{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T02:03:51Z","timestamp":1789524231813,"version":"build-2803163510"},"reference-count":53,"publisher":"MDPI AG","issue":"24","license":[{"start":{"date-parts":[[2023,12,6]],"date-time":"2023-12-06T00:00:00Z","timestamp":1701820800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Intensive Care Unit (ICU)-Acquired Weakness (ICU-AW) is a generalized muscle weakness that is clinically detected in critical patients and has no plausible etiology other than critical illness. ICU-AW is uncommon in patients undergoing orthotopic liver transplantation (OLT). Our report sheds light on the highest number of ICU-AW cases observed in a single center on OLT patients with early allograft dysfunction. Out of 282 patients who underwent OLT from January 2015 to June 2023, 7 (2.5%) developed generalized muscle weakness in the ICU and underwent neurophysiological investigations. The neurologic examination showed preserved extraocular, flaccid quadriplegia with the absence of deep tendon reflexes in all patients. Neurophysiological studies, including electromyography and nerve conduction studies, showed abnormalities with fibrillation potentials and the rapid recruitment of small polyphasic motor units in the examined muscles, as well as a reduced amplitude of the compound muscle action potential and sensory nerve action potential, with an absence of demyelinating features. Pre-transplant clinical status was critical in all patients. During ICU stay, early allograft dysfunction, acute kidney injury, prolonged mechanical ventilation, sepsis, hyperglycemia, and high blood transfusions were observed in all patients. Two patients were retransplanted. Five patients were alive at 90 days; two patients died. In non-cooperative OLT patients, neurophysiological investigations are essential for the diagnosis of ICU-AW. In this setting, the high number of red blood cell transfusions is a potential risk factor for ICU-AW.<\/jats:p>","DOI":"10.3390\/jcm12247529","type":"journal-article","created":{"date-parts":[[2023,12,6]],"date-time":"2023-12-06T06:01:07Z","timestamp":1701842467000},"page":"7529","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Intensive Care Unit-Acquired Weakness after Liver Transplantation: Analysis of Seven Cases and a Literature Review"],"prefix":"10.3390","volume":"12","author":[{"given":"Rita","family":"Gaspari","sequence":"first","affiliation":[{"name":"Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"},{"name":"Department of Basic Biotechnological Science, Intensive and Peri-Operative Clinics, Catholic University of the Sacred Heart, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giorgia","family":"Spinazzola","sequence":"additional","affiliation":[{"name":"Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0228-0603","authenticated-orcid":false,"given":"Paola","family":"Aceto","sequence":"additional","affiliation":[{"name":"Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"},{"name":"Department of Basic Biotechnological Science, Intensive and Peri-Operative Clinics, Catholic University of the Sacred Heart, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2491-7625","authenticated-orcid":false,"given":"Alfonso Wolfango","family":"Avolio","sequence":"additional","affiliation":[{"name":"Department of Translational Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy"},{"name":"General Surgery and Liver Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Manuel","family":"Delli Compagni","sequence":"additional","affiliation":[{"name":"Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-3468-7616","authenticated-orcid":false,"given":"Stefania","family":"Postorino","sequence":"additional","affiliation":[{"name":"Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Teresa","family":"Michi","sequence":"additional","affiliation":[{"name":"Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniele Cosimo","family":"Fachechi","sequence":"additional","affiliation":[{"name":"Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2429-1960","authenticated-orcid":false,"given":"Anna","family":"Modoni","sequence":"additional","affiliation":[{"name":"Department of Geriatric, Neurologic, Orthopedics and Head-Neck Science, Area of Neuroscience, Institute of Neurology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3007-1670","authenticated-orcid":false,"given":"Massimo","family":"Antonelli","sequence":"additional","affiliation":[{"name":"Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"},{"name":"Department of Basic Biotechnological Science, Intensive and Peri-Operative Clinics, Catholic University of the Sacred Heart, 00168 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,12,6]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"931","DOI":"10.1016\/S1474-4422(11)70178-8","article-title":"Critical illness polyneuropathy and myopathy: A major cause of muscle