Rhabdomyolysis: need for high index of suspicion

Trauma-related electrolyte disturbances: From resuscitation to rhabdomyolysis

Traumatic injury results in drastic changes to a patient's normal physiology. The hormonal stress response, as well as some treatment strategies, lead to significant disruptions in electrolyte homeostasis that are important for clinicians to understand. In addition, advances in fluid resuscitation and modern transfusion practices have led to their own unique set of consequences, which we are just beginning to appreciate. Special attention is placed on rhabdomyolysis, as this distinct entity represents an extreme example of injury induced electrolyte derangements. This review describes the physiologic response to trauma and highlights some of the important electrolyte abnormalities that can be encountered while caring for the injured patient.

Rhabdomyolysis after the free fibular flap operation for mandibular reconstruction: a case report

Background

Free fibular flap is one of the most useful methods in the hard tissue reconstruction of the maxilla-mandible. Free fibular flap presents some advantages in which the reconstruction of both soft and hard tissues can be done at the same time. It also provides a safe and successful bone graft for the reconstruction, along with a low rate of complications. Despite these advantages and the rarity of a postoperative complication, particularly in oral and maxillofacial surgery procedures, a prolonged operation might exhibit some complications related with rhabdomyolysis. We experienced the rare event of rhabdomyolysis after oral cancer surgery.

Case presentation

In this article, we report the case of a patient who developed rhabdomyolysis after undergoing free fibular flap surgery.

Conclusions

Despite the advantages of the free fibular flap operation, clinicians must be aware of the risk of complications because there are multiple factors that could result in rhabdomyolysis, such as duration of operation, position of the subject, and pre-existing conditions of diabetes and hypertension. Once the diagnosis of rhabdomyolysis is confirmed, a prompt treatment plan should be made and applied as soon as possible. This will increase the chance of a full recovery for the patient who is exhibiting symptoms of rhabdomyolysis.

Establishment of a drug-induced rhabdomyolysis mouse model by co-administration of ciprofloxacin and atorvastatin

Rhabdomyolysis is one of the serious side effects of ciprofloxacin (CPFX), a widely used antibacterial drug; and occasionally, acute kidney injury (AKI) occurs. Often, rhabdomyolysis has occurred in patients taking CPFX co-administered with statins. The purpose of this study is to establish a mouse model of drug-induced rhabdomyolysis by co-administration of CPFX and atorvastatin (ATV) and to clarify the mechanisms of its pathogenesis. C57BL/6J mice treated with L-buthionine-(S,R)-sulfoximine (BSO), a glutathione synthesis inhibitor, were orally administered with CPFX and ATV for 4 days. Plasma levels of creatinine phosphokinase (CPK) and aspartate aminotransferase (AST) were significantly increased in the CPFX and ATV-co-administered group. Histopathological examination of skeletal muscle observed degeneration in gastrocnemius muscle and an increased number of the satellite cells. Expressions of skeletal muscle-specific microRNA and mRNA in plasma and skeletal muscle, respectively, were significantly increased. The area under the curve (AUC) of plasma CPFX was significantly increased in the CPFX and ATV-co-administered group. Furthermore, cytoplasmic vacuolization and a positively myoglobin-stained region in kidney tissue and high content of myoglobin in urine were observed. These results indicated that AKI was induced by myoglobin that leaked from skeletal muscle. The established mouse model in the present study would be useful for predicting potential rhabdomyolysis risks in preclinical drug development.

Rhabdomyolysis After Prolonged Surgery: Report of 2 Cases and Review of Literature

Rhabdomyolysis is a condition in which damaged muscle tissue breaks down and intracellular contents, including myoglobin, are released into the circulation. This produces a nonspecific clinical syndrome including electrolyte disturbances, hypovolemia, metabolic acidosis, coagulopathies, and risk of acute kidney injury. Rhabdomyolysis has been reported as a complication of prolonged surgical procedures but has rarely been reported in the oral and maxillofacial surgery literature. Early diagnosis and treatment of rhabdomyolysis are important to avoid long-term complications such as renal failure. We present 2 cases of postoperative rhabdomyolysis after prolonged maxillofacial surgical procedures in which the patients were managed without long-term sequelae. The pathophysiology, risk factors, diagnosis, and treatment of postoperative rhabdomyolysis are discussed, with a brief review of the literature.

