Fig. 6.

The muscle ultrasound flowchart for the assessment and minimization of ICUAW. This flowchart suggests a protocol for logical and early identification of ICUAW. Ideally, within the first 48 h, a first muscle ultrasound assessment should be performed for a baseline picture of patient muscle characteristics (the evaluation should at least regard the quadriceps rectus femoris, and it may be “omni-comprehensive” of muscle thickness (TH), cross-sectional area (CSA), echointensity (if the operator is familiar with any image editing software), pennation angle. At the same time, the cognitive impairment should be evaluated using standard reproducible scales (such as the Richmond agitation sedation scale and the confusion assessment method for the ICU). If these scores are in the normal range, the application of manual muscle testing such as the medical research council scale is possible. These first evaluations might be reconsidered within the first 7–10 days after the admission in the ICU, and their modifications over time, integrated with each other as well as with the reevaluation of MRC scale, allow an accurate diagnosis of ICUAW and should be used to modify the different patient-dependent factors, such as pharmacological strategies, muscular overloading or inactivity, and metabolic derangements. RASS Richmond agitation sedation scale, CAM-ICU confusion assessment method for the ICU, ICU intensive care unit, MRC Medical Research Council scale, TH muscle thickness, CSA cross-sectional area, ICUAW ICU-acquired weakness