis in experimental sepsis still awaits exper-
imental clarification. In an isolated in vitro study in C2C12
myotubes, TNF-␣ treatment (10 ng/ml) decreased electri-
cally evoked Ca2⫹ transient amplitudes significantly from
⬃0.4 to ⬃0.2 ␮M after 48 h (741). Resting Ca2⫹ levels were
also ⬃30% reduced. A decreased rate of Ca2⫹ transient
decay by TNF-␣, however, suggested that SR Ca2⫹ pump
function might have been compromised with less SR Ca2⫹
available for release (741). In another in vitro study chal-
lenging single isolated flexor digitorum brevis fibers with a
rather large dose of TNF-␣ (500 ng/ml), resting [Ca2⫹]i and
tetanic [Ca2⫹]i amplitudes were almost identical pre- and 4
h post-treatment (571). A very recent study in mouse EDL
skinned fibers challenged with IL-1 (␣ isoform) revealed a
rather unexpected mode of action in skeletal muscle: incu-
bation of skinned fiber bundles with IL-1 at concentrations
to those found in septic patients (⬎10 ng/l) reversibly re-
duced the SR Ca2⫹ release induced by relieving the Mg2⫹
inhibition on the RyR1 (220). Co-immunoprecipitation
and immunofluorescence colocalization experiments sug-
gested an association of IL-1␣ to RyR1 to putatively in-
crease the Mg2⫹ inhibition on the RyR1. Assessment of the
SR leak as the “Ca2⫹-retention index” (408) indicated a
reduction of SR Ca2⫹ leak by IL-1␣ (220). In contrast, in
cardiac muscle, IL-1 (␤ isoform) increased SR Ca2⫹ leak
(170). Therefore, in skeletal muscle, this may point towards
a novel mechanism where IL-1␣ associates with the RyR1
to interfere with SR Ca2⫹ release. Although the store con-
tent was found increased (220), the increased blockage of
Ca2⫹ release by IL-1␣ may be one explanation for weakness
in critically ill patients with increased pro-inflammatory
response. The question of how IL-1␣ would enter the mem-
brane barrier from outside was also addressed in the afore-
mentioned study. Prolonged incubation of intact single fi-
bers with IL-1␣ dose-dependently impaired membrane in-
tegrity, and IL-1␣ was subsequently found deposited within
the muscle cells, where it then could associate with RyR1 to
impair EC coupling (220) (FIGURE 7F). In support of this,
experimental animal sepsis has been shown to induce mem-
brane damage in myofibers using membrane impermeant
dyes. In diaphragm muscle, both CLP and LPS-induced sep-
sis increased the percentage of myofibers with compromised
membrane integrity from ⬍1% (control) to between 15 and
20%. In soleus muscle, LPS failed to compromise mem-
brane integrity but CLP-induced sepsis rose the percentage
of damaged fibers to ⬃8% (427, 673). Alongside with
membrane damage, resting membrane potentials were sig-
nificantly depolarized in diaphragm muscle fibers (from
1055
 FRIEDRICH ET AL.
⫺79 to ⫺68 mV; Ref. 427) (FIGURE 7E). Thus sepsis “per
se” or the combination of pro-inflammatory cytokines (like
TNF-␣ or IL-1) may compromise membrane integrity with
an additional entry pathway for cations and small-molecu-
lar-weight factors to depolarize membrane potential, in-
crease resting [Ca2⫹]i, or exert specific effects like the puta-
tive direct binding of IL-1 isoforms to RyR1. The mem-
brane damage mechanism may be unspecific or involve
specific signaling pathways, e.g., free radicals that are up-
regulated in inflammatory myopathies and in response to
cytokines (225, 679, 681, 683). Sepsis-induced membrane
damage was substantially reduced by NG-monomethyl-L-
arginine (L-NMMA), an inhibitor of NOS activity, pointing
towards a role of NO-mediated compromise of membrane
integrity (427). As long as sufficient myofiber repair mech-
anisms were still active, such membrane damage would be
sufficiently repaired with fibers not necessarily undergoing
necrosis (93). However, the damage would be sufficient
enough to let Ca2⫹, other cations and small molecules pass
the membrane.
D. Ca2ⴙ Regulation of the Contractile
Apparatus in Critical Illness
Apart from the effects of increased [Ca2⫹]i in septic muscle
on motor protein turnover and energy metabolism leading
to proteolysis (see sect. XI), it is of interest to highlight
regulatory consequences on the motor proteins with respect
to Ca2⫹ activation during EC coupling. Studies in the 1980s
already showed an in vitro inhibition of myofibrillar Mg2⫹-
activated ATPase activity in myofibrillar preparations from
both rabbit skeletal and dog heart muscles when incubated
with E. coli endotoxin (⬃0.05– 0.3 mg/ml) (537). Already
after 2 h, ATPase activity was reduced by 60% in skeletal,
and even more pronounced in cardiac myofibrils. Whether
those results can be of pathophysiological relevance in the
pathogenesis of sepsis-induced dysregulation of myofibril-
lar activity, however, is unknown. It would require LPS
itself to be translocated to the myoplasm of septic muscle to
exert this direct effect. A mechanism similar to that found
for IL-1 in muscle (220) or in cerebro-microvascular endo-
thelial cells (645) might be possible where endotoxin could
enter through local membrane defects, e.g., also induced by
NOS activation (427, 673). Probably more important are
subsequent inflammatory reactions induced by endotoxin
in the tissue, i.e., immune activation of macrophages and
release of pro-inflammatory cytokines that provide the
grounds for subsequent alterations of contractile perfor-
mance (692). During endotoxin shock, large amounts of
NO, either released by endothelial cells but also by myo-
cytes, seem to be causative for a deregulation of thin fila-
ment troponins by raising cGMP and phosphorylation of
troponins by cGMP-dependent protein kinases, at least in
the heart (75, 629, 673, 693, 791). In a positive-feedback
loop, NO released by endothelial and vascular smooth mus-
1056 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
cle cells stimulates neutrophils in a paracrine fashion to
increase their production of cytokines, i.e., TNF-␣ (739).
In both cardiac and skeletal muscle (diaphragm), a decrease
in myofibrillar Ca2⫹ sensitivity can be routinely detected,
either in CLP- or LPS-induced sepsis models (94, 674). This
decrease in Ca2⫹ sensitivity seems to be a direct conse-
quence of production of free radicals since prevention of
peroxynitrite formation with superoxide scavengers (e.g.,
pegylated superoxide dismutase; SOD) or NOS inhibition
with L-NMMA not only rescued mitochondrial dysfunction
in muscle (61, 95; see sect. X), but also pCa-force curves in
diaphragm single fibers from endotoxin-treated rats co-ad-
ministered with PEG-SOD but not with denatured PEG-
SOD (94). The reason for the NO production may be seen
in the appropriate cytokine profile during sepsis. In partic-
ular, TNF-␣ and IL-1 are prime candidates that have been
shown to result in adjacent activation of NO production. In
skeletal muscle, the inducible isoform iNOS is upregulated
in response to inflammation or other infectious conditions
(74, 394, 609). Upregulation of iNOS by combined incuba-
tion of IL-1␤ and IFN-␥ in rat skeletal myoblasts was asso-
ciated with ERK1/ERK2 activation and was completely ab-
rogated by NF-␬B blockade (4). In skeletal muscle biopsies
of congestive heart failure patients, a linear correlation be-
tween IL-1␤ content and iNOS expression was detected (4).
In C2C12 skeletal muscle myocytes, combinations of
TNF-␣, IFN-␥, and IL-1␣, but not either cytokine alone,
were found to substantially increase iNOS activity, and RT-
PCR analysis revealed that the iNOS mRNA sequence
showed exact homology with macrophage iNOS, indicat-
ing stimulation of skeletal muscle NO production via induc-
tion of the macrophage-type iNOS gene (778). A 4 h incu-
bation of isolated mouse limb and diaphragm muscle with
TNF-␣ markedly suppressed force production in response
to field stimulations up to 150 Hz (571). This force depres-
sion was located downstream to Ca2⫹ signaling since no
compromise of tetanic [Ca2⫹]i by TNF-␣ (500 ng/ml) was
detected (571). A later study by the same group confirmed a
depression of field-stimulated myofibrillar force without
any changes in Ca2⫹ sensitivity of the contractile apparatus
(286). Using TNFR1-deficient mice treated with TNF-␣, the
decrease in myofibrillar force was prevented and was simi-
lar to wild-type animals treated with vehicles, pointing to-
wards the absolute requirement of TNF-␣ signaling
through its TNFR1 receptor to suppress myofibrillar force,
probably indirectly through ROS and RNS production
(286). So far, the molecular proteins affected by TNF-␣ are
not yet known (286). Apart from indirect phosphorylation
of regulatory proteins by peroxynitrite, a direct interaction
of TNF-␣ with intracellular target proteins similar to as has
been suggested for IL-1␣ (220) may be possible but has not
yet been tested.
The literature reviewed above exclusively refers to the
association between sepsis, pro-inflammatory mediators,
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
and myopathic changes, indicative of sepsis-induced my-
opathy. For CIM, surprisingly no published data seem at
hand on Ca2⫹ regulation of the contractile apparatus in
CIM patients (i.e., nonseptic). In a preliminary study,
sequential vastus lateralis biopsies from 12 critically ill,
septic, and mechanically ventilated ICU patients, of
which six were clinically diagnosed with CIM, were pre-
pared for pCa-force recordings of skinned fiber bundles.
However, although there were some changes in myofi-
brillar Ca2⫹ sensitivity in two CIM patients between
early (⬃2– 4 days) and late (7–14 days) biopsies, the
baseline sensitivity in early biopsies between CIM and
non-CIM patients was similar (Friedrich, unpublished
observations). Regarding animal models of CIM, no data
on myofibrillar Ca2⫹ sensitivity are available so far from
the steroid-denervation model. In the rat ICU model,
myofibrillar Ca2⫹ sensitivity was consistently found to
decrease over the time course of 14 days intensive care
management (NMBs, mechanical ventilation and muscle
silencing) (517) (see also sect. XII).
E. Muscle Fatigue in Critical Illness
Another important yet rather unresolved symptom of ICU-
acquired muscle weakness is “muscle fatigue.” Increased fati-
gability has been repeatedly documented in patients with ex-
acerbated chronic inflammatory conditions (311, 449), but
only very few studies have looked at patients with sepsis and
multiorgan failure (181). Interestingly, force decrement after
fatiguing tetanic stimulations was not different between pa-
tients with sepsis and multiorgan failure and volunteers fol-
lowing 2 wk of immobilization, although the baseline tetanic
force was markedly depressed already before the fatigue pro-
tocol in the sepsis/MOF group (181). Although it is suggestive
that the patients in that study actually suffered from CIM (i.e.,
were septic, immobilized, and mechanically ventilated), the
authors only assessed the muscle weakness and electrophysi-
ology parameters but no muscle biopsies for preferential my-
osin loss confirmation. Thus, although the authors classify
their myopathy as “sepsis-induced myopathy,” patients might
in fact have been CIM patients.
Muscle fatigue is a very complex phenomenon that involves
multiple cellular correlates, e.g., transmission failure of ac-
tion potentials, tubular excitation spread failure, voltage
sensor dysregulation, SR Ca2⫹ release, metabolic impair-
ment through ATP depletion or reuptake alterations, or
myofibrillar protein alterations (13, 28, 172, 417, 572,
657). In critically ill patients, muscle fatigue is usually only
assessed via nerval routes either using voluntary muscle
exercise (278) or nerve stimulation (181). In a study on the
effect of acute infusion of LPS into healthy volunteers, it
was found that there was an acute onset of mild muscle
weakness within 3 h (471). Interestingly, there was no def-
icit in electrically stimulated muscle contractions. The au-
thors concluded that “loss of volition” may be a more im-
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
portant factor than intrinsic dysfunction in acute sepsis-
associated human muscle weakness. This finding, together
with the recent finding that there may be problems with
activation of lower motoneurons in septic patients and sep-
tic rats (500), raises the possibility that difficulties with
activation of motor units may contribute to weakness and
fatigue in critical illness.
Most mechanisms of muscle fatigue in human sepsis had
been tracked down to mitochondrial alterations and ATP
depletion in cases where muscle biopsies for biochemistry
assays were available (211), but other levels had not been
looked at. Surprisingly, animal studies on sepsis and muscle
fatigue are likewise rare and on animal CIM models, not yet
available (but on their way; Larsson, unpublished results).
In chronic CLP-induced sepsis, soleus muscles of rats after 7
days of sepsis were stimulated via ventral root single motor
units to assess fatigue index which indicated increased fati-
gability (567). However, mechanisms inherent to impaired
nerve transmission were not dissected from fatigue mecha-
nisms within the muscle itself. Another study that also em-
ployed CLP-induced sepsis in rats used direct muscular
stimulation of isolated diaphragm 16 h post-CLP proce-
dure. Trains of tetanic stimulations (50 Hz for 2 s every 10
s for 5 min) were applied. Times to half decrement of the
first peak tetanic tension (T50) as fatigability index revealed
an almost 50% shorter T50 indicative of massive fatigue
(488). This fatigue was associated with a marked increase in
myeloperoxidase activity (MPO) as an index of neutrophil
activation in septic muscle tissue. Since in septic patients
cAMP stores were found depleted (54), the authors also
speculated that phosphodiesterase inhibition would allevi-
ate fatigue patterns. Using the PDE inhibitor olprinone,
both MPO activity and fatigue were restored similarly to-
wards control levels, indicating a crucial involvement of
activated neutrophils or macrophages within septic tissue to
contribute to downstream muscle weakness and increased
fatigability, probably through their cytokine release pat-
terns of IL-1 and TNF-␣ or free radicals (94, 224, 488). In
chronic inflammatory conditions of polymyositis and der-
matomyositis, muscle weakness in patients was correlated
with a strong expression of IL-1␣ in patient muscle tissues
(516). An even more massive expression of several pro-
inflammatory cytokines and macrophage infiltration found
in muscle biopsies from critically ill patients with probable
CIM (patients septic and mechanically ventilated; evidence
for CIM from electrophysiology plus immunohistochemis-
try, but not assessed for preferential myosin loss) (150)
(FIGURE 7A) may already point to a common denominator
of such a hypothesis in several forms of myopathy-associ-
ated inflammatory conditions. This may also hold true for
conditions without primary presence of inflammatory cells
in primary inflammatory myopathies, where muscle fibers
have been found to intrinsically overexpress IL-1␣, TNF-␣,
IL-2, and IFN-␥ (150, 701).
1057
 FRIEDRICH ET AL.

Sepsis, critical illness

Diapedesis, Vessel PDE-inhibition

Direct
tissue infiltration
action?
Activated neutrophil/
+
macrophage Myeloperoxidase
(MPO) activity

LPS? Cytokine release

– AP
IFN-γ TNF-α IL-1α/β Em NO
+ Na+
Ca2+ Cytokine receptor
Membrane +
integrity ATP K+ iNOS, NO
DHPR depletion
+ expression
Ca2+
uptake
L-NMMA RyR1
Ca2+
Ca2+
↑NO ↓cAMP, ↑cGMP
SR SERCA
NF-κB
–
Intracellular ATP ADP, Pi
[Ca2+]i IL-1, IFN-γ
expression Ca2+
T-tubule –
Myosin Actin ATP ATP ATP

Νυχλευσ

• Pro-inflammatory cytokines + ATP

• DHPR upregulation, NO production depletion
cGMP-dependent
• Ca2+ influx↑, resting [Ca2+]↑ Tnl Actin Troponin/Tm
phosphorylation
• Membrane damage (primary/NO-induced)
• Membrane depolarization (10–15 mV) TNF-α Ca2+ Tnl Fatigue
• SR Ca2+ leak↑ or ↓ (?) sensitivity HMM
• Myofibrillar Ca2+ sensitivity ↓ aor
↕

• Fatigue↑

FIGURE 8. Cellular mechanisms that contribute to muscle dysfunction in the phase determined by altered
Ca2⫹ homeostasis, EC coupling, and motor protein function during critical illness. For details, see section IX.
CLP, cecal ligation and puncture; LPS, lipopolysaccharides; DHPR, dihydropyridine receptor; SR, sarcoplasmic
reticulum; RyR1, ryanodine receptor 1; SERCA, sarco/endoplasmic reticulum Ca2⫹-ATPase; L-NMMA: NG-
monomethyl-L-arginine; iNOS, inducible nitric oxide synthase.

FIGURE 8 summarizes most of the mechanisms found in septic
muscle explained in this section. Again, it has to be kept in
mind that results from septic ICU patients cannot assess sepsis
as independent variable for CIM development since all those
septic patients underwent mechanical ventilation and immo-
bilization simultaneously as part of the ICU treatment. For
potential separation of factors, refer to section XII.
X. METABOLIC EFFECTS IN CRITICAL
ILLNESS
Critical illness is hallmarked by striking endocrine and meta-
bolic disturbances, the severity of which has been associated
with a high risk of morbidity and mortality (730, 732, 784).
Already several decades ago the hypothesis was raised that
during sepsis and other types of critical illness, cellular en-
ergy metabolism is disturbed in several organs including
skeletal muscle. The mitochondria as power plants of the
cell are responsible for the majority of the ATP production
through oxidative phosphorylation (FIGURE 9A).
A. Disturbances in Energy-Rich Phosphates
in Critical Illness
The process of oxidative phosphorylation is crucial for ad-
equate production of ATP for energy available in the steady
state, but takes some time to respond to alterations in ATP
demands. Phosphocreatine (PCr), on the other hand, serves
as a rapidly mobilizable short-term storage of high-energy
phosphates in skeletal muscle. Several studies on critical
illness point towards a disturbance in the levels of these
high-energy phosphates in skeletal muscle.