weakness and paralysis","volume":"10","author":"Latronico","year":"2011","journal-title":"Lancet Neurol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1164\/rccm.200712-1829OC","article-title":"Acquired weakness, handgrip strength, and mortality in critically ill patients","volume":"178","author":"Ali","year":"2008","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1223","DOI":"10.1136\/jnnp.47.11.1223","article-title":"Polyneuropathy in critically ill patients","volume":"47","author":"Bolton","year":"1984","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"S299","DOI":"10.1097\/CCM.0b013e3181b6ef67","article-title":"A framework for diagnosing and classifying intensive care unit-acquired weakness","volume":"37","author":"Stevens","year":"2009","journal-title":"Crit. Care Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1016\/j.nmd.2018.12.005","article-title":"The clinical management of neuromuscular disorders in intensive care","volume":"29","author":"Damian","year":"2019","journal-title":"Neuromuscul. Disord."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"101","DOI":"10.4103\/1673-5374.125337","article-title":"Critical illness polyneuropathy and myopathy: A systematic review","volume":"9","author":"Zhou","year":"2014","journal-title":"Neural. Regen. Res."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"2859","DOI":"10.1001\/jama.288.22.2859","article-title":"Paresis acquired in the intensive care unit: A prospective multi-center study","volume":"288","author":"Sharshar","year":"2002","journal-title":"JAMA"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"583","DOI":"10.1378\/chest.13-2046","article-title":"Impact of early mobilization on glycemic control and ICU-acquired weakness in critically ill patients who are mechanically ventilated","volume":"146","author":"Patel","year":"2014","journal-title":"Chest"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"104","DOI":"10.1111\/ane.12964","article-title":"Risk factors for intensive care unit-acquired weakness: A systematic review and meta-analysis","volume":"138","author":"Yang","year":"2018","journal-title":"Acta Neurol. Scand."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"621","DOI":"10.1016\/S2213-2600(13)70183-8","article-title":"Effect of tolerating macronutrient deficit on the development of intensive-care unit acquired weakness: A subanalysis of the EPaNIC trial","volume":"1","author":"Hermans","year":"2013","journal-title":"Lancet Respir. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"781","DOI":"10.1016\/j.chest.2018.07.016","article-title":"Impact of vasoactive medications on ICU-acquired weakness in mechanically ventilated patients","volume":"154","author":"Wolfe","year":"2018","journal-title":"Chest"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1186\/s13054-018-2111-0","article-title":"Corticosteroid use and intensive care unit-acquired weakness: A systematic review and meta-analysis","volume":"22","author":"Yang","year":"2018","journal-title":"Crit. Care"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1107","DOI":"10.1056\/NEJMoa1005372","article-title":"ACURASYS Study Investigators Neuromuscular blockers in early acute respiratory distress syndrome","volume":"363","author":"Papazian","year":"2010","journal-title":"N. Engl. J. Med."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1997","DOI":"10.1056\/NEJMoa1901686","article-title":"Early neuromuscular blockade in the acute respiratory distress syndrome","volume":"380","author":"Moss","year":"2019","journal-title":"N. Engl. J. Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"291","DOI":"10.21037\/atm.2017.07.19","article-title":"Sedation and neuromuscular blocking agents in acute respiratory distress syndrome","volume":"5","author":"Bourenne","year":"2017","journal-title":"Ann. Transl. Med."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1016\/j.cnc.2016.02.003","article-title":"Complications of sedation in critical illness: An update","volume":"28","author":"Foster","year":"2016","journal-title":"Crit. Care Nurs. Clin. N. Am."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1579","DOI":"10.1016\/S0140-6736(96)91074-0","article-title":"Critical illness myopathy and neuropathy","volume":"347","author":"Latronico","year":"1996","journal-title":"Lancet"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1515","DOI":"10.1007\/s00134-003-1894-9","article-title":"Electrophoretic determination of the myosin\/actin ratio in the diagnosis of critical illness myopathy","volume":"29","author":"Stibler","year":"2003","journal-title":"Intensive Care Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"S309","DOI":"10.1097\/CCM.0b013e3181b6e64c","article-title":"Intensive care unit-acquired weakness: Risk factors and prevention","volume":"37","author":"Lacherade","year":"2009","journal-title":"Crit. Care Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"126","DOI":"10.1177\/1751143714563016","article-title":"The incidence of intensive care unit-acquired weakness syndromes: A systematic review","volume":"16","author":"Appleton","year":"2015","journal-title":"J. Intensive Care Soc."