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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