1058 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org

 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
A H+ H+
Intermembrane space
I e–
Q •–
e– e– II
FADH2 FAD
NADH NAD+
Matrix
B NOS
NO•
Reversible inhibition
I e–
Q •–
e– e– II
Irreversible inhibition
ONOO–
Damage to proteins, lipids, ...
In limb muscle of critically ill patients, especially with sepsis, a
low-energy charge potential with reductions in ATP, ADP,
and/or PCr and a rise in AMP and free creatine has been
described in the presence of high lactate levels and an increased
lactate-to-pyruvate ratio (210, 425, 426, 444). In rats with
hemorrhagic shock, ATP, ADP, and PCr levels already
dropped after 1 h in diaphragm (continuously working mus-
cle) and after 2 h in soleus muscle (more sedentary or resting
muscle) (115). These reductions were less severe than those in
vital organs as liver and kidney. 31P magnetic resonance spec-
troscopy studies in rats after CLP sepsis showed a decrease in
the PCr/Pi ratio as measure of energy stores after 24 h but not
in energy available for immediate use, as reflected in the
ATP/Pi ratio (348). The increased Na⫹-K⫹-ATPase activity,
decreased PCr/ATP, increased PCr breakdown, but unaltered
ATP levels and pH in this model were interpreted as increased
ATP utilization to help maintain the ionic balance and/or sup-
port other metabolic processes, whereas PCr stores are used to
buffer the ATP concentration (347, 489). Muscle energy
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
H+ H+
Cyt c IV
e–
III
O2 H2O V
FIGURE 9. Mechanisms of compro-
mised energy production in muscle during
critical illness. A: normal mitochondrial re-
spiratory chain function. Complexes I–V are
ADP + Pi ATP
shown. NAD⫹ and NADH, nicotinamide di-
nucleotide, oxidized and reduced form, re-
spectively; FAD and FADH2, flavine ade-
nine dinucleotide, oxidized and reduced
form, respectively; ATP, adenosine triphos-
phate; ADP, adenosine diphosphate; Pi, in-
organic phosphate. B: disturbed mitochon-
drial function in critical illness. A vicious
cycle of increased free radical generation
resulting from enhanced nitric oxide syn-
Cyt c IV thase and from increased escape of elec-
trons from the respiratory chain with for-
e– mation of superoxide anion radicals revers-
III ibly or irreversibly inhibits several
mitochondrial respiratory chain enzyme
complexes. Consequently, the supply of en-
O2 H2O V ergy-rich phosphates is compromised.
e–
–
O2• – e– e
ADP + Pi ATP
NO• e–
H2O2
PCr
OH•
charge was not altered after 1–3 wk of sepsis in another ex-
perimental study (475). Interestingly, patients with severe sep-
sis or septic shock (probably CIM, but not assessed for) who
would not survive their illness had lower ATP levels, a smaller
total adenine pool, but higher levels of AMP in vastus lateralis
muscle biopsies taken within 24 h after ICU admission than
patients who would survive (77). Compromised ATP synthe-
sis was described in muscle of septic rats 6 days post CLP
(691). Also, burn injury in mice reduced the rate of ATP syn-
thesis, but did not affect high-energy phosphate levels apart
from a reduction in PCr (534).
B. Muscle Oxygenation in Critical Illness
Disturbances in cellular energy metabolism and consequent
bioenergetic failure in trauma and sepsis in humans were
originally ascribed to inadequate tissue perfusion leading to
cellular hypoxia and, thus, compromised availability of the
1059
 FRIEDRICH ET AL.
final electron acceptor in the respiratory chain (350). This
notion was based on the high lactate levels observed in these
conditions which are traditionally attributed to anaerobic
glycolysis as the result of inadequate oxygen delivery. How-
ever, studies on tissue oxygenation yielded ambiguous re-
sults. In a rat endotoxemia model, oxygen tension in resting
muscle was reduced after 4 h in the presence of a normal
microcirculatory perfusion and remained refractory to in-
creasing inspired oxygen (605). A 6-h rat peritonitis model
of sepsis-induced myopathy showed reduced oxygen ten-
sion in rectus femoris muscle, an increased lactate-to-pyru-
vate ratio, and reduced levels of ATP and total adenine
nucleotides (23). These accompanying abnormalities were
still observed when normal tissue oxygenation was main-
tained. After 36 – 42 h, no evidence of cellular hypoxia was
detected in skeletal muscle or diaphragm in septic rats with
peritonitis, based on infusion of a hypoxia marker, al-
though circulating lactate levels increased (324). Patient
studies suggested that muscle oxygenation is even increased
in fluid-resuscitated, hemodynamically stable sepsis and re-
lated to disease severity, unlike in patients with limited in-
fection, cardiogenic shock, or after cardiopulmonary by-
pass (62, 63, 606). Altogether, these data suggest that cel-
lular hypoxia is not the major driving force of energetic
disturbances in critical illness. Importantly, elevated lactate
levels in hemodynamically stable patients may well be the
consequence of stimulated aerobic glycolysis rather than of
tissue hypoxia (350).
C. Intrinsic Mitochondrial Abnormalities in
Muscle During Critical Illness:
Morphological and Functional
Mitochondrial Damage
Recent studies infer a disturbance in oxygen utilization
rather than in oxygen delivery, leaving us with an acquired
intrinsic derangement in cellular energy metabolism, which
has been identified as “cytopathic hypoxia” (198, 640).
Mitochondrial ultrastructural damage had been described
for hindlimb skeletal muscle of endotoxemic rats already
more than 40 years ago with frequent distortion of inner
and outer mitochondrial membranes and the presence of
large vacuolar areas (620). These alterations were clearly
present after 18 h but not yet after 6 or 12 h. In a porcine
model of endotoxemia, mitochondrial swelling was ob-
served in skeletal muscle at 18- and 48-h time points (293).
A study of serial skeletal muscle biopsies taken after 12 and
24 h and at the time of death showed that bacteremia in
baboons led to mitochondrial swelling and even membrane
fragmentation with advanced injury (638, 769). Less
densely packed cristae were also observed in diaphragm
mitochondria of 48 h endotoxemic rats (99). Mitochondria
in biopsies of vastus lateralis or intercostal muscles taken
after 2–22 days from patients with sepsis-induced multiple
organ failure showed no differences in morphology com-
pared with elective surgery patients (210). Early degenera-
1060 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
tive mitochondrial changes have been observed in skeletal
muscle of patients and experimental animal models in con-
ditions of ischemia-reperfusion which may persist for days
to weeks after the insult (644, 708).
Evidence for a functional correlate of the mitochondrial
morphological damage with an intrinsic dysfunction of the
organelles during critical illness continuously increases, al-
though apparently conflicting results have been obtained
depending on the species, model, and severity and duration
of the insult. Nevertheless, mitochondrial function appears
mostly depressed in models of longer duration and greater
severity of illness (640). The majority of studies focused on
sole sepsis as severe insult which, therefore, will be the focus
here. Function of the mitochondrial respiratory chain is
most commonly assessed via the activities of its individual
enzyme complexes (FIGURE 9A) or via oxygen consumption
studies, with evaluation of state 3 and state 4 mitochondrial
respiration as well as the respiratory control ratio or index
and the ADP/O ratio.
Very early after an acute insult, mitochondrial function may
be enhanced, as illustrated by the increased activities of
complex I and citrate synthase in vastus lateralis biopsies
taken 2 h (but not at 4 h) after an endotoxin challenge in
human healthy volunteers (209). This may be in line with
increased cytosolic Ca2⫹ in sepsis (see previous sections on
Ca2⫹ homeostasis). Elevated cytosolic Ca2⫹ has been
shown to stimulate mitochondrial biogenesis (524). How-
ever, such Ca2⫹-induced stimulation of biogenesis may
strongly depend on the level and duration of increased Ca2⫹
(524). In several (mostly rat) models of sepsis (endotoxin
administration, peritonitis induced by CLP, or injection of
fecal slurry or live bacteria), no consistent results have been
obtained regarding mitochondrial function in limb muscle
up to 18 –24 h, with either no effect on individual enzyme
activities, state 3 and state 4 respiration, respiratory control
index, and ADP/O ratio or either marked loss of respiratory
control (78, 96, 235, 436, 620). Early partial uncoupling
has been described in the diaphragm but was not observed
in limb skeletal muscle (61, 436). The time point of 24 h
may be a borderline at which mitochondrial functional al-
terations develop in diaphragm and limb skeletal muscle of
endotoxin models, if the administered endotoxin dose, and
thus severity of illness, are sufficiently high (96, 97, 552, 672,
716). The decrease in complex I activity in skeletal muscle
from rats with fecal peritonitis also depended on the severity of
the disease (78). Importantly, mitochondrial functional alter-
ations in vastus lateralis biopsies taken within 24 h after ICU
admission were more severe in patients who would succumb
to severe sepsis/septic shock than those who would survive
(77). Unlike with shorter time windows of illness, mitochon-
drial function appears uniformly depressed with a prolonged
duration of illness beyond 24 h (78, 96 –98, 210, 672). There
was no uncoupling of the mitochondria beyond this time point
(96, 97, 672).
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
Sepsis appears to most consistently affect the activity of
complex I, but also other enzyme complex activities have
been found to be reduced (78, 97, 442, 716). The impact of
sepsis on mitochondrial function may also differ according
to the substrate that is used to stimulate mitochondrial res-
piration. In that regard, pyruvate- or octanoylcarnitine-de-
pendent respiration, but not succinate-dependent respira-
tion, appeared to be reduced in endotoxin-treated rabbits
after 24 h (716). One or two weeks of bacteremia evoked a
decrease in pyruvate-dependent respiration, whereas
branched-chain keto-acid and ketone body utilization si-
multaneously increased in rat muscle (475).
Apart from inhibition of electron flow along the mitochon-
drial respiratory chain or uncoupling of oxidative phosphor-
ylation, disturbances in other metabolic processes may impact
on cellular ATP generation. These include altered activities of
glycolytic or tricarboxylic acid cycle enzymes, as illustrated by
the reduced expression and activity of diaphragmatic phos-
phofructokinase 36 – 48 h after endotoxin administration
(98). Also, impaired ATP synthase activity and hampered
transport of ADP/ATP in and out of mitochondria may com-
promise cellular ATP generation. The decreased maximal res-
piration after addition of a chemical uncoupling compound
was, however, interpreted as ruling out alterations in ATP
synthase activity and transport of ADP or ATP across the inner
mitochondrial membrane (97, 672). Nevertheless, the activity
and expression of the mitochondrial creatine kinase (MtCK)
shuttle appeared dramatically reduced in rat diaphragm 48 h
after endotoxin injection (99). In most tissues, the adenine
nucleotide transporter system is the most important way by
which ATP is transported from the mitochondrial matrix side
to the intermembrane space. From there, ATP goes through
the outer mitochondrial voltage-dependent anion channel into
the cytosol. However, in organs requiring extremely high rates
of transmitochondrial ATP transport, a mitochondrial crea-
tine kinase isoform (MtCK) constitutes the major ATP
transport system, such as the sarcomeric MtCK in striated
muscle. As the MtCK is also an important structural protein
that stabilizes mitochondrial membrane architecture by
cross-linking of the inner and outer mitochondrial mem-
branes at contact sites, the mitochondrial morphological
alterations with less densely packed cristae may be related
to the loss of MtCK (99). The cytosolic muscle type creatine
kinase (CK-MM) which is responsible for delivery of high-
energy phosphates to the myosin ATPase was not affected
by sepsis (99).
Several biophysical mechanisms may contribute to mito-
chondrial dysfunction among which are disruption of mi-
tochondrial membrane integrity, modification of protein
side-groups, increased degradation or reduced synthesis of
the pathway components, and dissegregation of the multi-
protein complexes. Selective depletion of several respira-
tory chain subunits and other mitochondrial proteins, in-
cluding multiple cytochromes, has been described in rat
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
diaphragm and/or limb muscle after prolonged sepsis (96,
97, 99, 691), which may be related to decreased gene ex-
pression and rate of mitochondrial protein synthesis (98,
592) or increased degradation secondary to side-group
modification. It also has been suggested that a reduction in
intramitochondrial calcium levels during endotoxemia may
contribute to metabolic derangement, specifically through
its impact on calcium-dependent intramitochondrial en-
zymes (358). Interestingly, plasma from patients with sepsis
contained increased levels of extracellular mitochondrial
DNA and inflammatory cytokines and tended to reduce
oxygen consumption by skeletal muscle mitochondria from
healthy volunteers (232).
Apart from sepsis, other severe insults have been shown to
impair mitochondrial function in skeletal muscle, such as
severe burn injury (553). This is illustrated by reduced mi-
tochondrial respiration and activities of individual mito-
chondrial enzymes after severe burn trauma in children and
downregulated expression of several genes involved in gly-
colysis, tricarboxylic acid cycle, and oxidative phosphory-
lation in burn-injured mice (135, 136, 534). Furthermore,
burn injury elicited early and prolonged activation of apo-
ptosis which was preceded by a disturbance in mitochon-
drial membrane potential (24, 411, 792) and evoked an
early transient rise in the expression of the uncoupling pro-
tein UCP3 (803).
Unlike the abundance of data available on mitochondrial
function from critically ill septic patients and animal models
of sepsis, no studies involving animal models on critical
illness to dissect sepsis from mechanical ventilation and
immobilization or steroid-denervation have yet been pub-
lished but are on their way. Profound structural mitochon-
drial changes were observed early in rats subjected to me-
chanical ventilation and immobilization in the absence of
any other insults (i.e., sepsis). Severe changes developed in
the diaphragm already after 6 h of mechanical ventilation
and after 18 h in a distal hindlimb muscle (soleus) (Shalah
and Larsson, unpublished observations). Likewise, the con-
nection between cytoplasmic and mitochondrial Ca2⫹ on
the one hand and biogenesis on the other hand has not been
addressed yet in critical illness or sepsis models. Adequate
ICU animal models, such as outlined in section XII, thus
represent an important strategy for future studies on mito-
chondrial dysfunction in CIM.
D. Mitochondrial Dysfunction, Oxidative/
Nitrosative Stress, and Impaired Muscle
Force During Critical Illness
Endotoxin treatment has been shown to decrease force gen-
eration over the entire range of pCa tested, as well as max-
imal calcium-activated muscle force (Fmax) of skinned myo-
fibers of diaphragm and limb muscle (94, 682). These ob-
servations point to altered intrinsic functional properties of
1061
 FRIEDRICH ET AL.
the contractile proteins. Interestingly, decreased muscle
force coincided with a selective depletion of several proteins
and appeared preventable by treatment with a NOS inhib-
itor or superoxide scavenger (94). Thus increased free rad-
ical generation appears to play an important role in the
establishment of sepsis-related skeletal muscle dysfunction.
Free radicals may impair mitochondrial function, but recip-
rocally, disturbances in mitochondrial function may also
enhance free radical production.
Oxidative stress increases in skeletal muscle early after the
onset of sepsis induced by CLP in rats (436). NOS activity
rises within a few hours after the insult in this model as well
as in endotoxemia and is sustained for several hours or
days, especially in diaphragm, but is less unequivocally
demonstrated or occurring at a later time point in limb or
abdominal skeletal muscle (60, 61, 182, 233, 427, 607). In
most of these studies, the rise in total NOS activity is as-
cribed to the increased expression and activity of the induc-
ible NOS isoform (iNOS), but also increased levels of the
eNOS and nNOS isoforms have been reported (182). A study
that combined the evaluation of iNOS, muscle histology, and
muscle function in rat diaphragm over time detected iNOS
protein and activity first in inflammatory cells 6 h after the
endotoxemia challenge in the presence of normal histology
and muscle force and fatigability (60). At 12 h, histology was
still normal and iNOS protein and activity were detected, co-
inciding with a decreased muscle force but not fatigability. At
24 h, the inflammatory cells had disappeared but iNOS was
still found in the myocytes and muscle force remained com-
promised. By 48 h, iNOS was no longer detectable and muscle
force was restored. In acute endotoxemia and subacute peri-
tonitis models, increased iNOS and macrophage staining were
associated with sarcolemmal injury in diaphragm and/or limb
skeletal muscle which correlated with membrane depolariza-
tion (427). Muscle injury and decreases in contractile force
were (at least partially) restored or prevented when the rise in
iNOS expression was prevented with dexamethasone admin-
istration or when iNOS activity was inhibited (60, 61, 94, 182,
233, 427). Later studies demonstrated increased mitochon-
drial NOS activity in diaphragm and limb skeletal muscle of
endotoxemic rats which was ascribed to an inducible (mti-
NOS) rather than constitutive isoform (mtcNOS) of NOS,
based on the absence of this response in iNOS⫺/⫺ mice (16,
186, 443).
NO reversibly inhibits the activity of the mitochondrial re-
spiratory chain complex IV by competing with molecular
oxygen (FIGURE 9B). NO can also induce reversible inhibi-
tion of complex I by thiol group nitrosylation and has been
shown to decrease complex III activity by impairing elec-
tron flow at the cytochrome bc1 level. The impairment of
the electron transfer chain leads to a decreased mitochon-
drial membrane potential, leakage of electrons, and forma-
tion of more reactive oxygen/nitrogen species, at first in-
stance the superoxide anion radical (O2·⫺). SODs can con-
1062 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
vert superoxide to molecular oxygen and hydrogen
peroxide which in the presence of transition metal ions can
give rise to the extremely reactive hydroxyl radical. Both
catalase and glutathione peroxidase are able to detoxify
hydrogen peroxide. Importantly, the reaction of NO with
superoxide yields peroxynitrite (ONOO⫺), a potent nitrat-
ing agent that irreversibly inhibits the four complexes of the
mitochondrial respiratory chain and the ATP synthase (FIG-
URE 9B), as well as several other mitochondrial enzymes
such as aconitase and the mitochondrial superoxide dismu-
tase (MnSOD), and also oxidizes membrane lipids.
Elevated nitrotyrosine levels as a footprint of ONOO⫺ have
been shown in parallel with peak iNOS protein levels in
diaphragm of endotoxemic rats (182). Progressive increases
in nitration of mitochondrial proteins preceded the decrease
in muscle force, which could be reversed by administration
of a NOS inhibitor (61). In another study, tyrosine nitrosy-
lation of some mitochondrial proteins preceded the selec-
tive depletion of several mitochondrial proteins and com-
promised mitochondrial function which all could be pre-
vented or attenuated by administration of a NOS inhibitor
or superoxide scavenger (96). Selective reductions in some
but not all mitochondrial proteins, including components
of the electron transfer chain, have been observed simulta-
neously with disturbed mitochondrial function in other
studies but may also be partly related to decreased mRNA
expression (97, 98, 99). The rise in nitrotyrosine levels and
decrease in muscle force could also be blunted by adminis-
tration of a NADPH oxidase inhibitor, suggesting involve-
ment of this enzyme as well (684).
Soon after induction of sepsis, mitochondrial production of
superoxide radicals and hydrogen peroxide rises, associated
with increased (mitochondrial) NOS activity, elevated (in-
tramitochondrial) levels of NO, hydrogen peroxide, and
ONOO⫺ and nitration of mitochondrial proteins (16, 61,
436, 506). These responses appeared preventable with NOS
inhibition (61). Several studies have implicated increased
production of superoxide, hydrogen peroxide, and/or hy-
droxyl radicals in the decreased muscle contractility of re-
spiratory and limb muscles in endotoxemia, in parallel with
markers of oxidative stress-induced macromolecular dam-
age (increased levels of the lipid peroxidation markers mal-
ondialdehyde, 8-isoprostane, and of protein carbonyls) (61,
634, 672, 681, 683).
While ROS production is increased, the antioxidant defense
mechanisms are compromised in sepsis. A few hours of
endotoxemia increased the diaphragmatic activity of the
antioxidant enzyme MnSOD but did not affect catalase
activity (16). The activities of MnSOD, catalase, and gluta-
thione peroxidase, as well as mitochondrial function, were
decreased in limb muscle 12 h after CLP (436). Simultane-
ously with remarkable inhibition of mitochondrial respira-
tory chain activity and ATP production, intramitochondrial
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
oxidative stress was observed after 24 h in diaphragm and
limb muscle of septic mice with a decreased ratio of oxi-
dized (GSSG) over reduced (GSH) glutathione levels, re-
duced total glutathione levels, higher activity of the GSH
consuming glutathione peroxidase, and lower activity of
the GSH regenerating enzyme glutathione reductase (186,
442, 443). These disturbances did not develop in iNOS⫺/⫺
mice. Also, administration of melatonin, which scavenges
reactive oxygen and nitrogen species, counteracted mtNOS
induction and respiratory chain failure, and restored the
redox status. The degree of the decrease in GSH levels in
limb muscle of a fecal peritonitis model was shown to de-
pend on the severity of illness (78). Interestingly, complex I
activity correlated inversely with NO production and di-
rectly with levels of GSH and ATP. Also, in skeletal muscle
of severely burned rats, a remarkable decrease in mitochon-
drial GSH was observed (456).
E. Mitochondrial Repair Mechanisms in
Critical Illness
Persistent mitochondrial damage can be evoked by sus-
tained direct mitochondrial damage and/or impaired or in-
sufficient activation of the mitochondrial repair mecha-
nisms. Damaged organelles in turn can perpetuate further
damage, e.g., through production of more ROS. Several
repair mechanisms cooperate to remove or compensate for
mitochondrial damage. Mitochondria undergo continuous
cycles of fusion and fission. Mitochondrial fusion and fis-
sion not only determine mitochondrial size and distribution
in the cell but are also involved in the repair of mitochon-
dria (116, 700). These processes allow the exchange of
damaged mitochondrial components and either dilution of
molecular damage over the daughter organelles or bundling
of dysfunctional structures by asymmetric fission into a sin-
gle, irreversibly damaged depolarized organelle, which is
fusion-incompetent and is subsequently targeted for re-
moval by mitochondrial autophagy or “mitophagy” (365,
700, 721). Autophagy is a crucial cellular quality control
mechanism to clear damaged organelles and potentially
toxic protein aggregates (295, 379). Mitochondrial fusion
and fission are also important for mitochondrial biogenesis.
This pathway generates new mitochondria when needed,
such as in response to mitochondrial damage and increased
energy demand (282, 615). Under normal physiological
conditions, the three processes are nicely balanced. FIGURE
10 shows a simplified presentation of these processes and
their interactions. Compared with mitochondrial damage,
much less attention has been paid to the mitochondrial
repair mechanisms in critical illness. Actually, interest in
these pathways is only recently emerging.
1. Mitochondrial biogenesis in critical illness
Initially, studies on mitochondrial repair rather focused on
mitochondrial biogenesis, mostly in tissues other than skel-
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
etal muscle (e.g., liver) where activation of mitochondrial
biogenesis preceded restoration of mitochondrial mass and
oxidative metabolism and appeared an important pro-sur-
vival factor (137, 282, 667). In vastus lateralis muscle bi-
opsies harvested within 1– 42 days after ICU admission
from patients with sepsis-induced multiple organ failure,
most of whom survived their illness, mitochondrial biogen-
esis may have been partially activated as illustrated by some
increased mitochondrial transcription factors, but never-
theless failed to maintain mitochondrial function (212). In
another clinical study, an early mitochondrial biogenesis
response (within 1–2 days after ICU admission) was ob-
served in muscle from surviving but not from nonsurviving
patients with severe sepsis (105). This activation was
mainly seen upstream in the respective pathway and was
not accompanied by a clear difference in mitochondrial re-
spiratory chain proteins. In a heterogeneous group of criti-
cally ill patients, upstream activation of the mitochondrial
biogenesis program was observed in postmortem biopsies
of rectus abdominis, but not in in vivo biopsies of vastus
lateralis taken after 2 wk in ICU, and this was irrespective of
future survival status (FIGURE 10) (727). In muscle taken
within 10 days from children with severe burn injury,
downregulated mitochondrial biogenesis has been sug-
gested (723). In experimentally denervated gastrocnemius
muscle of rats and mice (a model of disuse), strong reduc-
tions in mitochondrial content coincided with a remarkable
downregulation of several key players of mitochondrial
biogenesis several weeks after the insult (5, 750). Several
components of the mitochondrial biogenesis pathway ap-
peared downregulated at gene expression level after 24 h of
endotoxemia, which was more pronounced in mouse tibia-
lis anterior and soleus muscle than in diaphragm (490). On
the other hand, freeze injury of murine gastrocnemius mus-
cle (a model of degeneration and regeneration) suggested
that mitochondrial biogenesis plays a role in muscle regen-
eration because this pathway appeared activated early dur-
ing muscle regeneration (751).
2. Mitochondrial fusion and fission in critical illness
Data on the impact of critical illness on mitochondrial fu-
sion and fission hardly exist. Both processes need to be
appropriately balanced, since both unopposed fusion and
unopposed fission are detrimental for cellular function. The
only study on mitochondrial fusion and fission in skeletal
muscle during critical illness found that key players in these
processes were upregulated in postmortem rectus abdomi-
nis biopsies, but not in in vivo vastus lateralis biopsies of a
heterogeneous group of critically ill patients (FIGURE 10)
(727). There was no relationship with eventual survival,
and patients were not investigated to classify for CIM. In a
rabbit model of critical illness induced by severe burn in-
jury, key players of mitochondrial fusion and fission in liver
and kidney were also not significantly different between
survivors and nonsurvivors (277).
1063
 FRIEDRICH ET AL.

