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Rhabdomyolysis

A case study
By Andrea C. Tenley, BS
Definition
Rhabdo = Striated, or skeletal muscle
Myo = Muscle
Lysis = Breakdown
The breakdown of skeletal muscle (cells)
causes toxic intracellular contents of muscle
cells to travel into the bloodstream
Electrolyte disturbances
Hypovolemia
Metabolic acidosis
Coagulopathies
Myoglobinuric renal failure
Pathophysiology
Damage to the muscle cell membrane caused by:
Trauma: Physical damage to cell
Hypoxia: O2 and ATP cannot keep up with demand
Severe electrolyte imbalances: Disruption of the Na-K pump

Disruption of the balance between intra- and


extracellular ions
Extracellular: Na, Ca, Cl, & HCO 3
Intracellular: K, Mg, PO4
Disease Cascade,
Primary Symptoms
Cell membrane breaks Na influx into cell
H2O follows salt Rapid swelling of cells
Extracellular fluid caught in the cells
Decrease in plasma Vasoconstriction, renal failure,
hypocalcemia
Ca deposits in skeletal muscle and renal tissue Metabolic
acidosis Clotting agents released into blood Coagulopathies

Muscle pain & Acidosis


weakness ARF; late stage symptom; affects
Hyperphosphatemia 15%
Myoglobinurea Hyperkalemia; arrhythmia &
cardiac arrest
Diagnosis Treatment
Elevated Creatine Increase urine output
>150ml/hr; Catheter
Phosphokinase (CPK) Lasix & P-binders
Normal levels: 22-269
Fluid & mannitol infusion
IU/L Preserve kidneys
Can be 10,000 to
Increase urine pH
3,000,000 IU/L
>6pH
Primary diagnostic
Limit nephrotoxic
criteria
agents
Altered electrolytes Certain antibiotics and
Increase in K and PO4 analgesics
Decrease in Ca Treat underlying
cause
Treatment continued
Prevent further muscle breakdown
Loosen tight casts or dressings
Enhance the clearance of toxins
May require 500-1000ml/hr
Ongoing nursing care
Monitor urine output & prevent fluid overload
Monitor electrolytes closely
Restore intravascular volume
Nutrition and Prognosis
Nutrition
Specific to drugs used
Underlying illnesses
Nephroprotective measures

Prognosis
Aggressive early interventions
77% recovery
Resiliency of skeletal and renal tissues
Most deaths are associated with underlying illnesses
Patient: [Identifying factors
removed]
Ht: 6 4 Wt 149.7kg (329#) Pt is at UBW
Pt lives with [social history removed]

PMH: Operative pituitary tumor age 10, hypopituitarism,


hypothyroidism, obesity, HTN, T2DM (recent dx ~2weeks
prior), A1c 12.5%, peripheral vascular disease, recent
surgical drainage to abscess on right foot (presumed to
be DM ulcer) and current casted fx to left tibia/fibula
Physical Findings: Difficult to understand, edentulous,
large scars on head from surgery, obese, long cast on
left leg (to upper thigh), surgical dressing on right foot
Upon Admission
Symptoms: Dx:
AMS Early sepsis w/shock

