1. Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN

2. Objectives Identify the causes of rhabdomyolysis. Describe signs and symptoms of rhabdomyolysis. Utilizing a case study, identify management strategies of a patient with renal dysfunction resulting from rhabdomyolysis.

3. “Rhabdomyolysis was first reported in 1881, in the German literature” (Abbeele, Parker, 1985). “Rhabdomyolysis was first described in the victims of crush injury during the 1940- 1941 London, England, bombing raids of World War II” (Craig, 2006).

4. Rhabdomyolysis accounts for an estimated 8-15% of cases of acute renal failure. the overall mortality rate for patients with Rhabdomyolysis is approximately 5% Rhabdomyolysis is more common in males than in females may occur in infants, toddlers, and adolescents

5. disintegration of striated muscle results in the release of muscular cell constituents into the extracellular fluid and the circulation major component released is myoglobin

6. massive amounts of myoglobin are released  the binding capacity of the plasma protein is exceeded myoglobin is then filtered by the glomeruli and reaches the tubules, where it may cause obstruction and renal dysfunction

7. syndrome characterized by muscle necrosis and the release of intracellular muscle constituents into the circulation creatine kinase (CK) levels are typically markedly elevated, and muscle pain and myoglobinuria may be present

8. severity of illness ranges from asymptomatic elevations in serum muscle enzymes to life-threatening disease associated with: extreme enzyme elevations electrolyte imbalances acute kidney injury

9. Rhabdomyolysis is the breakdown of muscle fibers, specifically of the sarcolemma of skeletal muscle, resulting in the release of muscle fiber contents (myoglobin) into the bloodstream.

10. The sarcolemma is the cell membrane of a muscle cell. The membrane is designed to receive and conduct stimuli Source: (Muscle Anatomy & Structure, 2007)

11. when muscle is damaged, a protein pigment - myoglobin is released into the bloodstream and filtered out of the body by the kidneys. broken down myoglobin may block the structures of the kidney, causing damage such as acute tubular necrosis or kidney failure. dead muscle tissue may cause a large amount of fluid to move from the blood into the muscle, leading to hypovolemic shock  reduced blood flow to the kidneys.

13. may result from a large variety of diseases, TRAUMA, or toxic insults to skeletal muscle hereditary myopathies

14.  Causes  trauma  burns  compression syndrome  infection  seizures  heat intolerance  heat stroke

15.  Causes  vascular occlusion  prolonged shock  electrolyte disorders  drugs (cocaine, alcohol, statins, amphetamine)  low phosphate levels  shaking chills

16.  Clinical Manifestations  muscle tenderness  myalgias  muscle swelling & weakness  DIC  color of urine

17. Additionally some possible symptoms include: −Overall fatigue −Joint pain −Seizures −Weight gain

18. Diagnosis an examination reveals tender or damaged skeletal muscles Creatine Phosphokinase (CK) levels are very high serum myoglobin test is positive serum potassium may be very high

19. serum CK begins to rise within 2 to 12 hours following the onset of muscle injury and reaches its maximum within 24 to 72 hours decline is usually seen within three to five days of cessation of muscle injury

20. CK has a serum half-life of about 1.5 days and declines at a relatively constant rate of about 40 to 50 percent of the previous day’s value patients whose CK does not decline as expected, continued muscle injury or the development of a compartment syndrome may be present

21. Diagnosis Urinalysis may reveal protein and be positive for hemoglobin without evidence of red blood cells on microscopic examination Urine myoglobin test is positive

22. Urine Myoglobin visible changes in the urine only occur once urine levels exceed from about 100 to 300 mg/dL can be detected by the urine dipstick at concentrations of only 0.5 to 1 mg/dL half-life of only two to three hours, much shorter than that of CK. rapidly excreted and metabolized to bilirubin, serum levels may return to normal within six to eight hours

23.  Lab Values  elevated muscle enzymes (CK)  hyperkalemia  hyperphosphatemia  hypocalcemia

24. Complications Kidney damage Acute renal failure Hyperkalemia Cardiac arrest Disseminated Intravascular Coagulation Compartment syndrome

25.  Treatment  volume replacement  treat electrolyte abnormalities  protect renal perfusion  alkalinization of urine  fasciotomy

26. early and aggressive fluids (hydration) may prevent complications by rapidly remove myoglobin out of the kidneys. administer isotonic crystalloid fluids (Normal Saline or Lactated Ringer’s) give as much fluid as you would give a severely burned patient.