3. Autophagy in critical illness and development of a phenotype of myopathy (465). Myo-

An adequately balanced activation of autophagy appears
crucial for maintenance of normal muscle homeostasis. Ini-
tial studies on autophagy in conditions of muscle atrophy
implicated excessive autophagy in muscle breakdown, in
conjunction with the activation of the ubiquitin-protea-
some system (42, 451, 756, 805). This conclusion was
based on the upregulation of several autophagy-related or
-regulating genes in different atrophy models. However,
selective genetic inactivation of autophagy in skeletal mus-
cle of mice resulted in a spontaneous induction of atrophy
fibers in skeletal muscle of these mice were smaller than in
wild-type mice and showed degenerative changes, including
vacuolization and central nuclei, damaged mitochondria,
and accumulation of aberrant concentric membranous
structures. The lipidation of microtubule-associated protein
light chain-3 (LC3) with formation of LC3-II from LC3-I,
which is required for mature autophagosome formation,
was reduced. These abnormalities coincided with the accu-
mulation of p62 protein and aggregates positive for p62
and ubiquitin, which are normally cleared by autophagy. As
a functional correlate, muscle force was remarkably re-

Mitochondrial biogenesis
Post-mortem R. abdominis
in vivo V. lateralis PGC-1α
Diaphragm
RIP-140
NRF-1 NRF-2
Mitochondrial fusion and fission

Mitofusin TFAM Pol-γ mtSSB

mtDNA Replication/transcription
mtDNA copy number
Enzyme complex subunits
OPA1

Fis1 +
Drp1
Low ΔΨm
Low OPA1
Fusion-incompetent
Fis1 +
Drp1 Intact ΔΨm
Normal OPA1
Fusion-competent
Initiation
Autophagy
Phagophore Organelle,
(isolation cytoplasm
membrane)

Insufficiant activation:
Autophagy substrates
Upstream components
LC3-II/LC-3-I
Degenerative
myofiber changes Elongation

Autophagosome

Lysosome
Maturation

Autolysosome

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 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL

duced. Furthermore, inhibition of autophagy unexpectedly
promoted more severe muscle loss instead of protecting
against atrophy in several experimental stress models of
atrophy, including denervation and fasting (465). Hence, it
is clear that autophagy is required to preserve muscle mass,
myofiber integrity, and function. This is in line with the
crucial role of autophagy in cellular protein quality control,
by removal of toxic proteins, aggregates, and dysfunctional
organelles that otherwise would amplify the damage. Over-
all, it remains controversial whether activation of au-
tophagy is actually detrimental in catabolic conditions by
contributing to atrophy or whether it is rather beneficial by
clearance of damage and promotion of survival (612).
This controversy also holds true for critical illness and as-
sociated muscle pathology, in particular. Upregulated gene
and/or protein expression of several components of the au-
tophagy-lysosome system and/or accumulation of au-
tophagic vacuoles has been observed in skeletal muscle of
experimental models of acute and prolonged critical illness
(55, 322, 434, 490, 616, 690). Muscle disuse may be an
important factor since multiple (though not all) studies on
denervation-induced atrophy (model of chronic muscle dis-
use) also found such alterations, with one study addition-
ally showing an increase in autophagic flux (356, 525, 526,
715). However, different models of disuse have suggested
differential involvement of either the ubiquitin-proteasome
system or autophagy in the associated atrophy (58). A hu-
man patient study suggested that diaphragm disuse induced
by prolonged mechanical ventilation triggers autophagy,
based again on the increased expression of several key play-
ers in autophagy and an increased number of double-mem-
brane autophagosome vesicles (335). Unlike the dia-
phragm, quadriceps muscle of these patients showed mostly
no changes or even a decrease in these components in re-
sponse to mechanical ventilation. The development of CIM
was not investigated in this study. In contrast, alterations in
limb muscle were more pronounced than those in dia-
phragm of endotoxemic mice (490).
Activation of autophagy suggested by the scarce studies on
this pathway in critical illness has been interpreted as a
detrimental response which contributes to hypercatabolism
and wasting. However, the hypothesis that autophagy
could be protective for skeletal muscle and other organs
during critical illness had initially been overlooked but war-
rants consideration in light of the lessons from mice with
tissue-selective autophagy (372, 465). In fact, the initial
studies did not investigate whether autophagy is sufficiently
activated to cope with the severe damage inflicted by critical
illness. However, a clinical study that considered conse-
quences of insufficient autophagy confirmed similar
changes in skeletal muscle and liver of critically ill patients
as observed in autophagy-deficient mice (FIGURE 10) (154,
728). These included the accumulation of ubiquitin aggre-
gates and other autophagy substrates, such as p62, de-
formed mitochondria, and aberrant concentric membra-
nous structures. Likewise, an autophagy deficiency pheno-
type has been observed in skeletal muscle, liver, and kidney
of a severe burn injury model of critical illness (155, 277).
Signs of insufficient autophagy in muscle were also ob-
served several days after severe insults such as sepsis and
denervation (31, 565). Fasting is the strongest physiological
activator of autophagy, whereas feeding and insulin inhibit
this pathway (247). As in the latter studies patients and
animals were artificially and continuously fed, this may in-
dicate that early provision of nutrients during critical illness
may impair autophagy activation, thereby reducing damage
removal that is required for recovery. This constellation is
supported by a study in critically ill rabbits demonstrating
that early parenteral nutrition (especially when enriched in
amino acids) reduced muscle catabolism at the expense of

FIGURE 10. Alterations in the mitochondrial repair mechanisms in muscle during critical illness. Mitochondrial repair mechanisms include
three major processes: mitochondrial fusion and fission, removal of damaged mitochondria by autophagy (mitophagy), and generation of new
mitochondria via mitochondrial biogenesis. Mitochondrial fusion and fission are important in determining the overall shape of these organelles,
have the potential to dilute damage over different organelles, and are also involved in mitochondrial biogenesis and autophagy. Mitofusins and
optic atrophy-1 (OPA1) are important in mitochondrial fusion, whereas dynamin-related protein-1 (Drp1) and Fission-1 (Fis1) are required for
mitochondrial fission. Asymmetric fission can generate uneven daughter organelles and, thus, can segregate the daughter unit that contains
most of the defects. Due to low membrane potential ⌬⌿m and low OPA1 content, this daughter organelle will have an impaired fusion capacity,
hence predisposing the organelle to removal by autophagy. Autophagy is a multiphase process by which portions of cytoplasm and/or organelles
are degraded, and this can be either selective or nonselective. In the initiation phase, a phagophore or isolation membrane is formed, which
elongates in the elongation phase to surround the material that is to be degraded. This phase ends with the formation of a double-membrane
structure, the autophagosome, which in the maturation phase fuses with a lysosome to form an autolysosome. This structure contains all the
enzymes that are needed to degrade the sequestered content. Microtubule-associated protein-1 light chain-3 (LC3) plays a central role in the
autophagy process. LC3 needs to be converted from its cytosolic precursor form LC3-I to its active mature form LC3-II by lipidation. LC3-II is
translocated to the growing autophagosomal membrane where it probably functions as a scaffold protein that supports membrane expansion
and is used as an autophagosomal marker. The LC3-II/LC3-I ratio is often used as a marker for autophagosome formation. Mitochondrial
biogenesis is controlled by both nuclear and mitochondrial gene expression. Receptor inhibitory protein-140 (RIP-140) is an inhibitor of this
process. In contrast, peroxisome proliferator-activated receptor-gamma coactivator-1␣ (PGC-1␣) stimulates mitochondrial biogenesis via
regulation of the nuclear respiratory factors NRF-1 and NRF-2. The NRFs control mitochondrial transcription factor-A (TFAM), mitochondrial
DNA polymerase-␥ (Pol-␥), and single-strand binding protein (SSB), which in turn stimulate mtDNA replication and transcription of several
mtDNA-encoded respiratory chain complex subunits. The NRFs also regulate other proteins, including several subunits of the respiratory chain
complexes that are encoded by the nuclear DNA. The colored signs indicate the reported impact of critical illness on these pathways in different
types of skeletal muscle during critical illness (increases indicated by the arrows, equal signs indicate no change).

Physiol Rev • VOL 95 • JULY 2015 • www.prv.org 1065

 FRIEDRICH ET AL.
suppressed autophagy, thus compromising myofiber integ-
rity as well as vital organ function compared with fasting
(155). This was confirmed in a recent RCT (300), and this
may also explain the delay in recovery observed with early
versus late initiation of parenteral nutrition to supplement
insufficient enteral nutrition in critically ill patients (107,
109, 300). Indeed, muscle biopsies of the patients showed a
suppression of autophagy activation with early compared
with late initiation of parenteral nutrition, in the absence of
any effect on muscle atrophy markers (300). Importantly,
the impact on autophagy was independently associated
with a higher risk of clinically relevant muscle weakness.
Adequate autophagy activation clearly appeared crucial to
confer protection against mitochondrial dysfunction as well
as cardiac dysfunction, hepatic injury, and kidney failure in
animal models of critical illness as shown by genetic inter-
ference or pharmacological activation of autophagy (103,
277, 327). The importance of autophagy for muscle is fur-
ther underscored by studies in mouse models of muscular
dystrophy. Skeletal muscles of Col6a1⫺/⫺ mice showed im-
paired activation of autophagy, but myofiber survival could
be restored and the dystrophic phenotype could be amelio-
rated by forced activation of autophagy with genetic, di-
etary, and pharmacological interventions (271). Potent ac-
tivation of autophagy also restored the sensitivity of mito-
chondria to calcium-induced permeability transition pore
opening in diaphragm of mdx mice, associated with im-
proved histopathology and force-generating capacity (540).
In summary, a critical balance between autophagy activa-
tion and suppression is important for the maintenance of
muscle mass, but more importantly, muscle quality. Most
studies (human and animal models) show insufficient au-
tophagy activation in critical illness, but the level of sup-
pression of autophagy activation required to contribute to
CIM is yet unknown. Also, whether impaired autophagy
will be considered as a diagnostic requirement for CIM is a
topic for future studies.
F. Glucose Toxicity During Critical Illness
The development of hyperglycemia as a consequence of insulin
resistance and increased hepatic glucose production is a com-
mon complication of critical illness that has been associated
with morbidity and adverse outcome of patients irrespective of
the underlying diagnosis that required admission to the ICU
(470). In three large randomized clinical studies performed in
surgical, medical, and pediatric ICUs of Leuven, insulin infu-
sion to the strict age-adjusted target of normal fasting blood
glucose levels during the ICU stay improved survival and re-
duced morbidity (736, 737, 738, 748). Some studies of other
investigators have provided support for the beneficial effects of
this intervention, whereas others did not show any benefit or
even suggested harm (197, 731, 732). Discussing the contro-
versy surrounding the efficacy and safety of this intervention is
beyond the scope of this review, but methodological issues
1066 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
including the quality of glucose control likely played a major
role in the different outcomes (734). In fact, the discussion
appears not to be about the need for glucose control but rather
about which is the optimal level of glycemia to target for.
Maintaining strict normoglycemia with insulin infusion
during critical illness in relation to a disturbed cellular en-
ergy metabolism was investigated in patients and animal
models. The intervention protected the endothelium in pa-
tients where lowering of adhesion molecules prevented or-
gan failure and death (393). In critically ill rabbits, glycemic
control improved endothelium-mediated relaxation of aor-
tic rings, but had no effect on tissue perfusion and oxygen
delivery to different organs, including skeletal muscle (183,
726, 729). Strict glycemic control with insulin protected
against severe mitochondrial morphological abnormalities
seen in liver from hyperglycemic critically ill patients (725).
It also improved the activity of several mitochondrial respi-
ratory chain enzymes. Mitochondrial protection in liver,
kidney, and myocardium was attributed to glucose control
rather than direct insulin effects, as shown in critically ill
rabbits (726, 729). Intriguingly, the intervention had no
impact on the mitochondria in skeletal muscle of critically
ill patients or rabbits (725, 726). Nevertheless, it attenuated
iNOS expression in muscle and prevented excessive NO
production (184, 725). The different mechanisms responsi-
ble for glucose uptake in these organs were put forward as
a potential explanation for the observed organ specificity of
the mitochondrial effects. As such, cellular glucose overload
may develop in organs with insulin-independent glucose
transporters, whereas tissues that rely predominantly on
insulin-dependent glucose uptake may be relatively well
protected from glucose overload in view of the development
of insulin resistance. However, strict glycemic control did
improve skeletal muscle mitochondrial function in children
with severe burn injury (207). Apart from any impact on the
mitochondrial compartment, strict glycemic control with
insulin may also affect the muscle by anticatabolic actions
in view of the catabolism-promoting property of hypergly-
cemia and anabolic properties of insulin (205, 261, 262). In
critically ill rabbits, increasing the amount of intravenously
infused glucose calories was able to dose-dependently atten-
uate several proteolytic responses but only when hypergly-
cemia was simultaneously prevented (156). In the same
model, prevention of hyperglycemia better preserved au-
tophagy in liver and kidney which correlated with improved
mitochondrial function and less organ damage (277). The
impact of glycemic control on autophagy in skeletal muscle
has not been investigated yet. Several studies support pro-
tection of the central and peripheral nervous system during
critical illness. Maintenance of normoglycemia during crit-
ical illness lowered intracranial pressure and seizures in pa-
tients with isolated brain injury and reduced the incidence
of critical illness polyneuropathy (309, 735, 736). Nor-
moglycemia also improved neurocognitive development of
critically ill children 4 yr after ICU admission (482). Fur-
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL

thermore, strict blood glucose control during critical illness, tein metabolism is outlined below. A central difference to
independently of glucose load, attenuated the neuropatho- pure atrophy usually seen in bedrest conditions, micrograv-
logical alterations at the level of neurons, astrocytes, and ity, or muscle unloading and sepsis-induced myopathy is
microglia in vulnerable areas of the brain as shown in hu- that critical illness myopathy is characterized by a preferen-
man and animal brain specimens (649, 650). The impact of tial myosinolysis that exceeds the mechanism of atrophy
this therapy on peripheral nerves remains to be investigated. (balanced proteolysis of sarcomeric proteins) by far and is
responsible for muscle weakness in CIM that is more severe
compared with sepsis alone. This is also highlighted in sec-
XI. PROTEIN REGULATION IN MUSCLE IN tion XII.
CRITICAL ILLNESS

Critical illness is commonly associated with loss of muscle A. The Ubiquitin-Proteasome Pathway in
protein and decrements in skeletal muscle mass (FIGURE Critical Illness
11A). The resulting muscle atrophy may contribute to
weakness, premature fatigue, and glucose intolerance (561) The ubiquitin-proteasome pathway is a major mechanism
and has been associated with morbidity and mortality in of regulated proteolysis. As reviewed elsewhere (498),
critically ill patients (10, 102, 147). At the cellular level, structural and regulatory proteins are selectively targeted
reductions in myofiber size reflect an imbalance between for degradation by covalent attachment of polyubiquitin
proteolysis and protein synthesis (FIGURE 12). This is regu- chains to lysine residues. This ATP-dependent process re-
lated by complex changes in signaling pathways and gene quires sequential interaction among three enzyme families:
products that regulate protein breakdown and accretion ubiquitin activating enzymes (E1 proteins), ubiquitin con-
(353, 575). The influence of critical illness on muscle pro- jugating enzymes (E2 proteins), and ubiquitin ligases (E3

A B C
Control

Patient

0.50
Respiratory Leg
pmol/μg protein x min

20S proteasome
0.40

0.30 MAFbx

0.20
MuRF1
0.10
Actin
0.00
Sepsis* Control Sepsis* Control

D E F Control
Tyrosine Release (nmol/g x 2h)

500 600 BN 82270 2000

0.35
Sepsis Control
Calpain activity (FU)

*
pmol/μg protein x min

400 500
Tyrosine Release
(nmol/g ww x 2h)

0.30
* 1500
0.25 400
300 *
0.20
300 *,+ 1000 *,+
0.15 200 * * +
200 +
0.10 500
100
0.05 100

0.00 0 0 0
Left* Right* Left* Right*

FIGURE 11. Critical illness and skeletal muscle proteolysis. A: primary data from critically ill patients
document decreased nitrogen balance and an increased rate of muscle protein breakdown in individuals with
sepsis; the rate of muscle protein synthesis was not different between septic and nonseptic individuals. [From
Klaude et al. (366).] B: Western blot analyses show higher levels of E3 proteins (MuRF1, MAFbx) and 20S
proteasome subunits in muscle biopsies from critically ill patients. [From Constantin et al. (130). Copyright
John Wiley and Sons.] C: immunocytochemical staining illustrates greater ubiquitin density in small vs. large
muscle fibers of ICU patients, consistent with fiber atrophy via the ubiquitin-proteasome pathway. [From
Helliwell et al. (298). Copyright John Wiley and Sons.] D: enzymatic assay data demonstrate greater 20S
proteasome activity in muscle of septic individuals. [From Klaude et al. (366).] E: proteasome inhibition lessens
degradation of muscle protein in the rat CLP model of sepsis. [From Hobler et al. (315).] F: calpain activity and
the rate of protein degradation are elevated in limb muscles of septic rats; proteolysis is partially inhibited by
pharmacologic calpain blockade. [From Fareed et al. (191).]

Physiol Rev • VOL 95 • JULY 2015 • www.prv.org 1067

 FRIEDRICH ET AL.

