Rhabdomyolysis

Author(s): Donna Purviance, DNP, FNP-BC

Rapid response

Quick symptom recognition is key.

Takeaways:

  • Rhabdomyolysis is a complex medical condition caused by direct trauma, physical exertion, illness, infection, sepsis, congenital or metabolic abnormalities, prolonged seizures, or drugs.
  • It manifests from rapid destruction of skeletal muscle with direct release of intracellular muscle products such as myoglobin, creatine kinase, and electrolytes leads to acute kidney injury.
  • Rhabdomyolysis is characterized by limb weakness, myalgia, swelling, and red or brown urine.

Michael*, a 12-year-old boy, is admitted to a pediatric unit for a fulminating sinus infection. His history includes treatment for six sinus infections over the past year. A computed tomography scan of the sinuses reveals complete obstruction with pyrogenic infiltration of the maxillary, frontal, and ethmoid sinuses bilaterally.

History and assessment hints

Michael’s vital signs are BP 100/50 mmHg, HR 120 bpm, RR 24 breaths per minute, temperature 37° C (98.6° F), and weight 50 kg. He’s drowsy but oriented and scared. You note erythema over both cheeks and dried brown purulent exudate on his front teeth. His right tympanic membrane is red and bulging.

Michael was taken to surgery for endoscopic sinus surgery. During surgery, his temperature rises to 39° C (102° F). Cooling blankets are applied and I.V. acetaminophen is administered.

About 14 hours after surgery, Michael’s mother calls you to his son’s room and says that he woke up to go to the bathroom (and reported that his urine was brown) but now she can’t wake him. Your assessment reveals BP 90/48 mmHg, HR 128 bpm, RR 40 breaths per minute, and temperature 40.6° C (105° F). Michael is moaning and shaking, and his jaw muscles are clenched. Recognizing a potential response to the infection, you call the rapid response team (RRT).

On the scene

The RRT arrives and obtains a 12-lead ECG and starts infusing normal saline 0.9% at 30 mL/kg. Blood is obtained for laboratory analysis, and a urinary catheter is inserted to measure hourly urine volume. Michael is transferred to the ICU for more intensive monitoring. The following lab results are high: WBC 20,000 mm3, BUN 37 mg/dL, serum creatinine 4.7 mg/dL, ALT 75 IU/L, AST 82 IU/L, creatinine kinase 3,000 IU/L, and lactate level 3 mmol/L; the ABG results show metabolic acidosis.

Outcomes

Michael’s recovery goes smoothly, and he’s discharged home after receiving fluid resuscitation. His mother, who is nurse, is concerned about malignant hyperthermia (MH) as a possible cause of his symptoms and requests he be tested for an inherited genetic mutation of the ryanodine receptor 1 gene, which is associated with MH. He is found to not be a carrier of the gene mutation.

Education

Rhabdomyolysis is a complex medical condition caused by direct trauma, physical exertion, illness, infection, sepsis, congenital or metabolic abnormalities, prolonged seizures, or drugs. Rapid destruction of skeletal muscle with direct release of intracellular muscle products leads to acute kidney injury (AKI). Rhabdomyolysis is characterized by limb weakness, myalgia, swelling, and red or brown urine. Michael had a known severe fulminating infection prior to surgical intervention and was dehydrated. The surgery lasted an extended period of time due to the complexity. All factors contributed to his complication.

Promptly recognizing rhabdomyolysis and addressing the release of muscle necrosis byproducts decreases the risk of AKI. Early I.V. fluid resuscitation is key to increasing renal perfusion and preventing renal ischemic damage caused by filtration of large-cell muscle by-products. No specific rhabdomyolysis management guideline exists, but accepted treatment includes infusing 10 to 20 mL/kg I.V. fluid boluses and monitoring serum levels and renal function. Continuous I.V. fluid in- fusion of 30 mL/kg is recommended to correct metabolic acidosis and provide renal support, and to provide a route for administering I.V. antibiotics.

If MH is suspect, intervention, including the administration of dantrolene, should occur in the operating room. More information about MH management can be found on the Malignant Hyperthermia Association web site.

*Name is fictitious.

Donna Purviance is an assistant professor of advanced practice nursing at Indiana State University in Terre Haute and serves as an advanced practice provider to the Indiana University School of Medicine Integrated Pain Management ECHO Center.

References

Alaygut D, Bayram MT, Kasap B, Soylu A, Türkmen M, Kavukcu S. Rhabdomyolysis with different etiologies in childhood. World J Clin Pediatr. 2017;6(4):161-8.

Lehman KD. Evidence-based updates to the 2016 surviving sepsis guidelines and clinical implications. Nurse Pract. 2019;44(2):26-33.

Mathias B, Mira JC, Larson SD. Pediatric sepsis. Curr Opin Pediatr. 2016;28(3):380-7.

Park Y, Song J, Kim SY, Kim S. Clinical characteristics of rhabdomyolysis in children: Single center experience. Child Kidney Dis. 2018;22(2):52-7.

Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017;45(3):486-552.

Rosenberg H, Pollock N, Schiemann A, Bulger T, Stowell K. Malignant hyperthermia: A review. Orphanet J Rare Dis. 2015;10(93):1-19.

Selewski DT, Symons JM. Acute kidney injury. Pediatr Rev. 2014;35(1):30-41.

Rhabdomyolysis education

Michael and his family should receive education about avoiding fluid imbalances that may occur with activity (for example, Michael should fluid load with electrolyte solutions prior to exercise and avoid wearing rubber sweat suits during exercise). He also should avoid non­steroidal anti-inflammatory drugs and take precautions against infection, including handwashing. All patients who develop rhabdo­­myo­lysis secondary to malignant hyperthermia and metabolic abnormalities should undergo genetic testing and muscle biopsy for definitive diagnosis. Those diagnosed with malignant hyperthermia should not be given the muscle relaxant succinylcholine or halogenated volatile anesthetic agents (for example, sevoflurane) during anesthesia.

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