Safety of neuromuscular electrical stimulation among critically ill patients: systematic review

Sachetti, Amanda; Carpes, Marta Fiorvanti; Dias, Alexandre Simões; Sbruzzi, Graciele

doi:10.5935/0103-507X.20180036

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Revista Brasileira de Terapia Intensiva

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REVIEW ARTICLES • Rev. bras. ter. intensiva 30 (2) • June 2018 • https://doi.org/10.5935/0103-507X.20180036 copy

Safety of neuromuscular electrical stimulation among critically ill patients: systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To review the evidence on the safety of neuromuscular electrical stimulation when used in the intensive care unit.

Methods:

A systematic review was conducted; a literature search was performed of the MEDLINE (via PubMed), PEDro, Cochrane CENTRAL and EMBASE databases, and a further manual search was performed among the references cited in randomized studies. Randomized clinical trials that compared neuromuscular electrical stimulation to a control or placebo group in the intensive care unit and reporting on the technique safety in the outcomes were included. Hemodynamic variables and information on adverse effects were considered safety parameters. Articles were independently analyzed by two reviewers, and the data analysis was descriptive.

Results:

The initial search located 1,533 articles, from which only four randomized clinical trials were included. Two studies assessed safety based on hemodynamic variables, and only one study reported an increase in heart rate, respiratory rate and blood lactate, without clinical relevance. The other two studies assessed safety based on reported adverse effects. In one, 15% of patients described a prickling sensation, without any clinically relevant abnormalities. In the other, one patient suffered a superficial burn due to improper parameter configuration.

Conclusion:

Neuromuscular electrical stimulation is safe for critically ill patients; however, it should be applied by duly trained professionals and with proper evidence-based parameters.

Safety; Electric stimulation therapy; Respiration, artificial; Drug-related side effects and adverse reactions; Physical stimulation; Intensive care units

Study	Groups	Patients (n)	Main objective of study	Intervention parameters	Outcome for safety
Rodriguez et al.⁽²³23 Rodriguez PO, Setten M, Maskin LP, Bonelli I, Vidomlansky SR, Attie S, et al. Muscle weakness in septic patients requiring mechanical ventilation: protective effect of transcutaneous neuromuscular electrical stimulation. J Crit Care. 2012;27(3):319.e1-8.⁾	G1: NMES on one side of the body (contralateral side as control)	Total: 16	To assess the effects of NMES on the muscle strength of patients with sepsis under IMV	Frequency 100Hz; pulse duration 300µs; amplitude 20 - 200v; biphasic impulse; intensity controlled by visible or palpable contraction; stimulus applied twice per day for 30 minutes Brachial biceps and quadriceps vastus medialis muscles Application from IMV day 2 until extubation	Adverse effects: superficial burn in a single patient after the first NMES session due to improper configuration
Abu-Khaber et al.⁽²⁵25 Abu-Khaber HA, Abouelela AM, Abdelkarim EM. Effect of electrical muscle stimulation on prevention of ICU acquired muscle weakness and facilitating weaning from mechanical ventilation. Alexandria J Med. 2013;49(4):309-15.⁾	G1: conventional treatment G2: conventional treatment + NMES	Total: 80 G1: 40 G2: 40	To assess the effects of NMES on the peripheral muscles of critically ill patients	Frequency 50Hz; pulse duration 200µs; biphasic symmetrical impulse; duration 15 seconds (1 second rise and 1 second fall); intensity controlled by visible or palpable contraction; stimulus applied once per day for 60 minutes Bilateral quadriceps Application from IMV day 2 to ICU discharge	Adverse effects: six patients (15%) reported a prickling sensation, which was not clinically significant
Akar et al.⁽²⁶26 Akar O, Günay E, Sarinc Ulasli S, Ulasli AM, Kacar E, Sariaydin M, et al. Efficacy of neuromuscular electrical stimulation in patients with COPD followed in intensive care unit. Clin Respir J. 2017;11(6):743-50.⁾	G1: active mobilization + NMES G2: NMES G3: active mobilization	Total: 30 G1: 10 G2: 10 G3: 10	To compare the efficacy of active mobilization, active mobilization + NMES and NMES alone on muscles, ventilation weaning and NMES response to inflammation among critically ill patients with COPD	Frequency 50Hz; amplitude 20mA and 25mA; symmetrical biphasic square waves; duration 6 seconds (1.5 second rise and 0.75 second fall); stimulus applied five times per week Bilateral deltoid and quadriceps Application from IMV day 2 to ICU discharge	Hemodynamic variables: HR significantly decreased in G2; no changes in RR before or after intervention in any group
Stefanou et al.⁽²⁷27 Stefanou C, Karatzanos E, Mitsiou G, Psarra K, Angelopoulos E, Dimopoulos S, et al. Neuromuscular electrical stimulation acutely mobilizes endothelial progenitor cells in critically ill patients with sepsis. Ann Intensive Care. 2016;6(1):21.⁾	G1: high frequency G2: medium frequency	Total: 36 G1: 18 G2: 18	To investigate the effects of NMES on the mobilization of endothelial progenitor cells among critically ill patients with sepsis	G1: frequency 75Hz, 6 seconds on and 21 seconds off; G2: frequency 45Hz, 5 seconds on and 12 seconds off; biphasic impulse and pulse width 400µs; intensity defined as the maximum tolerated One single 40-minute session Vastus lateralis and peroneus longus	Hemodynamic variables: slight increase of HR and RR; MAP remained the same in both groups. Slight increase in blood lactate in both groups