Protein synthesis Sepsis, inflammation, cytokines Protein degradation

Altered Increased Ubiquitin

Blunted anabolic Compensatory Disrupted
transcriptional Ca2+-dependent proteasome
signaling protein synthesis autophagy
regulation proteolysis activation

Kinase Pro-catabolic Amino acids Proteolytic Debris

Ubiquitination
deactivation signaling cleavage accumulation

Anabolic
ATP U ADP
tRNA Ca2+
pathway
Transcription E2, E3
U
PI3K factors U
U
MAPK U
DNA
NF-κB
AKT Muscle genes Protein
FOXO Proteasome
HDAC Proteasome
mRNA activation
GSK
Ribosome
Myofibrillar
mRNA
Polypeptides
mTOR
Amino acids
p70S6K S6
4E-BP1 eIF-4E Autophagosome

FIGURE 12. Muscle protein homeostasis in critical illness. Diagram depicts changes to protein metabolism
caused by pathophysiological processes in critical illness including sepsis, inflammation, and prolonged expo-
sure to pro-inflammatory cytokines. Upper light grey boxes denote altered regulation of major steps in protein
synthesis (left) and degradation (right). Blue boxes identify the downstream effects of altered pathway regula-
tion. PI3K, phosphatidylinositol-4,5-bisphosphate 3-kinase; AKT, also known as protein kinase B; GSK, glyco-
gen synthase kinase; mTOR, mechanistic target of rapamycin; p70S6K, p70S6 kinase; S6, ribosomal protein
S6; elF-4E, eukaryotic translation initiation factor-4E; 4E-BP1, elF-4E binding protein-1; MAPK, mitogen-
activated protein kinase; NF-␬B, nuclear factor-␬B; FOXO, forkhead box-O; HDAC, histone deacetylase; DNA,
deoxyribonucleic acid; RNA, ribonucleic acid; mRNA, messenger RNA; tRNA, transfer RNA; Ca2⫹, calcium
ions; E2, ubiquitin-conjugating enzyme; E3, ubiquitin ligase; U, ubiquitin; ATP, adenosine triphosphate; ADP,
adenosine diphosphate.

protein). E2/E3 protein pairs regulate ubiquitin attachment
to protein substrates. The composition of each E2/E3 pair
confers substrate specificity, enabling selective tagging for
degradation via the 26S-proteasome complex. The 26S
complex is composed of a 20S multienzyme core capped at
each end by two 19S regulatory subunits. The 19S subunits
identify, bind, and unfold ubiquitinated proteins, cleaving
and recycling the attached ubiquitin moieties. Peptidases
within the 20S core then degrade the unfolded protein to
generate small polypeptides.
Critical illness appears to upregulate key components of the
ubiquitin-proteasome pathway in skeletal muscle. Constan-
tin et al. (130) found that muscle-specific E3 proteins
(MuRF1, MAFbx) and subunits of the proteasome were
elevated in vastus lateralis muscle of critically ill patients
(assessed by APACHE II scores, no information on mechan-
ical ventilation given). These changes were evident at both
the mRNA and protein levels, arguing for their physiologi-
cal relevance (FIGURE 11B). On the other hand, another
recent study in 63 critically ill ICU patients that demon-
strated increased catabolism in vastus lateralis muscle
showed the opposite: a downregulation of MuRF1 and
atrogin-1 (563). Helliwell et al. (298) found fiber atrophy
and reductions in myosin ATPase activity in tibialis anterior
muscle biopsies from critically ill patients that were accom-
panied by an increase in immunocytochemical staining of
ubiquitin conjugates (FIGURE 11C). At the functional level,
Klaude et al. (367) have shown that critical illness increases
chymotrypsin-like peptidase activity of membrane-associ-
ated proteasomes isolated from human leg muscles. The
activity of membrane-associated proteasomes was elevated
by 30% relative to healthy controls, whereas proteasome
activity in the soluble fraction was unaffected by critical
illness. A subsequent study by the same group (366) con-
firmed and extended these findings in patients with sepsis in
the ICU. Proteasome activity was elevated by 45–55% in leg
muscle biopsies from septic patients (FIGURE 11D). Interest-
ingly, proteasome activity was also elevated by 30% in
serratus anterior, a muscle of the rib cage. In rectus abdomi-

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 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
nis muscle, a more than twofold increase in chymotrypsin-
like activity of the 20S-proteasome has been described
(154). Such functional readouts are certainly more informa-
tive and preferable over simple transcript or protein content
analyses which may not account for the temporary nature
of mRNA levels, which can be as short-lived and fall
quickly during prolonged muscle proteolysis (409).
Rodent models of sepsis have confirmed observations in
humans and provided greater detail on the cellular and
molecular mechanisms by which the ubiquitin-proteasome
pathway is activated. Tiao et al. (704) first reported that
sepsis stimulates nonlysosomal, energy-dependent (i.e.,
proteasomal) proteolysis in skeletal muscles of rats as a
model for sepsis-induced myopathy. The process was
shown to affect total and myofibrillar protein levels and to
be associated with elevated ubiquitin mRNA. Subsequent
work has established that the response is greater in fast-
than in slow-twitch muscle (705) and that sepsis-stimulated
proteolysis can be blocked using proteasome inhibitors,
both in isolated muscle preparations (315) and intact ani-
mals (200) (FIGURE 11E).
Experimental sepsis appears to increase proteasomal activ-
ity, at least in part, via endogenous glucocorticoids. Tiao et
al. (703) treated septic rats with RU 38486, a glucocorticoid
receptor antagonist that inhibited the rise in total and myo-
fibrillar proteolysis and blunted increases in ubiquitin
mRNA, free ubiquitin, and ubiquitin conjugates. Con-
versely, dexamethasone administration to normal rats had
the reverse effects. The authors concluded that “ѧglucocor-
ticoids regulate the energy-ubiquitin-dependent proteolytic
pathway in skeletal muscle during sepsis.” Pro-inflamma-
tory cytokines have also been evaluated as downstream medi-
ators. There was no evidence that IL-1␤ or IL-6 play a signif-
icant role in sepsis-associated muscle dysfunction (228, 775).
In contrast, Garcia-Martinez and co-workers found that in-
creases in ubiquitin mRNA stimulated by sepsis could be rep-
licated in healthy rats by systemic administration of recombi-
nant TNF-␣ (227), and that this stimulus increases ubiquitina-
tion of skeletal muscle protein (226). This suggested that the
elevated TNF-␣ levels observed in sepsis might be responsible
for ubiquitin upregulation. Schakman et al. (616) have evalu-
ated the relative importance of glucocorticoids and TNF-␣
after systemic endotoxin administration. They found that the
glucocorticoid receptor antagonist RU 486 abolished activa-
tion of the ubiquitin-proteasome pathway, whereas inhibitors
of TNF-␣ production and NF-␬B activation had no effect.
Thus, in this LPS sepsis model, glucocorticoid production ap-
pears to play a more important role than TNF-␣/NF-␬B sig-
naling.
Experimental sepsis increases expression of gene products
that regulate the ubiquitin-proteasome pathway. This is
clearly true for regulatory proteins that control ubiquitin
conjugation. In septic rats, Voisin et al. (749) first observed
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
a rise in mRNA for E2-14k, an E2 protein that mediates
ubiquitin conjugation via the N-end rule pathway. Potential
involvement of E2-14k was reinforced by data from Hobler
et al. (316) who observed that E2-14k mRNA was elevated
in fast-twitch (but not slow-twitch) muscle of septic rats.
Later studies confirmed upregulation of E2-14k in fast-
twitch muscles of rats subjected to cecal ligation and punc-
ture (200) or endotoxemia (113). Fischer et al. (201) later
found that sepsis also increased mRNA levels for E3␣, an
E3 ligase that partners with E2-14k. The importance of E3␣
is reinforced by the finding that elevated rates of ubiquitin
conjugation can be suppressed by selectively inhibiting E3␣
function (648). In aggregate, these findings strongly argue
for an involvement of the N-end rule pathway. Other E3
proteins that regulate muscle proteolysis are also upregu-
lated during sepsis. For example, mRNA for MuRF1 and
atrogin-1/MAFbx were both elevated in extensor digitorum
longus muscles of septic rats (786). Substrates of MuRF1
include actin and the myosin heavy chains. Only MyoD and
IF3-f are currently known substrates for atrogin-1 (25).
Both are involved in the control of protein synthesis, thus
suggesting that atrogin-1 affects protein synthesis rather
than proteolysis. Such increases in MuRF1 and atrogin-1
can be inhibited by pretreating septic animals with gluco-
corticoid receptor antagonists, either RU 38486 (786) or
RU 486 (222), identifying these E3 proteins as glucocorti-
coid-sensitive components of the sepsis response. Down-
stream events that appear to upregulate atrogin-1/MAFbx
include increased signaling via stress-activated protein ki-
nases (123) and FOXO1 (646), complemented by less sig-
naling via PGC-1␤ (479) and HDAC (9). Alterations in
FOXO1 and PGC-1␤ signaling also appear to stimulate
MuRF1 expression (479, 646).
Proteasomal regulation is also altered by experimental sep-
sis. Voisin et al. (749) demonstrated that mRNA for sub-
units of the proteasome fluctuate in parallel with muscle
proteolysis rates. Proteolytic activity of the proteasome is
elevated by experimental sepsis (316), a response that in-
volves both trypsin- and chymotrypsin-like peptidase activ-
ities (486).
B. Calpain Regulation in Critical Illness
Calpains comprise a family of calcium-dependent, nonlyso-
somal proteases that are constitutively expressed in skeletal
muscle. Over two decades ago, Bhattacharyya et al. (56)
reported that sepsis increases calcium-dependent calpain
activity in rat limb muscles. Subsequent rodent studies have
generally confirmed this finding (FIGURE 11F). Greater cal-
pain activity leads to Z-band disintegration and myofibril-
lar protein breakdown (202, 776), thereby depressing myo-
fibrillar force (674). Calpain inhibitors lessen sepsis effects
on muscle, reducing proteolysis (191, 767) and preserving
contractile function (675, 685). The mechanism by which
sepsis increases calpain activity is less clear. Tissue levels of
1069
 FRIEDRICH ET AL.
active calpain protein appear to be elevated (675, 685). This
may reflect greater calpain activation by internal calcium
stores since sepsis effects are opposed by dantrolene (202).
Several studies have detected increases in mRNA for m-
calpain, mu-calpain, and p94, a calpain thought to be mus-
cle specific (156, 202, 749, 776). Mu-calpain requires about
10- to 100-fold lower Ca2⫹ concentrations for its half-max-
imum activation (in the low micromolar range) compared
with m-calpain, with the former, thus, being activated in the
range achieved during mild to strenuous exercise and the
latter in the range exceeded by normal muscle function
(hundreds of micro- to low millimolar range) (39). While
muscle can usually fully recover from activation of mu-
calpain after strenuous exercise with a period of relative
muscle weakness within a few days, global activation of
m-calpains will more likely result in irreversible muscle
damage and cell death. Finally, apart from activation by
Ca2⫹, the rise in calpain activity may reflect lower activity
of calpastatin, the endogenous inhibitor of calpain (767).
The importance of calpain activation in muscle of critically
ill patients is largely unstudied. To our knowledge, a recent
report by Klaude et al. (368) on eight critically ill patients
and seven healthy controls provides first information on
this topic. Patients had higher rates of protein degradation
and higher activities of proteasomal and lysosomal path-
ways. Calpain mRNA levels were elevated in muscle but
calpain activity was not. These initial data provide very
limited information on calpain involvement and illustrate
the need for more translational research on this topic.
So far, evidence from experimental sepsis animal models
has not been able to point towards a significantly preferen-
tial myosin loss, but only a general breakdown of myofi-
brillar proteins in septic muscle, i.e., similar proportions for
actin and myosin (776). This distinguishes the sepsis-in-
duced myopathy from the CIM phenotyope seen in criti-
cally ill patients, and sepsis and ICU models in rodents.
C. Caspase Involvement in Critical Illness
The caspase family of cysteine proteases is well recognized
as a regulator of apoptosis and immune function. In addi-
tion, animal studies suggest that one or more members of
the caspase family may contribute to muscle proteolysis in
critical illness or sepsis. Caspase-3 has been a primary focus.
Du et al. (167) originally observed that recombinant
caspase-3 degrades actomyosin (although degradation of
acto-myosin by caspase-3 is claimed throughout their work,
blots were only probed for actin). They speculated that
caspase-3 activation might be an early step in muscle catab-
olism that promotes proteolysis via the ubiquitin-protea-
some pathway. Wei et al. (767) examined this possibility in
limb muscles of rats with CLP-induced sepsis. They de-
tected no increases in caspase-3 mRNA, activated caspase-3
protein fragments, or caspase-3 enzyme activity. Nor was
1070 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
the rate of protein degradation altered by Ac-DEVD-CHO,
a caspase-3 inhibitor. These investigators concluded that
caspase-3 was not involved in the catabolic response to
CLP. However, later work showed that CLP increased
caspase-3 activity and active caspase-3 protein in rat dia-
phragm (685). CLP also decreased the specific force of dia-
phragm muscle fibers; this response was blunted by pre-
treating animals with zVAD-fmk, a caspase inhibitor. Sim-
ilarly, endotoxin administration activates caspase-3 and
increases procaspase-3 levels in porcine muscle (530). Mus-
cle caspase-3 mRNA levels were elevated in a rat ICU model
of critical illness myopathy, but appeared relatively late and
were preceded by both the upregulation of the E2 ligases
(MuRF1 and atrogin-1) and the preferential myosin loss
(434). However, total caspase activity was unaltered in
muscles from critically ill patients (368).
Caspase-8 has been identified as a key mediator of dia-
phragm weakness in endotoxin-treated mice. Supinski et al.
(679) originally reported that caspase-8 is activated in
C2C12 myotubes exposed to pro-inflammatory cytokines
and in diaphragm of endotoxin-treated mice. Endotoxin
also activated caspase-3 and depressed specific force of the
diaphragm. The latter responses were blocked by pretreat-
ing animals with a caspase-8 inhibitor, identifying
caspase-8 as an upstream mediator of caspase-3 activation
and diaphragm weakness. Subsequent studies by the same
group have identified JNK, p38 MAPK, and double-
stranded RNA-dependent protein kinase (PKR) as up-
stream regulators of caspase-8 activation (674, 676, 680).
These investigators proposed that pro-inflammatory cyto-
kines, such as TNF-␣, stimulate a postreceptor signaling
cascade in which PKR is upstream of p38 MAPK, JNK, and
other kinases. This cascade triggers cleavage of pro-
caspase-8 to caspase-8. In turn, caspase-8 acts on pro-
caspase-3 to generate caspase-3 which degrades myofibril-
lar proteins, thereby depressing the specific force of muscle.
Other caspases have also been linked to muscle dysfunction
in sepsis or critical illness. Shao et al. (630) have shown that
caspase-1 cleaves proteins that regulate glycolysis including
aldolase, triose-phosphate isomerase, glyceraldehyde-3-
phosphate dehydrogenase, ␣-enolase, and pyruvate kinase.
In a murine model of sepsis, systemic lipopolysaccharide
administration activated caspase-1 in diaphragm and inhib-
ited glycolysis in muscle extracts. Glycolytic capacity was
preserved in caspase-1-deficient mice, identifying caspase-1
as a mediator of sepsis effects on muscle metabolism. Llano-
Diez et al. (434) found that caspase-1 mRNA was increased
in a rat model of critical illness myopathy (rats mechanically
silenced and ventilated for up to 14 days), a late-phase
response observed after 9 –14 days. In the same window of
time, mRNAs for caspase-4 and caspase-12 were also ele-
vated, suggesting potential roles for these more obscure
family members.
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
D. Cathepsins in Critical Illness
Cathepsins are a family of proteolytic enzymes that have
long been recognized for their capacity to degrade proteins
and polypeptides (53). In general, these proteases are active
in acidic environments, are localized to lysosomes, and are
not regulated by calcium availability. Individual cathepsins
are categorized as cysteine, serine, or aspartyl proteases
based on substrate specificity.
Two members of the cathepsin family, cathepsins B and L,
have been evaluated extensively for their contributions to mus-
cle protein loss during sepsis. These studies began three de-
cades ago when Ruff and Secrist (600) first observed that skel-
etal muscle atrophy caused by experimental sepsis could be
prevented by pretreating rats with leupeptin, a cathepsin B
inhibitor. Cathepsin B mRNA levels, activity as well as protein
degradation rates, were elevated in limb muscles isolated from
septic rats (284, 329, 330, 749). The clinical relevance of this
finding was reinforced by Helliwell et al. (298) who observed
greater immunolabeling for cathepsin B in muscle fibers of
critically ill patients. Similarly, Deval et al. (157) reported that
cathepsin L mRNA and protein levels were elevated in skeletal
muscles of rodents with experimental sepsis. Increased expres-
sion of cathepsin L has also been observed in muscles of criti-
cally ill patients (130, 154), septic mice (569), and burn-in-
jured rabbits (156). However, the putative roles of cathepsins
B and L are highly controversial. In muscles of septic rats,
Bhattacharyya et al. (56) were unable to detect elevations in
cathepsin B activity or cathepsin L activity, and Ahmad et al.
(7) found that cathepsin B protein levels were unaltered. In
critically ill patients, Klaude et al. (368) found no changes in
the mRNA levels of either cathepsin B or cathepsin L. Inter-
ventional studies further challenge the importance of cathep-
sins. In 1988, Hummel et al. (329) reported that leupeptin, a
cathepsin B inhibitor, only partially blunted the rise in protein
degradation rate caused by experimental sepsis. They con-
cluded that proteases other than cathepsin B might be in-
volved. Later studies (284) showed that leupeptin inhibited
cathepsin B activity in muscles of septic rats but did not alter
protein degradation rates. The authors concluded that cathep-
sin B was not a major regulator of accelerated muscle proteol-
ysis during sepsis. Therefore, there is no current consensus on
the role of cathepsins nor are they a compelling target for
therapeutic drug development.
E. Muscle Protein Synthesis in Critical
Illness
Net loss of muscle protein in critical illness requires that
protein is degraded faster than it is synthesized. Preceding
sections have outlined mechanisms responsible for in-
creased proteolysis. So, what of synthesis? Relatively few
studies have addressed this question directly. Such studies
involved small, heterogeneous patient populations and ex-
perimental approaches that differed substantially. The re-
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
sults are intriguing, a partial glimpse into a complex prob-
lem.
A number of studies have evaluated muscle protein synthe-
sis in critically ill patients. Essen et al. (187) measured the
fractional rate of muscle protein synthesis in 15 ICU pa-
tients among all of which the fractional synthesis rate for
skeletal muscle averaged 1.5%/day (over a 5-fold range
individual variation). These values correlated with clinical
indices of metabolic status, notably arterial blood PO2 and
pH and with illness severity. However, evaluating the dis-
tribution of protein synthesis rates among muscle and other
tissues, the investigators identified no pattern that was char-
acteristic of critical illness. Gore and Wolfe (261) used iso-
topic tracer techniques to measure the fractional rates of
muscle protein synthesis in six critically ill septic patients
and six healthy controls. Under basal conditions, the frac-
tional synthesis rate in muscles of patients was more than
twice the value measured in controls. A follow-up study
(263) with similar experimental design reached the same
conclusion that critical illness significantly increases the
fractional synthesis rate of muscle protein. In contrast,
Klaude et al. (368) recently compared protein kinetics in leg
muscles of 16 ICU patients with sepsis or septic shock to
protein kinetics in 8 healthy control subjects using phenyl-
alanine and 3-methylhistidine tracers. Arteriovenous differ-
ences were measured across the leg for each tracer. These
data were used to compute protein synthesis using both a
two-pool model and a three-pool model. Neither model
detected any effect of critical illness. However, the variable
“sepsis” could not be separated from co-confounding vari-
ables of ICU treatment because all the patients studied suf-
fered from multiple organ failure and were analgo-sedated
and mechanically ventilated (368).
Of relevance to many ICU patients, Hammarqvist et al. (285)
examined the effect of surgery per se on markers of muscle
protein synthesis by evaluating ribosomal content in muscle
biopsies of 22 patients before and 3 days after elective chole-
cystectomy. After surgery, they observed decreases in 1) total
ribosomal concentration and 2) polyribosomes as a percent-
age of total ribosomes, suggesting that surgery depresses mus-
cle protein synthesis. Tjader et al. (707) tested this hypothesis
by measuring surgery effects on muscle protein fractional syn-
thesis rate. In 28 patients, measurements 90 min before sur-
gery were not different from measurements immediately after
surgery. Thus general anesthesia and surgical trauma did not
immediately alter muscle protein synthesis. The apparently
disparate findings of these two studies may reflect differences
between the metabolic states of muscle immediately after sur-
gery versus 3 days later.
Signaling pathways that regulate muscle protein synthesis
are sensitive to critical illness. As reviewed by Lang et al.
(389), animal studies suggest that signaling via the mamma-
lian target of rapamycin (mTOR) pathway is altered in
1071
 FRIEDRICH ET AL.
experimental models of sepsis, interfering with protein
translation and depressing protein synthesis. Data from
critically ill patients are less clear. On the one hand, Con-
stantin et al. (130) analyzed biopsies from vastus lateralis
muscles of 10 patients and 10 age- and sex-matched healthy
control subjects. They measured changes in signaling pro-
teins that regulate the initiation of translation. These in-
cluded v-akt murine thymoma oncogene homolog 1 (i.e.,
AKT1, PKB), glycogen synthase kinase 3 (GSK3), mTOR,
70-kDa ribosomal protein S6 kinase 1 (p70S6K), and eu-
karyotic translation initiation factor 4E-binding protein 1
(4E-BP1). Critical illness affected all of these signaling pro-
teins similarly; in each case, protein phosphorylation was
decreased. These findings suggest lower signaling activity in
the major pathways that promote protein translation. In
contrast, Jespersen et al. (353) used a similar experimental
design but obtained very different results analyzing AKT-
mTOR-S6K signaling in vastus lateralis biopsies from 12
ICU patients and 12 age- and sex-matched healthy control
subjects. In patient muscles, they observed higher phospho-
rylated-to-total protein ratios for AKT (threonine 308),
mTOR (serine 2448), and S6K (threonine 389), whereas
phosphorylated/total ratio for 4E-BP1 (threonine 37/46)
and GSK␤3 (serine 9) were indistinguishable from controls.
It is difficult to reconcile these apparently contradictory
data.
In response to critical illness, skeletal muscle appears to
upregulate a variety of genes that regulate protein synthesis.
Fredriksson et al. (212) analyzed vastus lateralis biopsies
from 17 ICU patients and 10 age-matched healthy controls.
Using microarray techniques, they detected increased
mRNA for 27 translation-related genes in muscles of pa-
tients, including proteins of the mitochondrial biogenesis
pathway and microRNA regulation. Subsequently, Con-
stantin et al. (130) used PCR techniques to document in-
creased mRNA for key signaling proteins including AKT1,
GSK3␣, GSK3␤, mTOR, p70S6K, and 4E-BP1 in muscles
of ICU patients. Less information is available about these
molecules at the protein level, but Jespersen et al. (353)
observed higher amounts of AKT and marginally higher
levels of 4E-BP1 in their patients.
Critical illness also alters gene expression for key structural
and functional elements in skeletal muscle. Fredriksson et
al. (212) found 1,457 unique genes/identifiers increased in
muscles from ICU patients, including genes associated with
catabolism, inflammation, and oxidative stress. Decreased
expression was observed in 525 genes including genes that
regulate mitochondrial biogenesis plus a variety of genes
that are skeletal muscle-specific. Importantly, myofibrillar
proteins were among the gene products that were down-
regulated. More recently, myofibrillar downregulation in
critical illness was confirmed in muscle biopsies from 208
ICU patients versus 35 healthy controls, the largest clinical
study yet completed on this topic (154). mRNA levels were
1072 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
severely reduced for actin and myosin heavy chain I
(MyHC-I) and IIa (MyHC-IIa). These findings are consis-
tent with overall reductions in myofiber size that also were
observed in these patients. At the protein level, myosin was
preferentially depleted by critical illness. The myosin-to-
actin ratio was diminished both in limb and trunk muscles
of patients relative to control values. Of those patients,
⬎90% were mechanically ventilated and ⬎65% received
corticosteroids while between 50 and 75% were septic so
that the preferential myosin loss reflects the consequences of
critical illness related to the mechanical ventilation and
analgo-sedation/steroid therapy and not primarily to sepsis.
This molecular imbalance is predicted to alter myofibrillar
architecture and cross-bridge stoichiometry, compromising
specific force of skeletal muscle.
In summary, the data in the literature related to protein
imbalance in critical illness consistently point towards a
general increase in protein catabolism and turnover result-
ing in severe atrophy. So far, no model of pure sepsis as only
confounding variable in critical illness, whether in patients
or in animal models has convincingly demonstrated prefer-
ential myosin loss as in critically ill patients, mechanically
ventilated, immobilized, and/or steroid-treated. Thus, while
sepsis seems to induce an atrophy-dominated phenotype of
muscle weakness, critical illness myopathy in addition al-
ters the quality of the atrophied muscle protein composition
towards preferential myosinolysis. More details are given in
section XII. FIGURE 12 summarizes the protein synthesis
and degradation mechanisms discussed in this section.
XII. ANIMAL AND HUMAN MODELS OF
CRITICAL ILLNESS AND ICU-RELATED
MYOPATHIES
A. The Problem of Choosing the Right
Animal Model: Matching Disease
Phenotype or Modeling Risk Factors?
When trying to model a clinical endpoint, such as muscle
weakness, that can arise from a complex combination of
risk factors, one has to either 1) follow a trigger factor-
oriented approach of modeling risk factors and their impact
on muscle function or 2) define specific pathological alter-
ations found within the syndrome that define a specific dis-
ease entity seen in patients. Any trigger factor itself or in
combinations capable of reproducing the spectrum of path-
ological changes is potentially causative for the disease. If
the trigger factor produces pathological alterations, but
they are distinct from the alterations present in patients,
they likely trigger a different disease entity within the syn-
drome ICUAW (FIGURE 1B). Potential causes of ICUAW in
critically ill patients include, e.g., CIP, CIM, and combina-
tions. Acquired CIM is the most common cause underlying
acquired paralysis in critically ill ICU patients, and it has
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
been reported in 25–58% of the general ICU population
and in 50 –100% of certain subgroups (52, 145, 216, 385,
415). For this reason, we will focus on animal models that
have been used to study CIM rather than CIP. As detailed
below, there is confusion in the literature about which as-
pect of CIM is being modeled by any given animal model,
e.g., in the case of sepsis models, for which the proof of
producing preferential myosin loss is still elusive. In ICU
patients suffering from CIM, the heterogeneity introduced
by variable timing of disease onset, differences in underly-
ing diseases, age/gender differences, and pharmacological
treatments make studies on mechanisms underlying CIM
extremely difficult. There is accordingly a strong need for
experimental models to explore 1) the relative importance
of different trigger factors; 2) the mechanisms underlying
muscle specific differences between limb, respiratory, and
craniofacial muscles; and 3) the temporal sequence of
events leading to the CIM phenotype with severe muscle
wasting and preferential loss of myosin in limb muscles. In
addition, there is a need for experimental mammalian in
vivo models allowing time-resolved analyses from short to
long durations in the search for specific intervention strat-
egies targeting CIM, i.e., models allowing detailed studies
on early and late effects of the intervention on intracellular
signaling, protein synthesis/degradation, and regulation of
muscle contraction. In vitro models give important infor-
mation on specific signaling pathways, but CIM is not
caused by an isolated mechanism but is the consequence of
a series of changes in a complex biological system, and in
vivo models mimicking the ICU condition are accordingly
warranted. One might argue that the perfect animal model
would combine sepsis and treatment with antibiotics, im-
mobilization and ventilator dependence, corticosteroid
treatment, and multiple organ failure as these are charac-
teristics shared by many ICU patients. Clearly, such a model
would be expensive and labor-intensive, threatening the
feasibility. The key issue for efficient use of animal models
of CIM is then which risk factors are relatively inexpensive
to model and yet sufficient to trigger CIM, so they can be
studied efficiently. A second issue is how well the animal
model recreates the pathological phenotype of CIM or just
belongs to another form of myopathy under the “ICUAW
umbrella” (FIGURE 1B). Pathological changes present in pa-
tients are unique to CIM, suggesting the presence of a
unique disease. The phenotype defining CIM in patients
should therefore be the starting point of our considerations
when comparing the power and limitations of different an-
imal models.
The changes seen in patients with definite CIM that should
be ideally reproduced by any animal model of CIM, on top
of severe muscle weakness, are as follows:
1) electrical hypoexcitability of the muscle and poor exci-
tation-contraction coupling,
2) severe muscle atrophy (beyond that caused by inactivity
alone),
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
3) preferential and significant myosin loss,
4) eventual sarcomere disorganization,
5) inadequate autophagy activation, and
6) altered protein turnover.
With regard to trigger factor-phenotype relationships, neu-
romuscular blockade (NMB), corticosteroids, and sepsis
have all been suggested to be important etiological factors,
but CIM has also been reported in the absence of one or two
of these trigger factors in mechanically ventilated ICU pa-
tients. However, all ICU patients with CIM have exposure
to long-term mechanical ventilation and immobilization in
common. Furthermore, the complete “mechanical silenc-
ing,” unique for ICU patients, has been shown to play an
important role in the development of CIM in experimental
and clinical studies (435, 517, 574). An additional factor
that needs to be taken into account is the relatively long
delay between exposure to trigger factors and the pheno-
type characterizing CIM, i.e., severe muscle wasting and
preferential myosin loss (399, 511, 610). The preferential
and significant myosin loss is the result of both a decreased
synthesis at the transcriptional level and increased myofi-
brillar protein degradation (399, 434, 496, 513, 517). Thus
early effects via specific signaling pathways on protein syn-
thesis and degradation become manifest relatively late at
the myofibrillar protein level, i.e., the preferential myosin
loss, due to the slow turnover rate of contractile proteins
with myosin having a 1–2% turnover rate per day (647).
On the other hand, actin has been reported to have a turn-
over rate twice as slow as myosin (457). Differences in
myosin and actin turnover rates and the preferential target-
ing of myosin by the E3 ligase MuRF1 for ubiquitination
and degradation (127) offer a mechanism underlying the
preferential myosin loss in spite of a similar transcriptional
downregulation of myosin and actin (513, 517). However,
there is reason to believe that the mechanism underlying the
preferential myosin loss is more complex, involving other
mechanisms such as compromised protection by, e.g., small
and large heat shock proteins. There is a need for experi-
mental studies allowing time-resolved analyses with a high
temporal resolution to detect early changes in the complex
intracellular signaling cascades and effects at the gene/pro-
tein levels leading to the CIM phenotype. Apart from the
preferential myosin loss, it is important to reproduce the
reduced muscle membrane excitability in the animal model,
as a hallmark of early manifestation of CIM. In the litera-
ture, there have been three principal approaches employed
as potential models for CIM: sepsis models; ICU-porcine,
-rabbit, and -rat models; and pharmacological steroid-de-
nervation. In the following sections, we present the ratio-
nale behind those different models, evaluate their advan-
tages and disadvantages, summarize prime findings and
whether the respective model was able to reproduce all
phenotypic manifestations of CIM or whether they may
point to a different disease entity within the ICUAW syn-
drome. Finally, some in vitro models are discussed briefly.
1073
 FRIEDRICH ET AL.

