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
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]
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