Rhabdomyolysis: Challenges in the ICU

1. Rhabdomyolysis:Challenges in the ICU Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN

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

11. Rhabdomyolysis • 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.

12. Rhabdomyolysis

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

14. Rhabdomyolysis • Causes • trauma • burns • compression syndrome • infection • seizures • heat intolerance • heat stroke

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

16. Rhabdomyolysis • Clinical Manifestations • muscle tenderness • myalgias • muscle swelling & weakness • DIC • color of urine

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

18. Rhabdomyolysis • 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. Rhabdomyolysis • 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. Rhabdomyolysis • 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. Rhabdomyolysis • 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. Rhabdomyolysis • 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. Rhabdomyolysis • Lab Values • elevated muscle enzymes (CK) • hyperkalemia • hyperphosphatemia • hypocalcemia

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

25. Rhabdomyolysis • Treatment • volume replacement • treat electrolyte abnormalities • protect renal perfusion • alkalinization of urine • fasciotomy

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

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

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

32. Acute Renal Injury

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

34. Rhabdomyolysis • Fraction Excreted Sodium (FENa) • FENa = Una X PCr / Pna X Ucr x 100 • Intrepretation • FENa < 1 (prerenal failure) • FENa > 1 (intrarenal failure)

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

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

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

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

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

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

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

43. Renal Replacement Therapies

44. Rhabdomyolysis Treatment • Replacement Therapies • acidosis • HCO3 < 10 mEq/L • K+ > 6.5 mEq/L • need high protein diet • deteriorating

45. Rhabdomyolysis Treatment: • Types • hemodialysis • continuous renal replacement therapy

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

47. Rhabdomyolysis 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. Rhabdomyolysis Case Study

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50. Rhabdomyolysis Case Study