Myosin loss, atrophy, disorganization of sarcomeres

Control CIM Control CIM

Control
H+E

CIM
Myosin
ATPase
Actin

Loss of electrical excitability Sodium channelopathy

Control Excitable Indeterm Inexcitable Hyperpolarized shift in inactivation
40 1.0

Normalized current
20 0.8
+ 0
0.6
mV
–20
Corticosteroids –40 0.4
–60 0.2
–80
10 ms 0.0
–100 –90 –80 –70 –60 –50
Voltage (mV)
FIGURE 13. Rat steroid-denervation model of CIM and phenotypic characterization. The steroid-denervation
(SD) model involves a combined surgical denervation (partial sciatic nerve removal) and a pharmacological
steroid treatment (e.g., dexamethasone 5 mg/kg ip daily). This model produces reduction/loss of electrical
excitability in limb muscle and Na⫹ channelopathy within a few days. In addition, severe atrophy (as seen in
reduced fiber cross-sectional areas), preferential myosin loss (as detected in gel electrophoresis), and sarco-
mere disorganization (as visualized by confocal microscopy) provide most of the phenotypic changes to model
CIM as seen in critically ill patients. [Top right panel from Kraner et al. (377). Left panel from Rich et al. (582).
Copyright John Wiley and Sons. Bottom middle panel from Rich and Pinter (580). Copyright John Wiley and
Sons.]

B. The Rat Steroid-Denervation Model
The issue of what aspect of muscle immobility triggers CIM
in patients is central to the validity of various animal mod-
els. There are ways to model different aspects of immobility
in patients. Immobility could trigger CIM due to either loss
of muscle action potentials or loss of passive muscle move-
ment, or a combination of both. Loss of muscle action po-
tentials can be easily modeled by cutting the sciatic nerve to
denervate leg muscles (FIGURE 13). A rat model of acute
CIM using denervation was first developed over 20 yr ago
(466, 597). The model involves pairing loss of muscle ac-
tivity (by denervation) with systemic administration of cor-
ticosteroids (FIGURE 13). The model was established to
mimic the situation in patients given systemic neuromuscu-
lar blocking agents in conjunction with high-dose cortico-
steroids to treat asthma and chronic obstructive pulmonary
disease (COPD). Those patients develop classical CIM. De-
nervation does not identically mimic the situation present in
immobilized patients as the intact nerve is still present in
patients. The rat model using denervation assumes that loss
of muscle activity due to denervation has the same effect on
muscle as loss of activity due to neuromuscular blockade or
immobilization due to sedation. The debate about whether
trophic factors from nerve are primarily regulated by activ-
ity or by chemical influences is a long-standing one. For an
excellent early review on this issue, see McArdle (468).
There are several studies which suggest that loss of action
potential activity in muscle is the primary factor inducing
denervation changes in muscle. In two papers, Lomo and
colleagues (440, 441) found that stimulation of denervated
muscle prevented the upregulation of extrajunctional
AChRs and prevented depolarization of resting potential.
More recently, in mutant mice with hyperexcitable muscle
due to a mutation in the muscle chloride channel ClC-1, it
was found that denervation of muscle did not prevent spon-
taneous activity. The spontaneous activity was sufficient to
prevent both depolarization of the resting potential and
development of extrajunctional ACh sensitivity following
denervation (757). These studies demonstrated that muscle
activity was sufficient to prevent some well described den-
ervation-induced changes. By extension, these data suggest
that some properties of muscle are primarily regulated by
action potentials rather than chemical trophic influences.
There are two main differences between the rat model and
patients. In the rat model, trophic signaling from the nerve
at the endplate is absent, whereas in patients, chemical
trophic signaling should still be present. For example, neu-
regulins are trophic signaling molecules from nerve that
modulate muscle acetylcholine receptor expression (586).
Loss of neuregulin signaling due to denervation may medi-
ate the terminal Schwann cell response to denervation
(586). A second issue is that in patients muscle is unloaded,
whereas in the rat leg following denervation by sciatic nerve
lesion, there is continued passive movement during gait. In

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 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
an early study that directly compared unloading to dener-
vation, it was found that unloading triggered atrophy sim-
ilar to denervation, but did not trigger upregulation of ex-
trajunctional AChRs (440). This suggests that unloading of
muscle does not trigger all of the changes triggered by de-
nervation. A recent study in patients examined the effects of
mild passive movement on muscle function in immobilized
patients and found that, while it improved specific muscle
force, it did not improve either atrophy or myosin loss
(435). Thus some defects in CIM are likely triggered by
unloading, but other defects are triggered by other aspects
of critical illness and immobility in the ICU.
While there are differences between the risk factors present
in the rat model and patients, the rat steroid denervation
model does an excellent job of recreating pathological
changes present in patients with CIM. The features re-
created by the rat model include (FIGURE 13):
1) dramatic atrophy of muscle fibers (377, 466, 496, 597),
2) preferential/selective loss of myosin (377, 466, 496, 597),
3) disorganization of sarcomeres (377, 466), and
4) electrical hypoexcitability (580 –582).
Thus all the major changes in muscle found in CIM patients
are shared by the rat model (it should be noted that inade-
quate autophagy and metabolic failure have not yet been
tested for in this rat steroid-denervation model). The sim-
plest interpretation of these pathological data is that loss of
action potentials and steroid treatment cause myopathy in
rats, which is very similar to CIM occurring in patients.
Major advantages of the model are that it is easy to create
and studies are inexpensive. The primary disadvantage of
the model is that although it reproduces the phenotypic
features of muscle in patients with CIM, the rats are not
critically ill and thus lack many of the triggers that are
involved in causing CIM in patients. It is important to note
that CIM can develop in critically patients and in experi-
mental animal models that have not been exposed to exter-
nally applied corticosteroids. Thus, while this model is ex-
cellent in studying and treating pathological mechanisms, it
should be used with caution for studies aimed at preventing
CIM by treating triggers of CIM.
C. Porcine ICU Model
Unfortunately, there are very few experimental models
where long-term effects of mechanical ventilation and im-
mobilization on skeletal muscle have been studied in detail.
However, experimental porcine models have for many
years been used to study the effects of sepsis on organ func-
tion (FIGURE 14) (11, 522) and in the development, treat-
ment, and testing of diagnostic markers of malignant hyper-
thermia (476). The porcine model was, therefore, for-
warded as an ideal candidate for an animal model of CIM,
due to the known similarity in metabolism between humans
and pigs and extensive experience with this model (511). In
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
this porcine model, the same type of ventilators used in ICU
patients can be used in pigs. Previously, experiments with
the porcine model were typically for shorter durations, i.e.,
a day or less. In pilot experiments, it was shown that me-
chanically ventilated pigs exposed to NMB, systemic ad-
ministration of corticosteroids, and sepsis for 5 days devel-
oped an electrophysiological phenotype resembling previ-
ous observations in ICU patients with CIM, i.e., reduced
compound muscle action potential (CMAP) amplitudes
with maintained motor nerve conduction velocity and in-
tact sensory nerve action potential amplitude and conduc-
tion velocity (511, 517) (FIGURE 14C). This model was sub-
sequently used in a series of studies focusing on the relative
importance of different trigger agents such as neuromuscu-
lar blockade, sepsis, and steroids in the pathogenesis of
CIM, muscle specific differences, as well as the effects of a
Ca2⫹ sensitizer on diaphragm muscle fiber function (1, 2,
32, 511, 517, 520, 566, 686). Specific interest was focused
on the early effects of NMB, systemic corticosteroid admin-
istration, and sepsis, separately or in combination, on mus-
cle fiber size, regulation of muscle contraction at the single
muscle fiber level in limb, respiratory and craniofacial mus-
cles, and electrophysiological properties (1, 2, 32, 517, 520,
686). Exposure to mechanical ventilation and sedation,
with or without NMB, did not have a significant effect on
limb muscle fiber size or specific force during the 5-day
observation period, but the addition of systemic adminis-
tration of corticosteroids, sepsis, or the combination of cor-
ticosteroids and sepsis resulted in a decreased specific force
and maintained fiber size (517). The most dramatic decline
in specific force was observed in pigs receiving the combi-
nation of mechanical ventilation, sedation, NMB, steroids,
and sepsis where specific force declined almost 50% in spite
of a maintained fiber size. In none of the groups were any
significant differences observed between muscle fibers ex-
pressing different fast or slow myosin heavy chain isoforms
(517). Maximum velocity of unloaded shortening was not
affected by any of the different trigger factors in muscle
fibers expressing the same myosin isoform, suggesting
maintained cross-bridge cycling kinetics in spite of the de-
creased force generation capacity (517). The CMAP ampli-
tude was reduced in all groups independent of the combi-
nation of trigger factors, suggesting that different mecha-
nisms underlie the decline in muscle membrane excitability
and force generating capacity in response to the ICU con-
dition (FIGURE 14C) (517). The sparing of both muscle fiber
size and force generation capacity in response to mechanical
ventilation with or without NMB were paralleled by a sig-
nificant upregulation of high- and low-molecular-weight
heat shock proteins (HSPs). In animals exposed to sepsis
and corticosteroids in addition to mechanical ventilation
and NMB, the decline in force generation capacity was
accompanied by decreased HSP levels (2, 32). In the dia-
phragm, 5 days of mechanical ventilation and sedation re-
sulted in a severe decline in muscle fiber force without any
structural remodeling at the cellular and motor protein lev-
1075
 FRIEDRICH ET AL.

A B D preferential myosin loss

Specific force (N.cm-2)

25

20
Myosin
15

10

5
muscle weakness
0
1800
1600
1400

CSA (μm2)
1200
1000
Actin
800
600
400
200 muscle atrophy
0 E ultrastructural disorganization

ys

ys

ys
da

da

da

da
control rat 10 d MV + IM rat
0

-4

-8

4
-1
2

5
0.

