Scribd Logo
Upload

Welcome to Scribd!

  • 26 views

    Rhabdomyolysis Without

    Uploaded by

    api-716714980

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Rhabdomyolysis Without

    Uploaded by

    api-716714980
    26 views13 pages

    Original Title

    rhabdomyolysis without

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    26 views13 pages

    Rhabdomyolysis Without

    Uploaded by

    api-716714980

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 13

    LET’S BREAK IT DOWN:

    RHABDOMYOLYSIS
    Vivian Phyo (PGY2 IM Pharmacy Resident)
    LEARNING OBJECTIVES

    IDENTIFY THE CAUSES AND DESCRIBE THE EVALUATE THE DIAGNOSIS DEVELOP TREATMENT
    POTENTIAL RISK FACTORS PATHOPHYSIOLOGY OF AND CRITERIA OF PLANS FOR A PATIENT CASE
    OF RHABDOMYOLYSIS COMPLICATIONS RHABDOMYOLYSIS
    ASSOCIATED WITH
    RHABDOMYOLYSIS
    RHABDOMYOLYSIS
    Definition: A state of severe muscle injury or breakdown of muscle tissue
    CAUSES/RISK FACTORS

     Most common: trauma, immobilization, sepsis, and cardiovascular surgeries


     Non-traumatic causes:
    • Statin, fibrates, daptomycin, colchicine, zidovudine, anticholinergics, illicit drugs
    Medication • Baclofen-withdrawal

    • Hyperosmolar hyperglycemic state, diabetic ketoacidosis


    Endocrine • Myxedema coma

    • Disorders of glycogenolysis, glycolysis, etc. – any disorders in ATP-muscle


    Myopathy production

    • Polymyositis, dermatomyositis
    Autoimmune
    • Malignant hyperthermia, neuroleptic malignant syndrome, frostbite
    Body temperature
    COMPLICATIONS

    Disseminated
    Electrolyte Acute Kidney
    Intravascular
    Imbalance Injury
    Coagulation (DIC)
    1. ELECTROLYTE IMBALANCE

    With muscle injury/cell destruction, the content inside muscle cell leaks out into the
    blood stream.
    What electrolyte changes would you expect?

    Hyper or Hypo?
    Potassium HYPERkalemia
    Phosphate HYPERphosphatemia
    BUN/Uric acid HYPERuricemia
    Calcium HYPOcalcemia → HYPERcalcemia
    2. ACUTE KIDNEY INJURY (AKI)

    Multifactorial causes:
    1) RAS activation, ↑vasoconstrictor, ↓vasodilator
     Renal vasoconstriction (reduced blood flow to kidneys)
    2) Proximal convoluted tubule (PCT): in acidic pH,
    recycling of ferrihemate of myoglobin produces
    oxygen-free radicals
     PCT cell injury
    3) Distal convoluted tubule (DCT): excessive myoglobin
    downstream promotes formation of cast
     Obstruction of DCT
    3. DISSEMINATED INTRAVASCULAR
    COAGULATION (DIC)
    Thought to be due to thromboplastin released during muscle/vasculature injury
    DIAGNOSIS

     Creatinine Phosphokinase (CPK): 3-5x the ULN (> 1000 IU/L)


     Higher CPK = higher likelihood of AKI

     Urine Analysis (UA): Positive for heme with < 5 RBCs


     Proteinuria may be present
     Myoglobin casts may be present
    TREATMENT

    Hydration!!! (usually 200-300 ml/hr but up to 10-20 L intake with adequate diuresis)
     Sodium bicarbonate
     MOA: Urine alkalinization to reduce PCT cell injury,
    prevent obstruction in DCT, and neutralize hyperuricemia
     Monitor: symptomatic hypocalcemia
     Goal: maintain serum pH < 7.5
     Mannitol (used in crush injury)
     MOA: hyperosmotic agent to reduce intracerebral hemorrhage
    and promote urine output
     Avoid in: AKI, oliguria, anuria → volume overload + hyperosmolality
     Potassium-containing fluids (e.g., LR) = AVOID!
    Loops - consider if volume overload
    Sodium bicarbonate 150 mEq in D5W at 100 ml/hr
    PATIENT CASE

    EO is a 84 years old male with PMH of HFrEF


    (15%, s/p ICD), CAD s/p CABG, CKD II, DM2,
    and HTN, who presented with progressive hip
    and leg pain for 3 days.
    Of note, son reports that patient recently
    restarted many medications after PCP visit
    last month as patient had been previously
    non-compliant. One of the medications
    restarted include rosuvastatin 40mg.

    Patient was started on:


    Sodium bicarbonate 150 mEq in D5W at 100 ml/hr
    SUPPORTIVE CARE

    Hyperkalemia Hyperuricemia
     Allopurinol (consider if uric acid > 8 mg/dL)
     C – calcium gluconate
     B – beta-agonist or sodium bicarbonate Dialysis – may consider in:
     Anuric AKI
     I, G – insulin, glucose  Refractory hyperkalemia
     K – kayexalate or lokelma  Volume overload
     Severe acidosis/uremia
     D – diuretics
     HD preferred over PD
    Symptomatic hypocalcemia
    (seizures, arrhythmia)  CRRT, not HD, may have a role in the
     Calcium gluconate removal myoglobin
    QUESTIONS?
    Vivian Phyo (PGY2 IM Pharmacy Resident)

    You might also like