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"637","DOI":"10.1007\/s00134-020-05944-4","article-title":"ICU-acquired weakness","volume":"46","author":"Vanhorebeek","year":"2020","journal-title":"Intensive Care Med."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1591","DOI":"10.1001\/jama.2013.278481","article-title":"Acute skeletal muscle wasting in critical illness","volume":"310","author":"Puthucheary","year":"2013","journal-title":"JAMA"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1097\/CCM.0b013e31822d7c18","article-title":"Muscle atrophy and preferential loss of myosin in prolonged critically ill patients","volume":"40","author":"Derde","year":"2012","journal-title":"Crit. Care Med."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"439","DOI":"10.1186\/s13054-023-04676-3","article-title":"Illness Weakness, Polyneuropathy and Myopathy: Diagnosis, treatment, and long-term outcomes","volume":"27","author":"Latronico","year":"2023","journal-title":"Crit. Care"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1270","DOI":"10.1007\/s00134-017-4757-5","article-title":"The ICM research agenda on intensive care unit-acquired weakness","volume":"43","author":"Latronico","year":"2017","journal-title":"Intensive Care Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1144","DOI":"10.1097\/00007890-199904270-00010","article-title":"Acute quadriplegic myopathy with myosin-deficient muscle fibres after liver transplantation: Defining the clinical picture and delimiting the risk factors","volume":"67","author":"Alonso","year":"1999","journal-title":"Transplantation"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"696","DOI":"10.1002\/(SICI)1097-4598(199606)19:6<696::AID-MUS2>3.0.CO;2-5","article-title":"Neuromuscular complications associated with liver transplantation","volume":"19","author":"Wijdicks","year":"1996","journal-title":"Muscle Nerve"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"880","DOI":"10.1097\/00007890-200209270-00024","article-title":"Severe acute polyneuropathy complicating orthotopic liver allograft failure","volume":"74","author":"Lefaucheur","year":"2002","journal-title":"Transplantation"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"4023","DOI":"10.1016\/j.transproceed.2018.06.026","article-title":"Diagnosis of Critical Illness Myopathy after Liver Transplantation and Muscle Condition Monitoring: A Case Report","volume":"50","author":"Jang","year":"2018","journal-title":"Transplant. Proc."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"3207","DOI":"10.1016\/j.transproceed.2016.09.005","article-title":"Recovery after critical illness polyneuropathy in a patient with orthotopic liver transplantation: A case report","volume":"48","author":"Watanabe","year":"2016","journal-title":"Transplant. Proc."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"896","DOI":"10.1002\/(SICI)1097-4598(199807)21:7<896::AID-MUS7>3.0.CO;2-1","article-title":"Mononeuropathies associated with liver transplantation","volume":"21","author":"Campellone","year":"1998","journal-title":"Muscle Nerve"},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Kimura, J. (2013). Electrodiagnosis in Diseases of Nerve and Muscle: Principles and Practice, Oxford University Press. [4th ed.].","DOI":"10.1093\/med\/9780199738687.001.0001"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"729","DOI":"10.1016\/j.jhep.2020.12.009","article-title":"L-GrAFT and EASE scores in liver transplantation: Need for reciprocal external validation and comparison with other scores","volume":"75","author":"Avolio","year":"2021","journal-title":"J. Hepatol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"434","DOI":"10.1016\/S0041-1345(98)01694-7","article-title":"Primary dysfunction after liver transplantation: Donor or recipient fault?","volume":"31","author":"Avolio","year":"1999","journal-title":"Transplant. Proc."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Zaragoza-Garc\u00eda, I., Arias-Rivera, S., Frade-Mera, M.J., Mart\u00ed, J.D., Gallart, E., San Jos\u00e9-Arribas, A., Velasco-Sanz, T.R., Blazquez-Mart\u00ednez, E., and Raurell-Torred\u00e0, M. (2023). Enteral nutrition management in critically ill adult patients and its relationship with intensive care unit-acquired muscle weakness: A national cohort study. PLoS ONE, 18.","DOI":"10.1371\/journal.pone.0286598"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"238","DOI":"10.1186\/cc7100","article-title":"Clinical review: Critical illness polyneuropathy and myopathy","volume":"12","author":"Hermans","year":"2008","journal-title":"Crit. Care"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1603","DOI":"10.1097\/CCM.0000000000001016","article-title":"Qualitative Ultrasound in Acute Critical Illness Muscle Wasting","volume":"43","author":"Puthucheary","year":"2015","journal-title":"Crit. Care Med."