9
C 6 hypoexcitability

soleus
action potential (mV)
Compound muscle

* *
*

diaphragm
2
* *
rat/porcine ICU model 1

0
V

CS

is

L
BA

AL
M

ps
NM

V+

se
M

V+
V+

M
M

FIGURE 14. Rat and porcine ICU animal models of CIM. A: settings of the rodent (top) and porcine (bottom)
experimental ICU models. B: single muscle (EDL, soleus) cross-sectional area (CSA) and specific force
progressively declined in mechanically ventilated rats with duration of treatment and fell to ⬃50% after 2 wk
(518). The data show prominent muscle weakness beyond pure atrophy. C: electrical hypoexcitability of porcine
tibialis anterior muscle seen as marked drop in CMAP amplitudes 5 days following mechanical ventilation (MV)
alone and in combination with NMBAs, corticosteroids (CS), sepsis, or all triggering factors (517). D:
preferential myosin loss during mechanical ventilation, documented in Coomassie-stained 12% SDS-PAGE
stained gels from rat soleus muscle in a control animal (1) and in a rat mechanically ventilated and immobilized
for 10 days (2). The myosin-to-actin ratio was 2.1 in the control and 0.5 after 10 days of complete
immobilization. The myosin-to-actin ratio in the diaphragm (3) from a rat mechanically ventilated and immobi-
lized for 10 days was 2.0, i.e., similar to control values in both limb and respiratory muscles. E: electron
micrographs from soleus and diaphragm muscles from control rats and rats mechanically ventilated for 10
days. In the soleus muscle, 10 days immobilization and mechanical ventilation (MV ⫹ IM) resulted in a
disorganization of the A-band in the sarcomere, while an intact A-band is observed in the diaphragm after 10
days of mechanical ventilation, in accordance with the maintained stoichiometric relationship between myosin
and actin. In spite of a maintained myosin-to-actin ratio in the diaphragm, a slight general myofibrillar protein
loss was observed in response to 10 days of mechanical ventilation. In the diaphragm, mitochondria appeared
swollen with disorganized cristae after 10 days of mechanical ventilation (mitochondria are indicated by the
arrows). Horizontal bars denote 1 ␮m.

els. The addition of sepsis, corticosteroids, and NMB, sep- masseter muscle were maintained in response to the 5-day
arately or in combination, did not add any significant neg- exposure to mechanical ventilation, NMB, corticosteroids,
ative effects, in sharp contrast to observations in limb mus- and sepsis, in contrast to limb muscles (1). This is consistent
cles (520). The unaltered myosin and actin contents in the with the sparing of craniofacial muscles in ICU patients
diaphragm indicate that qualitative changes in contractile with CIM. Gene expression analyses revealed highly com-
proteins by posttranslational modifications may be the plex mechanisms underlying this muscle-specific mecha-
dominant mechanisms underlying the ventilator-induced nism and HSPs appear to play an important role in this
deterioration of diaphragm muscle function. Both muscle muscle specific difference (1). However, other factors, re-
fiber size and force generation capacity of the craniofacial lated to metalloproteinase inhibition, oxidative stress re-

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 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
sponse elements, transcription, and growth factors are also
involved in the muscle specific difference between limb and
craniofacial muscles (1). The exact mechanism underlying
the relative sparing of craniofacial muscles versus limb mus-
cles, which is also reproduced in the porcine animal model,
is not known, but intrinsic differences related to differences
in embryonic origin and inherent differences in membrane
properties and myofibrillar protein expression may have a
significant effect on muscle-specific differences also in
mechanosensation and responsiveness to mechanical silenc-
ing (1, 8).
Both high- and low-molecular-weight HSPs are involved in
the protection of proteins in response to different types of
stress (1). The high-molecular-weight HSPs include HSPs
60, 70, 90, and 110, and the low-molecular-weight HSPs
include HSP 27 and ␣B-crystallin. HSP 27 and ␣B-crystallin
are translocated from the cytoplasm to the sarcomere where
they protect sarcomeric proteins, including myosin, during
stress. It was recently shown that low-molecular-weight
HSPs also prevent aggregation of the giant sarcomeric pro-
tein titin during stress (374). In addition to the protective
role of HSPs, they are also involved in different physiolog-
ical processes affecting muscle size and function. HSP 70 is
involved in FOXO signaling, and HSP 27 is a negative reg-
ulator of NF-␬B in skeletal muscle, and overexpression of
these HSPs reduces muscle atrophy during different muscle
wasting conditions (160, 627). Thus results from the por-
cine model indicate there is a loss in muscle function when
HSP expression is compromised and that a muscle specific
difference in HSP expression is one factor underlying the
sparing of craniofacial muscles in critically ill ICU patients.
The 5-day exposure to sepsis in mechanically ventilated pigs
is, to our knowledge, significantly longer than in any other
porcine sepsis experiment, but still, this duration was too
short to induce the preferential myosin loss observed in ICU
patients with CIM. This is consistent with clinical observa-
tions, i.e., that it typically takes longer than 5 days to de-
velop the CIM phenotype with the preferential myosin loss
in mechanically ventilated ICU patients (6). Thus there is a
need for an experimental model allowing both short- and
long-term studies. In principle, this could be achieved with
the porcine model, but it would be associated with signifi-
cant logistic problems and financial costs. The age of the
pigs is an additional problem, i.e., all experiments have so
far been performed in piglets weighing ⬃25 kg. These ani-
mals are in a significant growth phase with an expected
approximately fourfold increase in body weight within 6 –7
mo, i.e., an anabolic situation significantly different from
what is observed in ICU patients with CIM and may more
reflect a model of CIM in pediatric patients. Furthermore,
the incidence of CIM increases with patients’ age, and there
are only few reports of CIM in pediatric ICUs (608). How-
ever, these disadvantages could, at least in part, be over-
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
come by studying adult mini-pigs who have approximately
the same body weight as the piglets.
D. Rodent ICU Model
Experimental rodent ICU models offer a cost-efficient alter-
native to the porcine ICU model with significant logistic and
administrative advantages. Mouse models allow efficient
genetic engineering, but there is increasing evidence that the
rat is a better model for studies of muscle disease and aging
(336, 628). However, long-term mechanical ventilation in
small rodents imposes substantial challenges, since com-
mercially available rodent ventilators are unable to main-
tain life support for longer than a couple of days. Most
rodent studies using commercially available ventilators are,
therefore, limited to observation periods shorter than 24 h,
limiting the interpretative value both by adding a significant
confounding factor when studying a failing preparation,
and also that it takes significantly longer than 24 h to de-
velop CIM phenotypes.
More than two decades ago, Dworkin and co-workers
(174 –177) developed an experimental rat model to study
blood pressure regulation in a pharmacologically paralyzed
rat. A ventilator was designed allowing long-term con-
trolled mechanical ventilation of the rat, and the longest
duration one rat has been exposed to NMB and mechanical
ventilation is 3 months (174 –177). Thus this model offers a
unique possibility to conduct time-resolved analyses with a
high temporal resolution on the effects of the ICU condition
on muscle, muscle specific differences, as well as in the
design and evaluation of specific intervention strategies
(395). In accordance with clinical and experimental studies
using the porcine ICU model, mechanical ventilation and
immobilization are required for durations longer than 5
days to induce the CIM phenotype, i.e., muscle wasting and
a preferential myosin loss in limb muscles, relative sparing
of carniofacial muscles, and severe negative effects on reg-
ulation of diaphragm muscle fiber function (8, 133, 517,
520). The CIM phenotype was observed in the rat model in
the absence of both systemic corticosteriod hormone ad-
ministration and sepsis. Importantly, complete “mechani-
cal silencing,” i.e., no external load related to weight bear-
ing and internal load related to activation of contractile
proteins, was accordingly forwarded as an important factor
underlying the preferential and significant myosin loss,
leading to impaired muscle function and persistent paralysis
(510 –512, 517, 574). Current studies raise the possibility
that the complete mechanical silencing in the experimental
ICU models and in mechanically ventilated ICU patients is
unique for the ICU condition and different from the immo-
bilization during bed rest, joint fixation, hindlimb suspen-
sion, microgravity, or peripheral denervation. Detailed
time-resolved analyses of global protein synthesis rate, tran-
scriptional regulation of myofibrillar protein synthesis, and
activation of major proteolytic degradation pathways in
1077
 FRIEDRICH ET AL.
skeletal muscle revealed a unique and complex temporal
muscle-specific pattern in response to the ICU intervention.
Further studies directly comparing mechanical silencing in
the ICU to other manipulations of muscle activity will be
necesssary to test this hypothesis. The preferential myosin
loss in limb muscles was paralleled by a strong transcrip-
tional downregulation of both actin and myosin, an early
activation of the ubiquitin-proteasome degradation path-
way preceding the muscle atrophy and the preferential my-
osin loss. Calpain and lysosomal protein degradation path-
ways, on the other hand, were preceded by the preferential
myosin loss. The MuRF1 and MuRF3 E3 ligases showed a
biphasic spatial translocation in response to the mechanical
silencing with an early nuclear translocation and were fol-
lowed by a translocation to the cytoplasm with a distinct
perinuclear accumulation after long-term immobilization
and mechanical ventilation (517). Mild passive mechanical
loading of limb muscles ameliorates both the muscle fiber
atrophy and the loss of specific force in the rat ICU model.
In the slow-twitch soleus, with a higher protein turnover
rate than in fast-twitch muscles, the preferential myosin loss
was ameliorated together with lower levels of MuRF1
(574). Thus these insights offer molecular and cellular
mechanisms underlying the positive effects of early mobili-
zation in mechanically ventilated and immobilized ICU pa-
tients, as well as strongly supporting intense physical ther-
apy in immobilized ICU patients.
The major inspiratory muscle, the diaphragm, showed a
different temporal pattern in response to the ICU condition
compared with limb muscles. A rapid early decline in max-
imum diaphragm muscle fiber force, preceding fiber atro-
phy, was observed in response to mechanical ventilation.
Two weeks after controlled mechanical ventilation, resid-
ual function of diaphragm muscle to generate force was
⬍15% of control values when combining the effect of both
atrophy and loss of specific force at the single muscle fiber
level (133). These measurements were performed directly
assessing contractile protein function and bypassing EC
coupling in permeabilized diaphragm muscle fibers; thus
changes in membrane excitability and EC coupling may
accordingly add to the effects at the contractile protein level
in intact fibers. Furthermore, there was a progressive in-
crease in the number of no force generating fibers with
increasing duration of the mechanical ventilation, adding to
the 85% reduction in diaphragm muscle function (133). In
accordance with observations in limb muscles, there was an
early activation of the ubiquitin proteasome, but in contrast
to limb muscles, myosin-to-actin ratios were not affected,
and transcriptional regulation of myosin isoforms did not
show the dramatic and early downregulation as observed in
limb muscles. Although the exact underlying mechanisms
for the diaphragm weakness are not known, these findings
may point towards an altered quality of acto-myosin inter-
actions in the affected diaphragm where also the loading
pattern would be changed during ICU management (133,
1078 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
511, 517, 518). Interestingly, in intercostal muscles, there is
a similar decline in myosin-to-actin ratio as in the limb
muscle (512). Thus it may be speculated that the passive
loading of the diaphragm by the mechanical ventilator (72
times/min in the rat model) had an impact on transcrip-
tional regulation of myofibrillar protein synthesis but not
on the activation of protein degradation pathways. How-
ever, it cannot be ruled out that intrinsic muscle-specific
differences underlie the differences in transcriptional regu-
lation of myofibrillar proteins between diaphragm and limb
muscles. While the preferential myosin loss plays an impor-
tant role for the decreased specific force in limb muscle
fibers, other mechanisms are dominating in the diaphragm,
e.g., an early onset of oxidative stress, mitochondrial dys-
function, intracellular lipid accumulation, and posttransla-
tional protein modifications (PTMs) (133). Thus qualitative
changes in contractile proteins resulting in the severely im-
paired residual function appear to dominate in diaphragm,
while quantitative changes in myosin and myosin-associ-
ated proteins play a more important role for the decreased
force-generating capacity in limb muscles.
As discussed above, craniofacial muscles are typically
spared or less affected than limb muscles in CIM patients.
The masticatory masseter muscle was, therefore, studied in
the rat ICU model. In contrast to limb muscles, the masseter
showed only a mild and delayed decline in myosin-to-actin
ratio, smaller reduction in fiber size, and no transcriptional
downregulation of myofibrillar protein synthesis. In con-
trast to both limb muscles and the diaphragm, there was an
increase in MuRF1 levels and more sustainable levels of
sarcomere protective HSPs and autophagy (8). Thus the
better preserved myofibrillar protein expression and muscle
fiber size in the masseter muscle compared with limb mus-
cles in response to the ICU condition were the result of
muscle-specific differences in both transcriptional regula-
tion of myofibrillar protein synthesis and protein degrada-
tion pathways and coupled to a decreased activation of the
IGF-I/PI3K/Akt pathway as well as protective effects of HSP
and autophagy machineries (8).
The rat ICU model offers the opportunity to investigate
effects of different intervention strategies on muscle func-
tion. Passive mechanical loading has been discussed above,
and the rat experimental ICU model is presently being used
in different pharmacological intervention studies. Nutri-
tional status is another important factor in the treatment of
critically ill ICU patients, but the role of nutrition in the
pathogenesis of CIM remains unknown. In an attempt to
study the effects of caloric intake in the pathogenesis of
CIM, limb muscles were compared between animals given
low versus eucaloric parenteral feeding (523). However, the
preferential myosin loss, decline in specific force, and mus-
cle fiber atrophy did not differ between low and eucaloric
animals. Furthermore, passive mechanical loading had a
sparing effect on muscle weight independent of nutritional
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
status. Thus the mechanical silencing associated with the
ICU condition is forwarded as a stronger trigger factor than
nutritional status in the pathogenesis of CIM (523).
The major disadvantages of the rat and porcine ICU models
are the labor intense experiments with 24 h/day monitoring
of heart rate, respiratory function, blood pressure, EEG,
body temperature, PCO2, peep, urine output, peripheral per-
fusion, and PO2. In addition, most of the equipment has to
be custom-fabricated, continuously calibrated, and main-
tained. Despite these disadvantages, the in vivo experimen-
tal animal ICU models presented here (porcine and rat) are
best at modeling triggers for CIM in patients. These models
also do an excellent job at modeling pathological changes
such as (FIGURE 14)
1) severe atrophy (8, 133, 510 –512, 517),
2) preferential and significant myosin loss (510 –512, 517,
574),
3) sarcomere disorganization (FIGURE 14),
4) electrical hypoexcitability (511, 517), and
5) inadequate autophagy activation (8, 31).
E. Rodent Sepsis Models (CLP and LPS
Models)
Rodent models most commonly used in sepsis research are
the cecal ligation and puncture (CLP) model and the LPS
challenge model. The former is most commonly performed
in rats while the latter is preferred in rats or mice. Both
models have been extensively used to study muscle wasting
associated with sepsis and the underlying mechanisms
(317). The various detailed findings associated with CLP-
and LPS-induced sepsis are given in the respective sections
of this review. This section focuses on distinct differences of
both techniques and their strengths and weaknesses, while
details on the procedures are given in several reviews else-
where (317, 588). Although being used in abundance, sev-
eral lines of critique have recently emerged to the use of CLP
and LPS models to adequately reflect conclusions drawn for
sepsis in humans (199, 587, 628).
The CLP model has been used for over 30 yr as an animal
model of bacterial peritonitis in rodents (601, 772) and has
long been considered the “gold standard” in sepsis research
(85, 588). It involves suture-ligation below the ileo-cecal
valve and a needle puncture, allowing bacterial contamina-
tion of the abdominal cavity, followed by peritonitis and
septicemia (FIGURE 15A). The subsequent systemic inflam-
matory response may then lead to septic shock, multiorgan
failure, and death. The severity of sepsis can be modeled by
procedure variables such as needle size, length of ligation,
and number of punctures (588). However, it is exactly this
variability that is often not standardized in experimental
sepsis reports and which may complicate comparative re-
sults. The model adequately reproduces a hyperdynamic
circulatory response and cytokine surge within a few hours
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
(602) and reliably produces a marked increase in myofibril-
lar protein proteolysis from 6 h post-procedure (200, 291,
317, 776) (FIGURE 15A). However, myofibrillar protein loss
always seems to affect actin and myosin likewise, at least in
all studies investigating the time course of proteolysis up to
⬃20 h (200, 290, 291, 776). It may be that a significant
preferential myosin loss does not develop until longer times
post-CLP, but this has not been experimentally proven al-
though CLP in mice has been followed up until day seven,
but not for protein contents in skeletal muscle (809). Thus
this sepsis model has so far not qualified yet to reproduce all
the pathological hallmarks seen in CIM, most importantly,
preferential myosin loss, and is thus considered as sepsis-
induced myopathy (SIM) under the ICUAW umbrella (FIG-
URE 1B). Apart from this specific point, CLP in rodents has
been criticized in several further points. First, while the
approach is well accepted to mimic the situation of perfo-
rated appendicitis or diverticulitis with peritoneal sepsis in
patients, this model only applies to a fraction of septic pa-
tients, i.e., ⬍50% of septic patients show documented bac-
teremia (587). Also, CLP animals are often of young age
(although considered as adult; use of few weeks old animals
may serve as models for human pediatric CIM in future)
and without co-morbidities such as usually seen in older
patients with peritoneal sepsis. Moreover, the time window
of CLP sepsis in rodents is uncomparibly compressed to a
few days at most, unlike in patients (199). However, the
most prominent argument excluding a simple transfer of the
rodent procedure to the human situation of peritoneal sep-
sis-induced critical illness is the lack of supportive measures
in CLP-treated mice or rats, such as mechanical ventilation
or complete immobilization shown to produce the CIM
pathology (i.e., preferential and significant myosin loss,
Ref. 517). Last, probably similar to reasons explained be-
low for the LPS model, differences between the immune
system of mice and rats versus humans may preclude simple
transfer of conclusions to humans (628). However, it is
important to raise general caution against overstating limi-
tations of animal models of human disease. Reasons many
animal studies fail to predict clinical success of therapy
include poorly designed experiments and small sample size
(91, 345).
In the LPS challenge model, endotoxins are injected into
animals either subcutaneously, intraperitoneally, or via
intravenous routes. As a component of the bacterial wall
of gram-negative bacteria, LPS activates the innate im-
mune response via binding to toll-like-4 receptors
(TLR-4) with a dose- and administration-dependent re-
sponse (79). Since continuous or repetitive injections may
often result in tolerance, single-dose injections are most
commonly employed (317). Depending on the applied
dose mild, moderate (sublethal) and severe (lethal)
courses of sepsis can be observed (FIGURE 15B). Sublethal
doses (0.5–5 mg/kg body wt) induce a transient increase
in pro-inflammatory cytokines and febrile response with
1079
 FRIEDRICH ET AL.