Hypouresis Rhabdomyolysis
Adult onset diabetes
Hypotension
mellitus
Encephalopathy
AKI w/Hyperosmolar
hyperglycemic state
Abscess of right foot
Prior left tib/fib fx: cast
Lab Values
Test Ranges 12/7 12/18 12/29 1/8
BUN 5 - 26 mg/dL 43 H 10 9 20
Cr 0.5 - 1.50 mg/dL 5.16 H 1.69 H 1.16 0.95
GFR >/= 90 mL/min 13 L 52 L 82 L >90
Gluc 70 - 99 ml/dL 297 H 94 138 H 136 H
Ca+ 8.5 - 10.8 mg/dL 7.2 L 8.4 L 8.7 7.6 L
Phos 2.7 - 4.5 ml/dL 6.4 H 3.1 3.1 2.3 L
K+ 3.5 - 5.0 mmol/L 3L 3.8 4.6 3.8
Na+ 135 - 153 mmol/L 143 163 H 138 140
Cl- 100 - 114 mmol/L 97 L 127 H 112 113
Co2 21 - 31 mmol/L 32 H 23 22 22
AST 10 - 42 IU/L 128 H 47 H 54 H 63 H
ALT 10 - 60 IU/L 77 H 37 35 29
Alk-Phos 42 - 100 IU/L 215 H 183 H 335 H 320 H
CPK 22 - 269 IU/L 2347 H - - -
CPK MB 0.3 - 6 ng/mL 28.2 H - - -
TL Protein 6 - 8.3 g/dL 5.8 L 5.7 L 5.8 L 5.7 L
Alb 3.5 - 5 g/dL 2.2 L 2.4 L 2.2 L 2.2 L
PAB 18 - 45 mg/dL - - 7.5 L 5.7 L
(1/5/15)
Care Path
Rhabdomyolysis: Aggressive fluids; consult nephrology
T2DM: Q4 accuchecks with sliding scale correction; basal
added later
Encephalopathy: Should improve with other tx; NPO
AKI/Acidosis: Monitor lactic acid; dose HCO3; consult
nephrology
Sepsis/Shock: Antibx; IV fluids; consult critical care
R foot abscess: Antibx; consult infectious disease;
consult wound care
L tib/fib fx: Pain mgt; consult orthopedic when stable
Medications
Fortaz Antibx BGL
Clindamycin Antibx BGL
Solucorter Corticosteriod BGL
D5/HCO3 Sugar/Bicarbonate Alkalize urine
0.9% NaCl Fluids Rehydrate
Nutrition Assessment
PTA poor intake ~2 weeks, since fall
Requested puree foods; poor dentition
NPO since 12/6 adm
PES: Suboptimal oral intake related to decreased
ability to consume sufficient energy as evidenced
by poor appetite and poor intake ~2 weeks per
pt; poor dentition requiring mechanically
modified diet; and NPO since adm.
Sepsis: 1.2-2g protein/kg
Renal damage: Lowered to 0.8-1g/kg
Kcal: 2545-2994kcal/day; 17-20kcal/kg
Nutrition Care Plan
Short & Long Term
Sepsis: Late feeding can accelerate healing: NPO
Not tolerating food, emesis, diarrhea: Liquids
Nutrition replacement: Supplements
Education: AMS - Visit with CDE unsuccessful
Sepsis: Late feeding then 1.2-2g/kg protein
Rhabdomyolysis: Specific to underlying cause, adequate
hydration to dilute urine
AKI: 0.6-0.8g/kg protein; low K+, Phos, Na+
DM: Consistent CHO; insulin (basal and correction)
DI: Hydration, low Na+ diet, potential for low protein diet
Bone fx: High protein, high energy; adequate Ca+, Phos, vitamins
D, C, & K
Edentulous: MS diet
Diet Orders & Supplements
12/6 - 12/11 NPO FLD Soft/Ground meats (GS)
12/22 CLD (EC)
12/22 - 1/5 Clinimix (45g PRO / 53g CHO / 359kcal/day)
12/24 EN initiated
12/25 - 1/4 CLD NPO CLD (EC)
1/5 NPO PEG tube placed

Isosource 1.5 @65ml/hr + (2) Prostat


2540kcal / 135g PRO / 101g LIPDS / 265g CHO / 1817ml
free H2O
Standards: GRV <250ml, BGL 80-200mg/dL, BM <4/day
Issues Affecting Recovery
Poor appetite, poor intake, refusing meals
Chronic diarrhea & emesis
Diabetes Insipidus
Multiple Wounds
Anemia
Severe gastroparesis
PICC line infection with MRSA
Low body temperatures, hypotension,
bradycardia, hypoglycemia
Care Planning
Intramedullary nailing of fx w/removable boot
Discharge to Long Term Acute Care (LTAC)
Antibx, wound care
Continue nutrition support
DDVAP for DI
Reglan, reflux precautions, and continuous TF
for gastroparesis
References
Bosch, X., Poch, E., & Grau, J. M. (2009). Rhabdomyolysis and acute
kidney injury.New
England Journal of Medicine,361(1), 62-72.

Criddle, L. (2003). Rhabdomyolysis: Pathophysiology, recognition, and


management.
Critical Care Nurse, 23(6), 14-32.

Gabow, P. A., Kaehny, W. D., & Kelleher, S. P. (1982). The spectrum of


rhabdomyolysis.Medicine,61(3), 141-152.

Tomlinson, L., & Holt, S. (2008). Rhabdomyolysis and Compartment


Syndrome. InRenal
Failure and Replacement Therapies(pp. 38-41). Springer London.

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