A 53-year-old male is admitted to the ICU post 12-hour head and neck surgery. He has no other significant past medical history and normal baseline renal function.
Eight hours post ICU admission he is increasingly oliguric with dark-coloured urine. His laboratory results are as follows:
Parameter |
Patient Value |
Adult Normal Range |
Sodium |
130 mmol/L• |
134— 146 |
Potassium |
6.5 mmol/L•L• |
3.4 -5.0 |
Creatinine |
320 umol/L* |
45 - 90 |
Urea |
15.0 mmol/L• |
3.0 - 8.0 |
Ionised calcium |
0.85 mmol/L• |
1.10- 1.35 |
Phosphate |
2.6 mmol/L• |
0.8 - 1.5 |
Albumin |
28 g/L• |
35 - 50 |
Total bilirubin |
20 mol/l_ |
< 26 |
Aspartate transferase |
510 IU/L* |
< 35 |
Alanine transferase |
100 IU/L• |
< 35 |
Alkaline phosphatase |
110 IU/L* |
30- 110 |
Haemoglobin |
150 g/L |
120 - 160 |
White Cell Count |
20.0 x 10 |
4.3 - 10.8 |
Platelet count |
400 x 10 |
150 - 350 |
Give the most likely cause for the above results AND the rationale for your answer.
(30% marks)
List other useful investigations. (10% marks)
Briefly outline your management of this condition. (40% marks)
List four drugs that can cause this condition. (20% marks)
a) The results indicate rhabdomyolysis.
The history is suggestive of muscle ischaemia from the prolonged duration of surgery and
likely immobilization. The classic biochemical picture of hyperkalaemia, hyperphosphatemia,
hypocalcaemia, high aspartate aminotransferase (AST), AKI with reduced Urea:Creatinine
make rhabdomyolysis an important diagnosis to exclude. Other differentials causing an acute
kidney injury are unlikely.
b) CK levels
• ECG
• Urine for myoglobin
• Serum lactate dehydrogenase (LDH)
c)
• Treat the cause; muscle debridement / fasciotomy if indicated
• Ensure adequate hydration – you need generous amounts of fluid aiming for urine output 1ml/kg/h
• Consider urinary alkalization with bicarbonate to keep pH > 6.5 (although there is limited
evidence above fluid alone)
• Treat hyperkalaemia along conventional lines
• CRRT if remains oliguric, increasing U and Cr
d)
• Statins
• SSRIs
• Drugs of abuse: cocaine, amphetamines, heroin, LSD, ‘ Ecstasy’
It's clearly rhabdomyolysis. "Give rationale for your answer", they ask. Well:
Some other weirdness is also apparent:
List other useful investigations? To really confirm the crap out of it, you'd order the following series of tests:
The college also recommend an ECG, because potassium.
A recent meta-analysis of management strategies for rhabdomyolysis has presented the following conclusions:
Dialysis may be commenced to improve the removal of myoglobin, if a high-permeability membrane filter is available. Even if it is not, standard CVVHDF seems to decrease the risk of renal injury.
Drugs associated with rhabdomyolysis:
The best shortcut for the time-poor exam candidate is this UpToDate article.
Bosch, Xavier, Esteban Poch, and Josep M. Grau. "Rhabdomyolysis and acute kidney injury." New England Journal of Medicine 361.1 (2009): 62-72.
Shapiro, Mark L., Anthony Baldea, and Fred A. Luchette. "Rhabdomyolysis in the intensive care unit." Journal of intensive care medicine 27.6 (2012): 335-342.
Holt, S., and K. Moore. "Pathogenesis and treatment of renal dysfunction in rhabdomyolysis." Intensive care medicine 27.5 (2001): 803-811.
Vanholder, Raymond, et al. "Rhabdomyolysis." Journal of the American Society of Nephrology 11.8 (2000): 1553-1561.
Bosch, Xavier, Esteban Poch, and Josep M. Grau. "Rhabdomyolysis and acute kidney injury." New England Journal of Medicine 361.1 (2009): 62-72.
Allison, Ronald C., and D. Lawrence Bedsole. "The other medical causes of rhabdomyolysis." The American journal of the medical sciences 326.2 (2003): 79-88.
Brown, Carlos VR, et al. "Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a difference?." Journal of Trauma-Injury, Infection, and Critical Care 56.6 (2004): 1191-1196.
Scharman, Elizabeth J., and William G. Troutman. "Prevention of kidney injury following rhabdomyolysis: a systematic review." Annals of Pharmacotherapy47.1 (2013): 90-105.
Sorrentino, Sajoscha A., et al. "High permeability dialysis membrane allows effective removal of myoglobin in acute kidney injury resulting from rhabdomyolysis." Critical care medicine 39.1 (2011): 184-186.
Tang, Wanxin, et al. "Renal protective effects of early continuous venovenous hemofiltration in rhabdomyolysis: improved renal mitochondrial dysfunction and inhibited apoptosis." Artificial organs 37.4 (2013): 390-400.
Ioannidis, Konstantinos, et al. "Safety and effectiveness of the combination acetazolamide and bicarbonates to induce alkaline diuresis in patients with rhabdomyolysis." European Journal of Hospital Pharmacy 22.6 (2015): 328-332.
Hohenegger, Martin. "Drug induced rhabdomyolysis." Current opinion in pharmacology 12.3 (2012): 335-339.
Valade, N., et al. "Thrombocytosis after trauma: incidence, aetiology, and clinical significance." British journal of anaesthesia 94.1 (2005): 18-23.