Septic
Sham
Stds
Cecum ligation & puncture (CLP)

Myofilament Release (%)

12

a b c 10 * ← Titin

8 * 204 ← Myosin
6
141 ← α-Actinin
4 ← Desmin
78
2 ← Actin
39
0 30.7
0 2 4 6 8 10 12 14 16 18
Hours
B
Lipopolysaccharide challenge (LPS) Rat edl muscle

Myofibrillar proteolytic rate (a.u.)

s.c. Low dose: <5mg/kg bw
Moderated dose: 0.5–5 mg/kg bw
High dose: >5 mg/kg bw Endotoxemia
(10 mg/kg bw i.p)

i.v.
Control group

2 6 12 24
i.p.
Time (hrs)
FIGURE 15. Rodent animal models of sepsis. Cecum ligation and puncture (CLP) (A) and lipopolysaccharide
challenge (LPS) (B) are the most commonly used animal models to mimic various degrees of sepsis from mild
to moderate sublethal sepsis and septic shock, depending on details of the techniques. In CLP, the prominent
rodent cecum is exposed after median laparatomy, ligated with suture, and punctured with a needle. After
gently squeezing the cecum to allow feces to penetrate, the cecum is relocated back into the abdomen and the
incision closed. [Photographs from Rittirsch et al. (588). Reprinted by permission from Macmillan Publishers
Ltd.] CLP aims to model human peritonitis sepsis. In muscle, myofibrillar protein loss (actin and myosin) is
detected from ⬃4 h post-CLP. [Data from Williams et al. (776), with permission from The FASEB Journal
(www.fasebj.org).] In LPS challenge, lipopolysaccharides from various bacterial sources (mostly E. coli) are
injected as single doses either intravenously, intraperitoneally, or subcutaneously. Depending on the doses, the
degree of sepsis can be roughly controlled. LPS-induced sepsis results in marked protein loss in skeletal muscle
as early as 2 h postinjection. [Modified according to data from Chai et al. (113).]

recovery of animals within 48 h (317), whereas higher
doses produce severe sepsis, multiorgan failure, and en-
dotoxic shock that usually is lethal within 48 h, but there
is substantial variation (317). Both moderate and higher
doses alter muscle protein metabolism towards an in-
creased myofibrillar proteolysis and decreased protein
synthesis in many studies as early as 2 h post-LPS chal-
lenge (113) (FIGURE 15B). A selection of studies and their
findings is given in Holecek (317). Although very com-
monly used as a model mimicking endotoxin burden in
septic patients, the LPS model in rodents has been quite
recently challenged regarding its transferability to human
sepsis (628). In fact, the very transient increase in plasma
cytokine levels and rapid clearance of LPS from the sys-
temic circulation is not matching the situation in hu-
mans. This may be due to circulating factors in the
plasma of mice suppressing the production of pro-in-
flammatory cytokines following LPS challenge, such as
hemopexin (424). This may at least in part explain the
vast difference in LPS sensitivity between mice and hu-
mans, with mice requiring an LD50 of 1–25 mg/kg body
wt, a million times greater dosage than required to induce
fever in humans (199, 666). Seok et al. (628) even con-
clude that “while the genomic responses to different
acute inflammatory stresses are highly similar in humans,
these responses are not reproduced in current mouse
models” (628). Therefore, while the finding of myofibril-
lar proteolysis in LPS/CLP models might be attractive to
transfer to the situation in septic ICU patients, the impact
of the sepsis response on muscle in rodent models might
be an inadequate correlate of muscle wasting in septic
patients. This is because whenever clinical studies in ICU
myopathies usually refer to septic ICU patients in the first
place with the primary variable of sepsis, those patients
are almost always mechanically ventilated and/or immo-
bilized at the same time, at least in the initial phases.
Thus, the hallmark of CIM in patients (immobilized
and/or mechanically ventilated regardless of whether
septic or not) is reflected by a preferential myosin loss
that has so far not been confirmed in any pure CLP/LPS
model. It should be noted that almost all studies of sepsis
in rodents do not include mechanical ventilation and im-

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 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
mobilization (exceptions see above). To more accurately
mimic CIM in patients, these triggers need to be included.
F. Rabbit Burn Injury Model of Prolonged
Critical Illness
A well-validated model of prolonged critical illness is that of
catheterized and fluid resuscitated rabbits suffering from
hyperinflammation-induced critical illness evoked by third
degree burn injury (155). This model displays endocrine
and metabolic alterations that are very similar to those in
ICU patients suffering from prolonged critical illness (766).
Fasted critically ill rabbits lost weight and showed elevated
mRNA expression and/or activity of several ubiquitin-pro-
teasome pathway components, calpain-1 and cathepsin-L,
as well as a shift towards smaller myofibers in skeletal mus-
cle (155, 156). Intravenous feeding largely counteracted
this response, provided hyperglycemia was avoided. Re-
sponses in diaphragm and heart were roughly similar. In
this model, it was clearly shown that fasting during critical
illness also induces activation of autophagy in vital organs
and skeletal muscle. Intravenous feeding abolished these
responses, with most impact with amino acid-enriched nu-
trition. Accumulation of p62 and ubiquitinated proteins in
muscle and liver, indicative of insufficient autophagy, oc-
curred with parenteral feeding enriched with amino acids
and lipids. This was accompanied by fewer autophago-
somes, fewer intact mitochondria, suppressed respiratory
chain activity, and an increase in markers of organ damage
in the liver. In muscle, early parenteral nutrition enriched
with amino acids or lipids aggravated vacuolization of myo-
fibers. Hence, just as in human ICU patients, early paren-
teral nutrition during critical illness in this model was
shown to evoke a phenotype of autophagy deficiency in
skeletal muscle which in human patients was causally re-
lated to ICU-acquired weakness. From these initial studies,
the rabbit burn injury model of prolonged critical illness
may be a model worth pursuing to further investigate key
features of CIM in affected muscles.
G. “Human” Models of ICU-Related
Myopathies: The “Circulating Factor
Hypothesis”
In a very touching foreword, J. E. Fischer (289) refers to
George Clowe’s seminal work in 1983 concerning a prote-
olysis-inducing factor present in plasma from septic pa-
tients (124). That study, for the first time, showed that
serum from septic patients contained a ⬃4-kDa low-molec-
ular-weight protein that was able to induce muscle proteol-
ysis in vitro (124). This proteolysis-inducing factor (PIF)
was later suggested to be a degradation product of IL-1␤
(159). To assess the proteolytic potency of IL-1, its byprod-
ucts or other cytokines’ ability to induce muscle proteolysis,
a series of studies aimed at applying serum, serum fractions,
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
or purified protein factors (cytokines, etc.) to skeletal mus-
cle cells in vitro and studying protein contents and/or cell
functions thereafter. Usually, those muscle cells are of ani-
mal origin, either freshly isolated fibers, fiber bundles, or
myotubes. While some laboratories could not confirm a
proteolytic effect induced by IL-1 or TNF-␣ in vitro (251,
258, 491), TNF-␣ injection in vivo into rats was effective in
accelerating muscle proteolysis, similar to endotoxin treat-
ment, but unlike IL-1 injection which was ineffective (258).
Other studies, however, were able to detect a marked stim-
ulation of protein degradation by highly purified human
leukocytic pyrogen (IL-1) when applied to isolated rat mus-
cles kept at between 37 and 39°C (34). When the action of
purified IL-1 was compared with that of recombinant IL-1
(␣ or ␤ isoform), recombinant factors failed to reproduce
muscle proteolysis in vitro (251). From this finding, Gold-
berg et al. (251) suggested an additional, still unidentified
product of activated monocytes to essentially regulate pro-
teolysis in systemic infections, and which would still be
present in IL-1 purifications but not in the recombinant
cytokine. Similar as for IL-1, IL-6 was able to induce muscle
proteolysis, but only when applied in vivo. In vitro incuba-
tion of isolated muscles with IL-6 failed to induce proteol-
ysis (258). Since these studies suggested additional factors
present in the plasma during sepsis or systemic infection
distinct from the mentioned cytokines, Hasselgren et al.
(289) collected plasma from septic rats 16 h after CLP and
produced ⬍30-kDa molecular weight fractions to be
acutely applied to rat EDL and soleus muscles. Surprisingly,
no proteolysis of myofibrillar proteins was detected, further
blurring the role of a putative circulating proteolytic factor
in sepsis. To look for specific mechanisms in muscle weak-
ness in response to acute challenge with human sepsis serum
rather than rodent serum, Friedrich et al. (218) collected
serum samples from septic ICU patients with a clinical di-
agnosis of CIM and applied various molecular weight frac-
tions to single murine muscle fibers (217, 218). Acute serum
fraction applications were able to induce a membrane de-
polarization in time and also reduced caffeine-induced
Ca2⫹-activated force transients. The latter was only seen
with small-molecular-weight fractions ⬍10 kDa but was
blunted for larger molecular weight fractions. This finding
shows that it is important to dissect serum fractions to
identify active factors that might be present in a biologically
inactivated form in full serum studies. In a later study, van
Hees et al. (740) were able to demonstrate a proteolytic
effect of plasma from patients with septic shock when ap-
plied to C2C12 myotubes.
The in vitro septic serum challenge approach has the advan-
tage that any cell physiology parameter can be tested for
using established laboratory techniques in a control versus
post-exposure setting similar to as in pharmacological ex-
periments. The use of isolated cells removes many of the
uncontrolled variables usually present in in vivo experi-
ments. However, major disadvantages involve the inability
1081
 FRIEDRICH ET AL.
to model specific trigger factors inherent to ICUAW, and
results are often very inhomogeneous due to the diversity of
the underlying patient population, and even the time points
samples are retrieved from patients. In conjunction with the
small number of patients usually involved, the statistical
power remains limited in most studies.
So far, some studies point towards an existing “myotoxic”
factor systemically circulating in sepsis and systemic inflam-
mation. Whether this is also true for the controlled setting
of CIM, i.e., for pure mechanical ventilation and immobi-
lization, is currently not known. For this, the animal models
described in detail above would need to serve as serum
source (porcine/rodent ICU model) for subsequent in vitro
testing. One hypothesis could be that such a circulating
factor was in fact produced by the lungs in the setting of
mechanical ventilation. Whatever the source of such a fac-
tor, the identity of it has not been resolved yet, even after
more than 30 yr of its original proposition.
TABLE 6 compares the properties, the strengths, and the
weaknesses of each model presented in this section.
XIII. TREATMENT OF ICUAW: DRUG
INTERVENTIONS AND CLINICAL
IMPLICATIONS
A. Intensified Insulin Treatment
Effective strategies to prevent and/or treat ICUAW (CIM,
sepsis-induced myopathies) are still scarce. These strategies
mainly focused on avoiding or reducing risk factors (303).
As neuromuscular ICU complications are associated with
sepsis, hyperglycemia, prolonged immobilization, and du-
ration of mechanical ventilation as well as the use of corti-
costeroids and neuromuscular blocking agents, avoiding
these is theoretically of interest (which is probably not fea-
sible for the mechanical ventilation unless external lung
assist devices are being considered). Also, strategies that
avert the catabolic state associated with critical illness are
appealing and could be beneficial. The strongest data cur-
rently available concern the treatment of hyperglycemia
that inevitably accompanies acute illness. Several RCTs on
glycemic control in the ICU were recently performed (197,
557, 736, 738, 748). Two of these, comparing normaliza-
tion of glycemia using insulin (glycemic target 80 –110 mg/
dl: intensive insulin therapy, IIT) in critically ill patients,
versus tolerating hyperglycemia up to the renal threshold
(glycemia tolerated up to 215 mg/dl: conventional insulin
therapy, CIT) also evaluated the neuromuscular effects in
the subgroup of patients staying in ICU for at least 1 wk. In
the 405 long-stay surgical patients, electrophysiological
screening revealed that IIT reduced the incidence of critical
illness polyneuromyopathy, diagnosed by the presence of
abundant spontaneous electrical activity, from 49 to 25%
(735). Muscle strength data were not available, but the
1082 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
electrophysiological findings were accompanied by a re-
duced need for prolonged mechanical ventilation. These
results were confirmed in 420 long-stay medical patients
(309). Meta-analysis of both trials reported a relative risk
for developing neuromuscular complication with IIT of
0.65 (304). Benefits were mainly attributed to glycemic con-
trol rather than insulin dose (735). In a post hoc analysis,
the beneficial effects were only present in patients in whom
actual normalization of glycemia was reached but not in the
subgroup of patients reaching intermediate glycemic targets
(110 –150 mg/dl) (736). Similar findings were made in a
retrospective study on the incidence of electrophysiological
abnormalities before and after institution of IIT, reflecting
daily care practice (306). Insulin resistance is well known to
occur in critically ill patients and seems more pronounced in
patients with CIM (765). Insufficient GLUT-4 transloca-
tion to the sarcolemma may result in decreased glucose
supply in patients. Mechanistic studies based on muscle
biopsies from insulin trials indicated that despite improving
insulin resistance and skeletal muscle GLUT-4 expression
(483), IIT basically did not affect myofiber size, myofibrillar
protein synthesis capacity, or markers of muscle proteolysis
(154). This could indicate that benefits were mainly ex-
plained by neuroprotection, although no nerve histology
data are available to confirm this. Generalizing treatment of
critically ill patients towards reaching normoglycemia was
questioned by the NICE SUGAR trial. This multicenter
RCT pointed at the risks of broad implementation of IIT in
critically ill patients, including higher incidence of hypogly-
cemia and even increased mortality (197). Various method-
ological differences between trials may be responsible for
the distinct results (734). The discrepancy between results
of the large trials has come to the widespread acceptance
that hyperglycemia should be avoided (152), but the actual
blood glucose target to aim for depends on local expertise
and monitoring tools (733).
B. Early Mobilization Strategies
Reducing the duration of immobilization could also con-
ceptually reduce the incidence of ICUAW, since bed rest and
mechanical unloading induces a catabolic state, muscle at-
rophy, and loss of strength (114, 194, 373, 560). A first
logical approach to shorten the duration of immobilization
is to apply strategies aimed at reducing sedation. During the
last decade, multiple beneficial effects of such interventions,
including reduced duration of mechanical ventilation and
ICU stay as well as less delirium, were described (38, 378,
633). Muscle function, however, was not within the pri-
mary or secondary outcomes tested. Shortening duration of
immobilization can also be pursued by applying early phys-
iotherapy aiming at mobilizing limbs in the acute phase of
illness despite receiving life support treatments. This ap-
pears to be safe and feasible in the ICU (27, 429, 495, 551),
and a nonrandomized trial suggested beneficial effects on
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL

Table 6. Comparison of various animal models to study mechanisms in ICU-related myopathies

Model Manipulations Triggers Modeled Pathological Changes Replicated Strengths Weaknesses

Rat steroid Lesion to the sciatic Neuromuscular blockade Muscle atrophy (377) Easy to perform Does not model risk
denervation nerve, daily factors such as
administration of sepsis, loss of
corticosteroids movement
Corticosteroid treatment Preferential loss of myosin (377) Inexpensive
Immobilization not Disorganization of sarcomeres (377) Models all pathological
modeled changes seen in
CIM patients
Electrical hypo/inexcitability (582)
Rat ICU Infusion of Immobilization Muscle atrophy (518) Models atrophy and Labor intensive,
neuromuscular preferential myosin difficult to
blocking agents, loss perform
mechanical
ventilation
together with
treatments such
as LPS and/or
corticosteroids
Neuromuscular blockade Preferential loss of myosin (518) Muscle-specific
differences
observed in ICU
patients with CIM
Mechanical ventilation Disorganization of sarcomeres Suitable for
intervention studies
Sepsis Similar muscle-specific differences as
in ICU patients with CIM
Corticosteroid treatment
Porcine ICU Infusion of Immobility Muscle atrophy (517) Pigs as good model Labor intensive,
neuromuscular for human difficult to
blocking agents, physiology perform
mechanical
ventilation
Neuromuscular blockade Preferential loss of myosin (517) Models all triggers Expensive
Mechanical ventilation Decreased muscle membrane Reproduces atrophy,
excitability in mechanically preferential myosin
ventilated and immobilized animals loss and muscle
(independent of the addition of membrane
sepsis or systemic steroid hypoexcitability
administration) (517)
Corticosteroid treatment Similar muscle-specific differences as Muscle-specific
in ICU patients with CIM differences
observed in ICU
patients with CIM
Sepsis Suitable for
intervention studies
Cecum ligation and Median abdominal Various degrees of Muscle atrophy Simple to perform Animals not
puncture (CLP) laparotomy, sepsis (mild, immobilized
mobilization of moderate, severe),
cecum, suture- septic shock,
ligation of cecum depending on ligation
and needle length/level and
puncture, puncture number
relocation and
closure (588)
Myofibrillar protein loss (776) High reproducibility No mechanical
and grading of ventilation
sepsis severity
when sticking to
standardized
protocols (588)
Disorganization of sarcomeres (776) Systemic response Transferability to
and cytokine surge human
within 4–6 h problematic
postprocedure
Decrease in twitch/tetanic force
(595)

Continued

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 FRIEDRICH ET AL.

Table 6. Continued
Model Manipulations Triggers Modeled Pathological Changes Replicated Strengths Weaknesses

Muscular hypoexcitability (Na⫹

channel inactivation increased)
(594)
Mitochondrial dysfunction (543)
Lipopolysaccharide Single-dose Dose-dependent degrees Muscle atrophy (678) Simple to perform Animals not
challenge (LPS) injections of of sepsis immobilized
purified LPS from
gram-negative
bacteria (e.g., E.
coli) sc, ip, or iv
Mild ⬍0.5 mg/kg body Myofibrillar protein loss (317) Systemic response No mechanical
wt and cytokine surge ventilation
within 4–6 h
postprocedure
Moderate 0.5–5 mg/kg Decrease in twitch/tetanic force Use of genetically Transferability to
body wt (678) modified mice humans
enables study of problematic
LPS receptors and (628)
innate immune
activation
Severe (lethal) ⬎5–10 Muscular hypoexcitability (Na⫹ Easy to design studies Discrepancy
mg/kg body wt channel inactivation increased) for drug testing between LPS
(283) sensitivity of mice
and humans
Mitochondrial dysfunction (236) Systemic activation
of the innate
immune system
Rabbit burn injury Third degree burn Catheterization Muscle atrophy (156) Strongly mimics Labor intensive
model injury on 15–20% endocrine and
body surface metabolic
area alterations of
critically ill patients
(183,766)
Parenteral nutrition Ubiquitin proteasome activation High reproducibility No mechanical
(156,178) ventilation
Glucose Impaired autophagy activation with
monitoring/control (parenteral) feeding (156)
Hyperinflammation
Immobility due to
sickness
ICU patient in vitro Serum fractions Tests for a putatively Muscle atrophy (740) Easy to perform Does not model a
serum challenge from ICU patients myotoxic, systemically similar to drug single trigger
model are applied to circulating factor application factor
skeletal muscle experiments
cells (from
animals) and
acute or long-
term effects
studied in vitro
Preferential myosin loss (740) Defined in vitro Very
settings of single inhomogeneous
cells results profile
due to varying
patient cohorts
Decrease in chemically activated Controls (prior to Only studies with
force in skinned fibers (218) serum application) very small sample
well established sizes, patient
within labs samples not
readily available
Muscle membrane depolarization
(178, 218)
Ubiquitin proteasome activation
(740)

ICU and hospital length of stay (495). One RCT compared cluded patients who were expected to have an ICU stay for
20 min of daily bedside cycling exercise from the fifth day in another week. The incidence of weakness was not reported
the ICU in addition to standard physiotherapy with stan- in this study, but isometric quadriceps force as well as func-
dard physiotherapy alone in 90 patients (88). The trial in- tional status, measured by the 6-min walking distance at

