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A case of Rhabdomyolysis… March 1, 2012

Posted by Andy Jagoda, MD in : Musculoskeletal Emergencies, Renal and Genitourinary Emergencies, Trauma , trackback

A nurse informs you of a new patient who “just doesn’t look well.” You assess the patient, a 69-year-old woman who is coughing up green sputum, saturating 89% on room air, and is febrile, tachypneic, and tachycardic with a blood pressure of 86/40 mm Hg. The patient’s daughter informs you that her mother was just released from the hospital 6 days earlier after being treated for pneumonia. You suspect septic shock and instruct the nurse to place a nonrebreather mask on the patient. You administer broad-spectrum antibiotics, draw cultures and labs (including a venous lactate and a cardiac panel), and initiate a 30-cc/kg crystalloid infusion. The blood pressure normalizes, so you breathe a sigh of relief, but soon after, the lactate returns elevated at 8 mmol/L, which confirms your suspicion for severe sepsis. The nurse places a Foley catheter and reports that there is scant and “dark” urine in the bag. The WBC count returns at 18.4, and her BUN and Cr are 32 and 5.5, respectively. You note that the BUN:Cr ratio is odd, considering her previously normal renal function; you expected an increased ratio due to prerenal azotemia from severe sepsis. You then notice that the CK level is 67,000 U/L with normal MB fraction. To confirm your hunch, you check the UA, which returns positive for “blood” but does not show any red blood cells in the sediment.

This case reminds you that rhabdomyolysis has many causes, but the treatment in all cases is based on an aggressive hydration strategy. You recall that sodium bicarbonate infusion may be indicated and wonder: when, and how should it be initiated? You also wonder, “Is there anything else I can do for this patient that would mitigate against complications from renal failure?”

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Comments»

1. The latest What’s Your Diagnosis… « What's Your Diagnosis? - March 1, 2012

[…] Diagnosis challenge, titled “A case of Rhabdomyolysis,” has been posted on our new location; check it out here. Like this:LikeBe the first to like this […]

2. rick - March 2, 2012

Strep Pyogenes–>Acute Glomerulonephritis

3. Adam - March 2, 2012

My next step would be to check the urinary pH. If it is less than 5.5, I would initiate bicarbonate therapy. In terms of a diagnosis, I would suspect a possible ATN, or possible a CIN (contrast induced nephropathy) depending in whether or not she had received a contrasted scan on her last admission.

4. Tina Achacoso - March 2, 2012

Check serum electrolytes snd review medication history. Patient may have hypokalemia which can lead to rhabdiomyolysis. This can then lead to ATN then subsequently cause ARF.

5. rita cohen - March 3, 2012

The patient is usually admitted to hospital.
This patient m/p has infection induced rhabdomyolysis(might be pneumococc)/
the first aid consists of the correction of hypovolaemia and dehydration-
Start with physiological saline 1,000 milliliters(mL) during the first hour, Followed by 400-500 mL/hour
The aim is to prevent the development of acute renal failure, caused by myoglobin which is being released from the muscles.
Thus intensive fluid therapy is the cornerstone of the treatment. Forced alkaline diuresis aims at preventing renal failure; target level for urine pH is 6.5. In the recent years, the importance of urine alkalinization has been questioned .
initially 1,000 mL of 0.9% sodium chloride (NaCl) over 1 hour,Followed by 0.3% NaCl with 5% glucose 400 mL/hour
Urine is alkalinized with a side infusion of 7.5% NaHCO3 administered 10-20 mL/hour.
Diuresis may be encouraged with 20-40 milligrams of intravenous furosemide.
Dialysis is indicated in renal failure if the patient is anuric and diuresis is not induced with rehydration.
Dialysis will have no effect on the renal state, but will keep the patient alive until renal function spontaneously returns. This may take several days, even weeks.
Correction of symptomatic hypocalcaemia must be carried out cautiously, because hypercalcaemia often develops during recovery. Asymptomatic hypocalcaemia requires no treatment.

6. Anda - March 4, 2012

The cause of Rhabdomyolysis could also be drugs, like Codeine or Theophylline. Treatment of Sodium bicarbonate is needed for alkalisation of urine (pH more than 6,5). This prevents myoglobin dissociation into ferrihemate, which is toxic to the renal tubule. There is an option for hemodialysis as well.

7. Hugo - March 4, 2012

My next step is placed a central line , initiate Sodium bicarbonate and hydrated 500ml /h if respiratory compromise will intubated for a short period of time

8. Nicolas PESCHANSKI - March 5, 2012

Definitly severe sepsis.
Myoglobinuria explain the urine color.
Initiaite Bicarb to force alkaline diuresis.
Look alike severe Pneumococcial infection.

9. ref - March 6, 2012

The cause of rhabdomyolysis could be due to 1. infection (strep pneumonia) 2. combination of drugs so we have to review her medications. start aggressive IV rehydration 1L/hr initially then continue hydrating for the first 24 to 72hrs but caution should be observe because the patient is elderly. a central line should be inserted.next, check for electrolytes especially serum potassium because 10% to 40% of cases with rhabdomyolysis-induced acute renal failure have hyperkalemia. also check for urine pH if acidotic she will benefit from sodium bicarb 2-3 amps (88 to 132mEq) be added to D5W to run at 100ml/h to maintain a urine pH of 6.5 at the same time lowering the potassium level. if refractory dialysis is the next option. check for coagulation profile DIC and hemorrhagic complication may occur so blood typing and cross match is also requested. alkalinization of the urine or forced diuresis with mannitol or loop diuretic may have no benefit (mannitol can worsen dehydration and oliguria. furosemide can acidify the urine). urinary catheter should be place to monitor urine output and cardiac monitoring for dysrhythmias 2 to electrolyte and metabolic complication.

10. Abdel Rahman A Mokhtar - March 6, 2012

There are two directions :

Full supportive measures for salvaging the kidney function through aggressive hydration and correction of any electrolytes deficit .

Investigations for the possible cause in order to control e.g sputum culture , etc…, revision of drugs could this be drug induced , …etc, as control of the cause will definitely influence the outcome

11. weeblyzss - March 19, 2012

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