27. studies of patients with severe crush injuries resulting in Rhabdomyolysis suggest that the prognosis is better when prehospital personnel provide FLUID RESUCITATION!

28. medicines that may be prescribed include diuretics and sodium bicarbonate. hyperkalemia should be treated if present kidney failure should be treated as appropriate

29. if urinary flow is >20 mL/hour add mannitol to the intravenous alkaline solution providing an increase in urine output is demonstrated following a test dose suggested test dose is 60 mL of a 20 percent solution of mannitol administered intravenously over three to five minutes

30. if urine output increases by at least 30 to 50 mL/h above baseline levels in response to the test dose, 50 mL of 20 percent mannitol (1 to 2 g/kg per day [total, 120 g], may be given at a rate of 5 g/hour. mannitol is contraindicated in patients with oliguria

31. The outcome varies depending on the extent of kidney damage. Source: Silberber, 2007

33. Renal Failure Index (RFI) RFI = UNa x SCr/UCr Intrepretation RFI < 1 (prerenal failure) RFI > 1 (intrarenal failure)

34. Fraction Excreted Sodium (FENa) FE Na = U na X P Cr / P na X U cr x 100 Intrepretation FENa < 1 (prerenal failure) FENa > 1 (intrarenal failure)

35. Renal Failure Index (RFI) RFI = UNa x SCr/UCr Example  RFI > 1  UNa>40 mEq/L  FENa > 2-3%  UCr/SCr<20

36. Renal Biomarkers Urine interleukin – 18 (IL – 18) Urine or blood NGAL neutrophil gelatinase – associated lipocalin Increase 24 to 48 hours earlier than creatinine

37. Intrinsic Diagnostics BUN/Creatinine ratio RFI/FENa urinalysis

38. Treatment underlying cause prevention on injury high risk patient hydration limit exposure

39. Management Principles maintain fluid balance manage hyperkalemia glucose & insulin sodium bicarbonate calcium gluconate albuterol

40. Clinical Manifestations hyperkalemia hypocalcemia hypermagnesemia hyperphosphatemia acid – base imbalance

41. hypocalcemia occurs in up to two- thirds of patients with significant rhabdomyolysis increase in serum phosphate deposition of calcium phosphate into injured muscle decreased bone responsiveness to parathyroid hormone

42. Management Principles control hypertension in presence of encephalopathy bicarbonate for severe acidosis (pH < 7.2) manage anemia

43. Renal Replacement Therapies

44. Treatment Replacement Therapies acidosis HCO 3 < 10 mEq/L K + > 6.5 mEq/L need high protein diet deteriorating

45. Treatment: Types hemodialysis continuous renal replacement therapy

46. Treatment fluid balance anticoagulation prevent clotting prevent blood loss ultrafiltration

47. Case Study  20 – year old male with friends “doing drugs – cocaine”  police break up party – male runs from police but collaspes – states legs became so weak that he fell  admitted to ED – lower extremity weakness and severe pain in legs

48. Case Study Serum ElectrolytesABGs Na 141 K 6.7 Cl 104 CO 2 7 Creatinine 4.5 BUN 20 Ca 5.0 Mg 2.0 PO 4 11.2 pH 7.11 PaCO 2 27 PaO 2 97 SaO 2 98% HCO 3 7

49. Case Study Serum EnzymesHematology ValuesClotting Profile CK 4,780 LDH 812 Hct 30 WBC 18,400 PT 28 PTT >180 Platelets 80,000

50. Case Study UrinalysisSedimentUrine Chemistries Color Reddish brown SG 1.008 pH 5.0 RBC 0-1 WBC 4-5 Casts granular & epithelial Urine Na 42 Urine Osm 280

51. wide variety of situations that cause rhabdomyolysis focus is fluid resuscitation and surgical intervention if compartment syndrome develops ARF is a common consequence – treat as you would any type of intrinsic ARF