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 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
hospital discharge, was significantly higher in the interven-
tion group.
Combining both approaches of minimizing sedation with
early mobilization was examined in a second RCT in criti-
cally ill patients who were on mechanical ventilation for
⬍72 h (623). Early exercise and mobilization were com-
pared with standard care in 104 patients receiving daily
sedative interruption. This trial showed that early exercise
and mobilization resulted in better functional outcome at
hospital discharge, shorter duration of delirium, and more
ventilator-free days. There was no significant reduction in
the incidence of ICUAW and, therefore, the intervention
may have helped patients to cope with weakness rather than
improving muscle strength itself. These are promising find-
ings, but several barriers against the use of early rehabilita-
tion may impair widespread implementation of such prac-
tice (410, 551, 796). Some of these, including high severity
of illness, may not be modifiable. Others, such as depth of
sedation (796) and mental attitude of caregivers (320), can
be addressed in training programs. Optimal implementa-
tion of rehabilitation programs and resources will require
confirmation of beneficial effects, identification of the pa-
tient population that benefits, and definition of appropriate
intensity of treatment. In a retrospective analysis of 49 pa-
tients who failed to wean from mechanical ventilation for at
least 14 days, whole body rehabilitation and respiratory
muscle training showed to improve strength, weaning out-
come, and functional status (459).
Finally, several beneficial effects of rehabilitation strategies
following hospital discharge have been reported, although
based on limited data (128). It remains unclear to what
extent such strategies may promote recovery from ICUAW,
as this question has not yet been addressed.
C. Electrical Muscle Stimulation
Some patients may not be able to actively mobilize during
the acute phase, and electrical muscle stimulation (EMS)
may therefore be another method to preserve muscle mass
and function in such a setting. Preliminary data obtained
from muscle biopsies of five patients at risk for ICUAW
receiving unilateral EMS showed that EMS could improve
AMPK activation, glucose utilization, and GLUT-4 trans-
location (765). The stimulated leg also showed larger cross-
sectional area for type 2, but not type 1, fibers. In non-ICU
patient populations, EMS has been shown to increase mus-
cle strength and exercise tolerance (637). Preliminary re-
sults in small samples of critically ill patients were promis-
ing and found that EMS preserved muscle mass (237, 272,
474), reduced muscle catabolism (73), and exerted short-
term systemic microcirculatory effects (238). In another
eight patients with septic shock however, 7 days of EMS did
not preserve muscle volume (555). Several randomized
studies examining the effects of EMS on muscle function in
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
the ICU recently emerged. One trial in 140 patients reported
a decrease in incidence of ICUAW from 39.3 to 12.5%,
accompanied by a shorter time to weaning in the interven-
tion group (598). These data should be interpreted with
caution, since significant differences for baseline character-
istics, APACHE II, and certain comorbidities were present
between groups in the subset of actually evaluated patients
(357). Another RCT in COPD patients in the ICU found no
incidence of ICUAW in EMS-treated patients. Moreover,
quadriceps strength, measured using dynamometry, and
6-min walking distance were increased in the EMS group
(3). EMS improved muscle strength and decreased number
of days needed to transfer from bed to chair in mechanically
ventilated COPD patients (797). No formal assessment for
ICUAW was made. Sixteen septic, mechanically ventilated
patients were randomized to receive unilateral EMS versus
no EMS on the contralateral limbs. Muscle strength was
better on the stimulated side (589). In conclusion, data on
EMS are promising but remain scarce and, due to several
methodological issues, such as small sample size and incom-
plete outcomes, are prone to bias and should be confirmed
in larger trials.
D. Sepsis Treatment
As a key factor, aggressive treatment of sepsis to avoid
ICUAW is generally advocated. In addition to the general
guidelines for sepsis treatment (152), modulating the in-
flammatory response as a potential mechanistical pathway
may be of special interest with regard to the neuromuscular
complications. Overall effects of anti-inflammatory and im-
mune-directed therapies in sepsis appeared disappointing
(242, 745), although individualized approaches, including
optimal timing of such strategies, may be promising (243,
323). No trial has yet specifically addressed the effects of the
immune-modulatory treatments on neuromuscular compli-
cations, and this should be considered in future studies.
E. Corticosteroid Management
The use of corticosteroids, although also mentioned as a
risk factor, is important to consider, as corticosteroids may
reduce duration of organ dysfunction in a subgroup of pa-
tients with septic shock (22), which by itself is related to the
development of ICUAW. Moreover, when concomitant hy-
perglycemia is treated, steroids might have beneficial neu-
romuscular effects in critically ill patients, possibly due to
anti-inflammatory properties (309). Several RCTs compar-
ing corticosteroids versus placebo were performed in criti-
cally ill patients, but only few reported on neuromuscular
complications. The Corticus trial found no effect of corti-
costeroids on the incidence of polyneuropathy in 499 pa-
tients with septic shock (654). However, no diagnostic
methods for polyneuropathy were provided, and the figures
were unexpectedly low in both groups. Another RCT fo-
1085
 FRIEDRICH ET AL.
cused on 180 patients with persisting ARDS and compared
treatment with corticosteroids (methylprednisolone) versus
placebo (658). There was no difference in the incidence of
neuromyopathy between both intervention groups. Meth-
ylprednisolone increased the number of ventilator-free and
shock-free days during the first 28 days and did not affect
mortality. Serious adverse events related to neuropathy or
myopathy, however, were reported in nine patients in the
steroid group versus none in the control group. In some
clinical situations, such as status asthmaticus and systemic
vasculitis, corticosteroids are potentially life-saving, and
possible side effects should not compromise their prompt
institution. In other situations including septic shock (654)
or ARDS (658), benefits are less clear and should be
weighed against possible side effects, including weakness.
F. Management of Neuromuscular Blockade
Concerning the use of neuromuscular blocking agents, only
one RCT studied the effect on ICUAW (536). No difference
in incidence of ICUAW was found in patients with early
ARDS receiving neuromuscular blocking agents for 48 h
versus controls. Neuromuscular blocking agents are still
being used, although much less frequently and more selec-
tively to date, for several indications such as urgent intuba-
tion, patient-ventilator asynchrony, refractory respiratory
failure, intracranial hypertension, and therapeutic hypo-
thermia (265). Despite the lack of equivocal evidence of
negative neuromuscular effects, it is generally accepted to
limit use of neuromuscular blocking agents (146) and when
used, to evaluate depth of neuromuscular blockade apply-
ing monitoring techniques (744).
G. Nutritional Strategies
Severe muscle atrophy due to the catabolic state in critically ill
patients is generally considered to contribute to muscle weak-
ness. A nutritional deficit rapidly develops during critical ill-
ness due to dysfunction of the gastrointestinal tract. This is
most troublesome in patients who cannot be fed enterally be-
cause of contraindications. Postoperative esophagectomy or
pancreato-duodenectomy patients received no enteral feeding
in the first 6 days versus enteral feeding through a jejunos-
tomy. No effect on grip strength or respiratory muscle
strength was noted, and the fed patients tended to have less
rapid recovery of mobility (762). The EPaNIC trial ran-
domized 4,640 patients for early parenteral supplementa-
tion (early PN group) versus tolerating the caloric deficit
during the first week in ICU (late PN group) (107). Overall,
accelerated recovery, shortened duration of mechanical
ventilation, and fewer complications were shown for the
late PN group compared with the early PN group. Addi-
tionally, systematic evaluation of muscle strength using the
MRC sum score was performed in patients who stayed in
ICU for at least 8 days and were considered to be at high
1086 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
risk for developing ICUAW, as well as in a random sample
of short-stay patients (300). The evaluations were per-
formed three times weekly from day eight until ICU dis-
charge or death. The incidence of ICUAW at first evaluation
was significantly lower in the late PN group compared with
the early PN group. Muscle biopsies from 122 EPaNIC
patients showed that this was possibly due to more efficient
autophagic qualtity control of myofibers, whereas markers
of atrophy were not affected. Another large RCT focused
on a specific subgroup of ICU patients, deemed to have
contraindications for enteral feeding (161). This trial ran-
domized 1,372 subjects to conventional treatment or early
parenteral nutrition and indicated greater muscle wasting in
the standard care patients, but no assessment of muscle
strength or functional outcome was made (161). The Eden
trial studied full enteral versus trophic feeding during the
first 6 days in 1,000 acute lung injury patients (503). No
strength measurements were provided at ICU or hospital
discharge, but at 6 and 12 mo follow-up, physical perfor-
mance was below the predicted one for a subset of 174
survivors. No difference was found for MRC sum score,
handgrip strength, maximal inspiratory pressure, 6-mo
walking distance, and quality of life (504). Various supple-
mental therapies may be of interest. Glutamine concentra-
tion in plasma and skeletal muscle are low in critical illness,
which independently predicts mortality. This led to the hy-
pothesis that glutamine is a conditionally essential amino
acid and that supplementation may not only improve over-
all outcome but also muscle function (87, 770). A meta-
analysis reported beneficial effects of glutamine supplemen-
tation in critically ill patients (514), but this was not con-
firmed in two recent RCTs (18, 312). The latter even
showed increased mortality rates in critically ill patients
with multiple organ failure (312), and effects on muscle
function have not been studied yet. The use of other micro-
nutrients against oxidative stress is also sensible from a
pathophysiological point of view. Two recent meta-analy-
ses concluded that antioxidant micronutrients are of poten-
tial benefit for critically ill patients (452, 746). Again, ef-
fects on muscle weakness were not studied, and the recent
large RCT showed no beneficial effects from antioxidants in
critically ill patients with multiple organ failure (312). A
recent review concluded that there is no evidence for benefit
with early nutrition, nor supplemental therapies in critically
ill patients (108). Preliminary data from animal experi-
ments showed that mitochondrial emission of ROS is a
crucial element in atrophy development and contractile dys-
function of the diaphragm occurring during mechanical
ventilation (556) which was prevented by a novel mito-
chondria-targeted antioxidant.
H. Hormone and Electrolyte Balance
Several other hormones have a key role in the anabolic/
catabolic balance of the muscle and could, therefore, possi-
bly be of interest in the prevention of ICUAW. One of the
 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL

Table 7. Therapeutic strategies for ICU-related weakness

Presumed
Level of Evidence Target Presumed Target at Cellular/Molecular Level

Direct evidence for benefit

Tight glycemic control Nerve Improved microcirculation (E) (183, 393, 781)
Improved mitochondrial function (E) (735)
Attenuated loss of nerve fibers (E) (603)
Withholding parenteral nutrition during first Muscle Improved autophagic muscle quality control (A) (300)
week in ICU
Indirect evidence for benefit
Sedation sparing protocol Muscle Prevention of disuse atrophy caused by decreased protein
synthesis, anabolic resistance, and increased protein
degradation by the ubiquitin proteasome system (C, D) (81,
260)
Early limb mobilization Muscle Autophagy (C, D) (294, 689)
Potential evidence for harm: limit use unless evidence-based benefit
Corticosteroids Muscle Promoting atrophy by decreased protein synthesis and
increased proteolysis by the ubiquitin proteasome and
lysosomal system (A, B) (154, 616, 617, 703)
Neuromuscular blocking agents NMJ Prolonged neuromuscular blockade (A) (265)
Muscle Denervation atrophy (D)
Theoretical benefit
Careful electrolyte management (Na⫹, K⫹, Nerve Nerve membrane excitability (E)
P, Mg2⫹, Ca2⫹)
NMJ Neuromuscular transmission (E)
Muscle Muscle membrane excitability (E); excitation-contraction
coupling (E)
Ventilator weaning protocol Muscle Avoiding fatigue (E) (387)
Electrical muscle stimulation Muscle Prevention of atrophy by suppression of ubiquitin proteasome
system and calpain and increased anabolic pathways by
induction of growth factors (A, C, D) (73, 171, 467, 664,
765)
Autophagy (E)

The level of available evidence is graded as follows: A) human data from critically ill patients; B) experimental
data from ICU models; C) human data from noncritically ill or healthy volunteers; D) experimental data from
other animal models, including immobilization/denervation; E) hypothesis.

candidates to this effect was growth hormone, since resis-
tance to growth hormone is a characteristic feature of crit-
ical illness. Two large randomized trials showed clearly in-
creased mortality rates in patients treated with growth hor-
mone (688). Although the interest in the potential of growth
hormone treatment in the recovery phase for selected
chronically ill patients is reviving (694), current recommen-
dations are clearly against its use. Low sex hormone con-
centration in aging may be a key factor in sarcopenia and
muscle weakness (642). ICUAW is also associated with hy-
pogonadism in men (631). Testosterone derivatives reduced
length of stay and preserved lean body mass in burn patients
(352, 783). Data are not supportive for use in trauma (239)
or surgery (84) patients, although effects on ICUAW have
not formally been addressed. Also, concerns about hepato-
toxicity with the use of oxandrolone, an oral synthetic tes-
tosterone derivative, have been raised (352). Finally, elec-
trolyte disturbances could affect muscle function (768). The
need for correction, rate, and degree to which electrolytes
should be corrected depends on multiple factors and gener-
ally is not primarily determined by muscle function (768).
Also, dedicated weaning protocols might be indicated for
weak patients (80) to avoid muscle fatigue (387), although
no clinical data are available in this specific group of criti-
cally ill patients.
In summary, data on effective strategies to prevent and/or
treat muscle weakness in critical illness remain limited,
mainly due to lack of well-designed large RCTs. Further
research is clearly needed. In particular, strategies to re-
duce hypoglycemic events during insulin treatment
should be pursued, as well as further exploring the po-
tential of early rehabilitation and electrical muscle stim-
ulation and other treatments should be addressed, sug-
gested from targeting pathogenetically involved path-
ways in this review. TABLE 7 summarizes current views
on strategies with direct, indirect, and potential evidence
for therapeutic benefit as well as evidence for harmful
outcome and a list of some future challenges is provided
at the end of the next chapter.

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 FRIEDRICH ET AL.

nerve pathology muscle pathology

Critical illness +
cytokine production

electrical microvascular metabolic bioenergetic electrical microvascular altered Ca2+ metabolic bioenergetic mechanical
alterations alterations alterations failure alterations alterations homeostasis alterations failure silencing

hyperglycemia

vasodialation + impairment ↑generation inactivation vasodialation + ↑activation ↑apoptosis relative ↑anabolic + antioxidant tensegrity
↑permability microcirculation ↓scavenging of Na+ ↑permability of glutamine ↓catabolic depletion impairment
of the ROS channels of the proteolytic deficiency hormones
microcirculation microcirculation (calpain +
ubiquitin +
lysosomal)
pathways

nerve passage endo- mitochondrial muscle change protein mitochondrial aberrant

extra- extra- mechano-
mem- neuro- vasation neural dysfunction membrane in the catabolism dysfunction
vasation transduction
brane toxic of edema + inexcit- of excitation-
depolar- factors activated hypox- ability activated contraction
ization leukocytes emia leukocytes coupling
+ local + local of the
cytokine cytokine SR
production production

CIP muscle denervation CIM

NMBA CS

FIGURE 16. Flow chart of proposed mechanisms and their interactions contributing to the development of
CIP and CIM. [Extended from Hermans et al. (302).] Summary of pathophysiological mechanisms in ICU-related
weakness affecting the nerve/muscle function, demonstrating the various pathways affected and mechanistic
explanations for the development of CIP and CIM.

XIV. SUMMARY/OUTLOOK may be used, but it is mandatory to perform a focused

In this review, we have discussed the different entities of
ICU-related weakness as well as potential mechanisms in-
herent to and differentiating between those entities. One
important emphasis of the current consortium is to stress
the fact that inconsistencies exist in the literature regarding
the classification of weakness in general and myopathies in
particular, seen in critically ill patients. For critical illness
myopathy to be diagnosed appropriately, several patholog-
ical key features shall be present: 1) electrical hypoexcitabil-
ity of muscles, 2) severe atrophy, 3) preferential and signif-
icant myosin loss, 4) disorganization of sarcomeres and
ultrastructural abnormalities, and 5) impaired autophagy.
These findings may be present between patients in combi-
nations of varying degree. Unless all of those features are
confirmed, the definite diagnosis “CIM” does not hold and
the more pragmatic term “ICUAW” shall be used. How-
ever, it needs further clarification whether the finding of
impaired autophagy exclusively applies to CIM patients or
also to other subsets of ICUAW. If some of these features
are present, e.g., most clinical routine diagnostics will be
able to cover features 1, 2, and 4, the term probable CIM
search for features 3 and 5, in particular because the pres-
ence of preferential myosin loss seems, so far, to be the only
distinction between CIM and sepsis-induced myopathy,
and the presence of impaired autophagy may alter the clin-
ical handling with an initial calorie restriction protocol.
Strong symptoms arguing for the presence of CIM in most
patients are reduced membrane excitability and preferential
myosin loss.
The choice of appropriate animal models mimicking the
situation in ICU patients is crucial for current and future
studies of missing links in the pathophysiological puzzle
and to test for treatment efficiencies. While immobilization
is clearly a key risk factor for development of ICUAW and
CIM in particular, it is likely that there may also be a con-
tribution of an ongoing inflammatory process. As detailed
in our review, the pathophysiological mechanisms found in
neuropathies and myopathies in the critically ill are very
diverse and affect all facets of neuron and muscle function
(FIGURE 16). One unique complication of critical illness
appears to be an acquired channelopathy that affects mul-
tiple electrically active tissues and may contribute to myop-

1088 Physiol Rev • VOL 95 • JULY 2015 • www.prv.org

 NEUROMUSCULAR FAILURE IN THE CRITICALLY ILL
athy, neuropathy, cardiac failure, and poor recruitment of
motor units. However, whether this ion channel dysfunc-
tion is a primary pathology or simply a consequence sec-
ondary to alterations rendering the ion channel dysfunc-
tional, e.g., electrolyte disturbances, metabolic failure, pro-
teolytic activity in critical illness, etc., is not known and
represents a future field of studies where the animal models
discussed in this review may become extremely valuable.
Other pathological processes include impairments of the
neuromuscular transmission and postsynaptic membrane
depolarization, so muscle becomes electrically hypo- or in-
excitable. Aspects of critical illness related to intracellular
Ca2⫹ homeostasis have only scarcely been investigated in
muscle, while not at all in nerve. Evidence points towards
substantial alteration in Ca2⫹ handling mechanisms, at
least documented for sepsis-associated weakness. Complete
mechanical silencing, i.e., no weight bearing and no internal
strain related to activation of contractile proteins, is unique
for mechanically ventilated, deeply sedated, or pharmaco-
logically paralyzed ICU patients and has been shown in
experimental studies to play a very important role in the
pathogenesis of CIM via different mechanosensitive path-
ways, but other factors have additive/synergistic effects in
the development of the CIM phenotype. In addition, the
compromised inherent protective mechanisms of sarco-
meric proteins and mitochondria by heat shock proteins
triggered by systemic corticosteroid hormone administra-
tion and sepsis, in combination with mechanical silencing,
play an important role for the impaired muscle function in
CIM. Thus interventions targeting mechanosenstive path-
ways and heat shock protein expression offer novel venues
for future pharmacological treatments in mechanically ven-
tilated critically ill ICU patients. To date, the only therapeu-
tic strategies with a proven positive outcome include inten-
sified insulin therapy to prevent hyperglycemia and avoid-
ing early parenteral nutrition to allow autophagy activation
in muscle. Counteracting immobilization with early mobi-
lization may also help to reduce the severity of myopathy.
In summary, from a pathophysiological point of view, the
dissection of contributing factors to the clinical picture of
ICU-related weakness is still a challenging venue for future
research. Therefore, appropriate animal models such as the
ones presented here with their strengths and weaknesses
will become a major focus for critical illness-related re-
search and, hopefully, will become also a reliable tool to
more specifically test for therapeutic benefits of new treat-
ment regimes.
A. Future Research Topics (Basic
Mechanisms and Possible Therapeutic
Interventions)
Future research topics that will certainly represent an ad-
vancement in our understaning of the nature of muscle
Physiol Rev • VOL 95 • JULY 2015 • www.prv.org
weakness in the critically ill as well as test for novel poten-
tial therapeutic interventions include the following.
1. Animal models and human experiments
1) Elucidating the exact time courses of individual phenotypic
changes in CIM, e.g., beginning and duration of membrane
hypoexcitability, Ca2⫹ imbalance, metabolic changes, atro-
phy, preferential myosin loss in serial studies in patients and
animal models (FIGURE 2);
2) Using animal models at ages equivalent to human chil-
dren as a model for pediatric ICU-acquired weakness;
3) Using animal models with comorbidities (e.g., obese ICU
rat model, senescence models, etc.);
4) Extending the porcine ICU model (as model closest to the
human) for long-term intensive care treatment (also in
adult/old pigs);
5) Exploiting multimodal readout systems (metabolic imag-
ing, metabolomics, multiplex RNA analyses, etc.) to pa-
tient samples in serial studies on ICU patients, septic or
not, and septic patients with no mechanical ventilation
or immobilization to map the pathophysiological mech-
anisms found in animal models to human models; and
6) Assessing the Na⫹ channelopathy defined in animal mod-
els in ICU patients. In particular, is the hypoexcitability
seen in CIM patient muscle also reflected by the same
changes in ion channel biophysics as seen in rat SD mus-
cle? Fresh muscle biopsies from CIM patients would be
required to be electrophysiologically characterized (volt-
age/patch clamp).
2. Pathophysiological mechanisms
1) Assessment of complete electrolyte and osmolarity pro-
files in patients from different ICUAW entities to differ-
entially explain muscle membrane hypoexcitability;
2) Precise involvement of K⫹, Cl⫺, and Ca2⫹ channels in
muscle membrane excitability in critical illness and al-
tered Ca2⫹ homeostasis;
3) More evidence for the direct intracellular action of in-
flammatory cytokines, e.g., direct binding of IL-1 or
TNF-␣ to regulatory proteins in muscle; and
4) Elucidation of the pathways for altered Ca2⫹ homeosta-
sis on mitochondrial biogenesis and mitochdonrial activ-
ity on ATP outcome in the different animal models of
critical illness and criticially ill patients. Is there a myo-
toxic circulating factor in serum collected from non-sep-
tic animal models of ICUAW?
3. Therapeutic concepts to test for
1) Determination of the impact of glycemic control on au-
tophagy in skeletal muscle;
2) Design of strategies for immune modulation in septic
patients and animal models to suppress overt systemic
inflammatory reaction and to avoid ICUAW;
1089
 FRIEDRICH ET AL.
3) Follow-up the concept of reduced membrane excitability
to potentially increase survival of depolarized injured
cells (see sect. VIII).
ACKNOWLEDGMENTS
Address for reprint requests and other correspondence: O.
Friedrich, Institute of Medical Biotechnology, Department
of Chemical and Biological Engineering, Friedrich-Alexan-
der-University Erlangen-Nuremberg, Paul-Gordan-Str. 3,
91052 Erlangen, Germany (e-mail: oliver.friedrich@mbt.
uni-erlangen.de).
GRANTS
This work was supported by National Institutes of Health
Grant NS082354 (to M. Rich) and AR062083 (to M. B.
Reid); Research Foundation-Flanders (Fonds voor Weten-
schappelijk Onderzoek Vlaanderen), Belgium, Grants
G.0399.12 and G.0592.12 (to G. Hermans, I. Vanhore-
beek, and G. Van den Berghe); Postdoctoral Fellowship
from the Clinical Research Fund (Klinische Onderzoeks-
fonds, KOF) of the University Hospitals Leuven, Belgium
(to G. Hermans); structural research financing via the
Methusalem program funded by the Flemish Government
(METH08/07 to G. Van den Berghe and METH14/06 to G.
Van den Berghe and I. Vanhorebeek), via the University of
Leuven; and ERC Advanced Grant AdvG-2012-321670
from the Ideas Program of the EU FP7 (to G. Van den
Berghe). The Swedish Medical Research Council (8651),
the European Commission (MyoAge, EC Fp7 CT-223756,
and COST CM1001), the Swedish Foundation for Interna-
tional Cooperation in Research and Higher Educatiuon
(STINT), and Uppsala University Hospital provided sup-
port to L. Larsson.
DISCLOSURES
No conflicts of interest, financial or otherwise, are declared
by the authors.
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