Associação de Medicina Intensiva Brasileira - AMIB Rua Arminda, 93 - Vila Olímpia, CEP 04545-100 - São Paulo - SP - Brasil, Tel.: (11) 5089-2642 - São Paulo - SP - Brazil
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[1] Corresponding author: Amanda Sachetti, Hospital da Cidade de Passo Fundo, Rua Tiradentes, 295, Zip code: 99010-260 - Passo Fundo (RS), Brazil, E-mail: amandasachetti@gmail.com

#1	("Critical Illness"[Mesh] OR “Critical Illness” OR “Critical Illnesses” OR “Illness, Critical” OR “Illnesses, Critical” OR “Critically Ill” OR "Intensive Care"[Mesh] OR "Intensive Care" OR “Care, Intensive” OR “Surgical Intensive Care” OR “Care, Surgical Intensive” OR “Intensive Care, Surgical” OR "Intensive Care Units"[Mesh] OR "Intensive Care Units" OR “Care Unit, Intensive” OR “Care Units, Intensive” OR “Intensive Care Unit” OR “Unit, Intensive Care” OR “Units, Intensive Care” OR “critical illness polyneuromyopathy” OR “Polyneuropathy, Critical Illness” OR “Critical Illness Polyneuropathies” OR “Critical Illness Polyneuropathy” OR “Polyneuropathies, Critical Illness”)

#2	("Electric Stimulation"[Mesh] OR “Electrical Stimulation” OR “Electrical Stimulations” OR “Stimulation, Electrical” OR “Stimulations, Electrical” OR “Stimulation, Electric” OR “Electric Stimulations” OR “Stimulations, Electric” OR “Electric Stimulation Therapy"[Mesh] OR “Electric Stimulation Therapy" OR “Therapeutic Electric Stimulation” OR “Electric Stimulation, Therapeutic” OR “Stimulation, Therapeutic Electric” OR “Therapy, Electric Stimulation” OR “Stimulation Therapy, Electric” OR “Electrotherapy” OR “Neuromuscular electrical stimulation” OR “neuromuscular electric stimulation” OR “Electrical muscle stimulation”)

#3	((randomized controlled trial[pt] OR controlled clinical trial[pt] OR randomized controlled trials[mh] OR random allocation[mh] OR double-blind method[mh] OR single-blind method[mh] OR clinical trial[pt] OR clinical trials[mh] OR ("clinical trial"[tw]) OR ((singl[tw] OR doubl[tw] OR trebl[tw] OR tripl[tw]) AND (mask[tw] OR blind[tw])) OR ("latin square"[tw]) OR placebos[mh] OR placebo[tw] OR random[tw] OR research design[mh:noexp] OR follow-up studies[mh] OR prospective studies[mh] OR cross-over studies[mh] OR control[tw] OR prospectiv[tw] OR volunteer*[tw]) NOT (animal[mh] NOT human[mh]))

#4	((#1) AND #2) AND #3