Rapid Diagnosis of Rhabdomyolysis with Point-of-Care Ultrasound

It is important to rapidly diagnosis and treat rhabdomyolysis in order to decrease morbidity and mortality. To date there are no reports in the emergency medicine literature on the use of point-of-care ultrasound in the diagnosis of rhabdomyolysis. This unique case describes how ultrasound was used in the emergency department (ED) to quickly diagnose and treat rhabdomyolysis prior to confirmation with an elevated serum creatine kinase. When coupled with a high index of suspicion, ultrasound can be one of the most portable, readily available, low cost, and minimally invasive techniques for making a rapid diagnosis of rhabdomyolysis in the ED.

Perioperative Management of Peripheral Vascular Trauma

Peripheral vascular trauma is not uncommon in the civilian setting, and it can be uniquely challenging because of the limited time during which intervention can salvage an ischemic extremity. Injuries can be from a blunt or penetrating mechanism, and these injuries can be isolated or can be in the setting of a complex multisystem trauma. The intent of this review is to discuss the perioperative management of peripheral vascular trauma with an emphasis of predicting, preventing, and managing common postoperative complications.

Rhabdomyolysis

Rhabdomyolysis is a syndrome involving the breakdown of skeletal muscle causing myoglobin and other intracellular proteins and electrolytes to leak into the circulation. The development of rhabdomyolysis is associated with a wide variety of diseases, injuries, medications and toxins. While the exact mechanisms responsible for all the causes are not fully understood, it is clear that muscle damage can occur from direct injury or by metabolic inequalities between energy consumption and energy production. Rhabdomyolysis is diagnosed by elevations in serum creatine phosphokinase (CPK), and while there is no established serum level cut-off, many clinicians use five times the upper limit of normal ( approximately 1000 U/l). Rhabdomyolysis can be complicated by acute renal failure (occurring in 4%-33% of patients), compartment syndrome, cardiac dysrhythmias via electrolyte abnormalities, and disseminated intravascular coagulopathy. The mainstay of treatment is hospitalisation with aggressive intravenous fluid (IVF) resuscitation with the correction/prevention of electrolyte abnormalities. There are additional adjunctive therapies to IVF, such as alkalinisation of the urine with sodium bicarbonate, diuretic therapy or combinations of both; however the lack of large randomised control studies concerning the benefits of these treatments makes it difficult to make strong recommendations for or against their use in the treatment of rhabdomyolysis. Regardless of these controversies, the overall prognosis for rhabdomyolysis is favourable when treated with early and aggressive IVF resuscitation, and full recovery of renal function is common. Irrespective of the cause of rhabdomyolysis the mortality rate may still be as high as 8%. This is a comprehensive review of the pathophysiology, diagnosis, complications and treatment options for rhabdomyolysis.

Rhabdomyolysis: another complication after prolonged surgery

We present the case of a young patient who underwent a prolonged urological procedure in the lateral decubitus position. The patient's postoperative course was complicated by rhabdomyolysis manifested by elevated levels of serum creatine phosphokinase and the presence of myoglobin in urine and blood. To prevent renal failure, we managed the patient in the intensive care unit with generous volumes of intravenous fluids, forced diuresis, and urine alkalization. Subsequently, the patient had an uneventful recovery. The linkage between surgical positioning, prolonged surgery time, and rhabdomyolysis is discussed.

