2. 1. Which of the following statements is correct. A
1. Which of the following statements is correct? A. Rhabdomyolysis is caused by the breakdown of hemoglobin B. The diagnosis is confirmed by measuring urinary myoglobin levels C. Dark discolouration of the urine results from hypovolumia D. Status epilepticus is a cause of rhabdomyolysis

3. 2. Which of the following condition is NOT a recognized cause of rhabdomyolysis?
Paracetamol toxicity
Tetanus
Neuroleptic malignant syndrome
Dermatomyositis

4. 3. Regarding the management of rhabdomyolysis, which statements is/are correct?
After crush injury, treatment should be started in hospital when the patient is fully monitored
Normal saline 0.9% is an acceptable crystalloid to use
There is no requirement for arterial blood gas analysis in an asymptomatic patient
A urine output of 1ml/kg/hr is adequate

5. 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 London, England, bombing raids of World War II” (Craig, 2006).

6. Rhabdomyolysis Occurs in up to 85% of patients with trauma
Rhabdomyolysis accounts for an estimated 8-15% of cases of acute renal failure.
the overall mortality rate for patients with Rhabdomyolysis is approximately 5%, higher if MODS
Rhabdomyolysis is more common in males than in females
may occur in infants, toddlers, and adolescents

7. 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

8. 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

9. 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

10. 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

11. 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

12. Rhabdomyolysis
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. Rhabdomyolysis

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

15. Rhabdomyolysis Traumatic Crush injury Entrapment
Prolonged immobilization
Electrical injury
Excessive muscle activity: marathon running, status epilepticus, MH
Heat related: heat stroke, neuroleptic malignant syndrome, rarely hypothermia

16. Rhabdomyolysis Non traumatic Ischemic insult
Substance misuse: alcohol, cocaine, amphetamine, ecstacy
Drugs: statins, fibrates, antipsychotics
Toxins: carbon monoxide, heavy metals, snake venom
Infection: tetanus, legionella, sepsis syndrome
Electrolyte disorders: hypoK+, hypo/hyper Na+, hypocalcemia, hypophosphatemia, HONK, DKA< hypo/hyperthyroidism
Autoimmune: dermatomyositis, polymyositis

17. Rhabdomyolysis
Ranges from asymptomatic rise in CK -> hypovolumic shock with life threatening arrythmia
Clinical Manifestations
muscle tenderness
myalgias
muscle swelling & weakness
DIC
color of urine

18. Rhabdomyolysis Diagnosis
Creatine Phosphokinase (CK) levels are very high – most sensitive indicator
Serum/urine myoglobin test is positive
Serum electrolytes imbalance: ↑ K+, urea, PO42- , Mg2+ ,↓ Ca2+
High anion gap metabolic acidosis due to lactic acidosis

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 Lab Values elevated muscle enzymes (CK) hyperkalemia
hyperphosphatemia
hypocalcemia

23. Rhabdomyolysis Complications
Early: severe hyperkalemia may lead to arrythmia and cardiac arrest, especially in association with profound hypovolumia, hypocalcemia and acidosis
Early to late: compartment syndrome, hepatic dysfunction
Late: AKI, DIVC, hypercalcemia during recovery period

24. Rhabdomyolysis Treatment volume replacement
treat electrolyte abnormalities
protect renal perfusion
alkalinization of urine
treat underlying cause (fasciotomy etc)

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

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

27. Use of bicarbonate and mannitol therapy is recognized however observational data suggest that they provide NO additional clinical benefit to volume expansion with crystalloid
Fluid should be titrated to achieve urine output of ml/hr
Administration of both 0.9% NaCl & isotonic sodium bicarbonate (1.26%) is acceptable to avoid a worsening hyperchloraemic metabolic acidosis

28. Rationale for bicarbonate and mannitol therapy
Aim for urinary pH > 6.5
This potentially prevents precipitation & degradation of myoglobin in the urinary tubules
Also helpful in management of hyperkalemia and acidosis
No effect on the development of AKI, need for dialysis or death

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. RRT Indication: Established AKI Refractory hyperkalemia and acidosis
Unususal for fluid overload to be an indication
The prognosis of renal failure secondary to rhabdomyolysis is good with renal function usually returning to normal within 3 months.

34. Summary Common in ICU setting
Patients may have few symptoms, so high level of suspicion should be maintained
Serum CK is the most sensitive indicator
Initiate fluid resuscitation immediately
Treat acute hyperkalemia
Monitor for complications including compartment syndrome
Serial CK measurement
Renal replacement therapy may be required

35. References
Oxford journals: Continuing education in Anesthesia, Critical Care & Pain (CEACCP)
Anaesthesia tutorial of the week 198 (TOTW)
ICU bedside handbook Tan Tock Seng Hospital

36. Marathon, CrossFit & rowing has been associated with rhabdomyolysis
Thank you
Marathon, CrossFit & rowing has been associated with rhabdomyolysis