},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Avolio, A.W., Gaspari, R., Teofili, L., Bianco, G., Spinazzola, G., Soave, P.M., Paiano, G., Francesconi, A.G., Arcangeli, A., and Nicolotti, N. (2019). Postoperative respiratory failure in liver transplantation: Risk factors and effect on prognosis. PLoS ONE, 14.","DOI":"10.1371\/journal.pone.0211678"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"294","DOI":"10.1111\/j.1432-2277.2011.01423.x","article-title":"http:\/\/www.D-MELD.com, the Italian survival calculator to optimize donor to recipient matching and to identify the unsustainable matches in liver transplantation","volume":"25","author":"Avolio","year":"2012","journal-title":"Transpl. Int."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1918","DOI":"10.1016\/j.transproceed.2008.06.002","article-title":"Treatment of chronic hepatitis C virus infection with pegylated interferon and ribavirin in cirrhotic patients awaiting liver transplantation","volume":"4","author":"Annicchiarico","year":"2008","journal-title":"Transplant. Proc."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"110154","DOI":"10.1016\/j.jclinane.2020.110154","article-title":"Thromboelastography does not reduce transfusion requirements in liver transplantation: A propensity score-matched study","volume":"69","author":"Gaspari","year":"2021","journal-title":"J. Clin. Anesth."},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Alhamar, M., Uzuni, A., Mehrotra, H., Elbashir, J., Galusca, D., Nagai, S., Yoshida, A., Abouljoud, M.S., and Otrock, Z.K. (2023). Predictors of intraoperative massive transfusion in orthotopic liver transplantation. Transfusion.","DOI":"10.1111\/trf.17600"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1677","DOI":"10.1111\/trf.17496","article-title":"Super-massive transfusion during liver transplantation","volume":"63","author":"Lapisatepun","year":"2023","journal-title":"Transfusion"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1722","DOI":"10.1053\/j.jvca.2017.10.011","article-title":"Development of a Predictive Model for Blood Transfusions and Bleeding During Liver Transplantation: An Observational Cohort Study","volume":"32","author":"Massicotte","year":"2018","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"829","DOI":"10.1016\/j.amjsurg.2023.06.032","article-title":"Early predictors of prolonged intensive care utilization following liver transplantation","volume":"226","author":"Moore","year":"2023","journal-title":"Am. J. Surg."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"724","DOI":"10.1097\/LVT.0000000000000075","article-title":"Postoperative fibrinolytic resistance is associated with early allograft dysfunction in liver transplantation: A prospective observational study","volume":"29","author":"Moore","year":"2023","journal-title":"Liver Transpl."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1177\/0023677213516313","article-title":"Refinement of tourniquet-induced peripheral ischemia\/reperfusion injury in rats: Comparison of 2 h vs 24 h reperfusion","volume":"48","author":"Duehrkop","year":"2014","journal-title":"Lab. Anim."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"236","DOI":"10.1186\/s13054-019-2506-6","article-title":"Adipose tissue protects against sepsis-induced muscle weakness in mice: From lipolysis to ketones","volume":"23","author":"Goossens","year":"2019","journal-title":"Crit. Care"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1105","DOI":"10.1016\/j.jhep.2023.03.025","article-title":"Liver transplantation in the patient with physical frailty","volume":"78","author":"Tandon","year":"2023","journal-title":"J. Hepatol."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1002\/mus.22219","article-title":"Interobserver agreement of Medical Research Council sum-score and handgrip strength in the intensive care unit","volume":"45","author":"Hermans","year":"2012","journal-title":"Muscle Nerve"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"1929","DOI":"10.1097\/CCM.0b013e31821f050b","article-title":"The interobserver agreement of handheld dynamometry for muscle strength assessment in critically ill patients","volume":"39","author":"Vanpee","year":"2011","journal-title":"Crit. Care Med."},{"key":"ref_52","first-page":"CD006832","article-title":"Interventions for preventing critical illness polyneuropathy and critical illness myopathy","volume":"30","author":"Hermans","year":"2014","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"274","DOI":"10.1186\/s13054-015-0993-7","article-title":"Clinical review: Intensive care unit acquired weakness","volume":"19","author":"Hermans","year":"2015","journal-title":"Crit. 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