Long-term monitoring of renal function in poly-traumatized intensive care patients

INTRODUCTION

For the long-term monitoring of kidney function, polytraumatized patients were examined and routine as well as specialized parameters were compared.

MATERIALS AND METHODS

30 patients of the Surgical Intensive Care Unit (ICU) were examined daily over the entire period they stayed in the ICU. The patients were retrospectively classified as either survivors or deceased patients. Group 1 consisted of 20 patients who resided in the ICU for 11-15 (Median 14) days before they could be transferred to a normal hospital unit. Group 2 consisted of 10 patients who had passed away after 13-18 (Median 16) days in the ICU. In addition to the routine parameters diuresis, serum creatinine and serum urea, specialized parameters for kidney function including the excretion rates of alpha1-microglobulin (alpha1-MG), N-Acetyl-beta-D-glucosaminidase (NAG), angiotensinase A (ATA) and immunoglobulin G (IgG) were determined.

RESULTS

Similar biometric data were shown by all patients at admission into the ICU, but differences did exist regarding the Revised Trauma Score, Injury Severity Score and the APACHE-II-Score. In the period between the 5th and 8th day of intensive treatment almost all patients showed pathological excretion rates of tubular and glomerular parameters whereby no increased frequency of unusual events could be determined at these time-points.

CONCLUSION

During treatment in the ICU, all examined patients showed at times pathological excretion rates of specialized kidney function parameters. Such transient damage was only apparent in a few of the patients when the standard parameters serum creatinine and serum urea were employed. In 90% of the surviving patients the kidney parameters had normalized until the time they were transferred, indicating that such parameters reflected the general state of health of these patients.

Lovastatin-induced rhabdomyolysis possibly associated with clarithromycin and azithromycin

OBJECTIVE

To describe two cases of rhabdomyolysis in patients taking lovastatin that were precipitated by the use of the newer macrolide antibiotics clarithromycin and azithromycin.

CASE SUMMARIES

In each case, the patients were treated over 5 years with lovastatin and developed rhabdomyolysis that coincided with the completion of a prescribed regimen of a newer macrolide antibiotic. Following intravenous hydration and administration of bicarbonate, the patients' condition resolved without permanent' sequelae.

DISCUSSION

Rhabdomyolysis is a clinical syndrome resulting from the destruction of skeletal muscle that may progress to renal failure Several drugs have been associated with rhabdomyolysis, including lovastatin, a hydroxymethylglutaryl-coenzyme A reductase inhibitor. Erythromycin is a macrolide antibiotic that may increase the risk of lovastatin-induced rhabdomyolysis. To our knowledge, these cases are the first published reports of lovastatin-induced rhabdomyolysis associated with azithromycin and clarithromycin.

CONCLUSIONS

The risk of drug-induced rhabdomyolysis due to the potential interaction between lovastatin and azithromycin or clarithromycin should be considered before the concomitant use of these agents.

The clinical and biochemical features of acute renal failure due to rhabdomyolysis

Rhabdomyolysis caused 28 out of 903 (3.1%) of cases of severe acute renal failure (ARF) treated at Leeds General Infirmary over a 14-year period (1980-1993). The commonest cause of rhabdomyolysis was muscle compression, usually due to drug- or alcohol-induced coma. Other causes included fits, infection, acute limb ischemia, trauma, and heat stroke. Prognosis was relatively good, with a 78.6% survival rate and recovery of renal function to normal in all survivors who were followed up. The creatinine/urea ratio was higher in ARF due to rhabdomyolysis than in an unselected group of patients with other causes of ARF but not when the comparison was with sex- and age-matched controls with ARF. This suggests that this previously described feature of rhabdomyolysis simply reflects the increased muscle mass of a younger group of patients, rather than a specific effect of muscle damage. Clinical features of muscle damage were often absent and so the possibility of rhabdomyolysis should be considered in appropriate settings if the diagnosis is to be made early enough to administer treatment that may prevent ARF and the consequences of the compartment syndrome.