Rhabdomyolysis
An MHAUS Online Brochure
Last Updated: 4/1/2006

Evaluation of Rhabdomyolysis
in the Perioperative Period, ICU and ED

Henry Rosenberg, MD, CPE
Director, Department of Medical Education
Saint Barnabas Medical Center
Livingston, New Jersey

(this brochure is available only online)
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 After suspecting rhabdomyolysis on the basis of brown or cola colored urine, perform the following tests:

Urine Dipstick: If positive for blood but no RBCs seen on microscopic examination, myoglobinuria is very likely (sensitivity >80%).

CK: If the CK is >~7,000 IU/L, then myoglobinuria is likely.

Send specimen for myoglobin levels in blood and urine.

If any of the above tests are positive, check electrolytes, BUN, Creatinine, and CK every 12 hours.

 Preanesthesia evaluation of the patient with history of or currently experiencing myoglobinuria/rhabdomyolysis:

History:

  • Previous episodes of rhabdomyolysis?
  • History of use of the following drugs: statins, neuroleptics, drugs of abuse e.g. MDMA, cocaine, amphetamines, ephedrine?
  • Recent history: of vigorous exercise, heat exposure?
  • History of sepsis, influenza? Seizures, major trauma?
  • History of myopathic disorders such as glycogen storage disease, CPT-2 deficiency, Central Core Disease?
  • Is there a previous history of rhabdomyolysis?

Physical Exam: Muscle rigidity, muscle weakness, muscle tenderness, body temperature, systemic signs of sepsis?

Laboratory testing:  Bun/Creatinine, electrolytes, CK, glucose, myoglobin levels.

 Myoglobinuria/rhabdomyolysis during or immediately after anesthesia (PACU) to 24 hours:

Make sure that colored urine is not hemoglobin.

What drugs were used during anesthesia?

Specifically ask about succinylcholine, volatile anesthetic agents, preop statins, cocaine, amphetamines, Ecstasy use.

Did the patient experience masseter muscle rigidity?  Was there evidence of other forms of rigidity?

Was the patient septic prior to or during surgery?

If the patient is a male less than ~6 years old, consider Duchenne Muscular Dystrophy.  Check for history of muscle weakness, inability to run and keep up.

Position during surgery: lithotomy (especially extreme), decubitus, prone >5 hours.  Was a tourniquet used?  For how long?

Physical Exam:  Body temperature; muscle rigidity, muscle pain, weakness.

Labs:  CK, BUN, Creatinine, electrolytes, ABG, coagulation studies, serum and urine myoglobin, others as appropriate for diagnosis, e.g. tox screen.

Disorders to consider:  MH, CPT-2 deficiency, glycogen storage disease, muscular dystrophy (males), isolated masseter muscle rigidity only, urosepsis.

 Rhabdomyolysis 24 hours post-anesthesia

History: 

  • Examine records for evidence of MH.
  • Was succinylcholine used?  History of statin, Ecstasy, cocaine use?
  • Examine anesthesia record for evidence of hypoxia, cardiac arrest.  Post op seizures, sepsis.
  • Has the patient been feeling ill or healthy?
  • What has been the urine output, color?

Physical Exam:  Body temperature; muscle rigidity, muscle pain, weakness, neurologic changes, state of consciousness.

Laboratory tests:  CK, Bun, Creatinine, electrolytes, WBC, blood culture, urine and serum myoglobin.

Disorders to consider:  Succinylcholine-induced rhabdomyolysis, MH, drug abuse, sepsis, ischemic encephalopathy, epilepsy.

 Rhabdomyolysis in ICU
 
History: 

  • Cardiac arrest, hypoxia?
  • Sepsis, trauma, hyperthermia, diabetic acidosis and hyperglycemia (adolescents)?
  • Asthma, status epilepticus?
  • Prolonged immobilization and then succinylcholine?
  • History of MH in family?
  • Previous history of myopathy?

Drug history: haloperidol, neuroleptics, alcoholism, propofol infusion.  Succinylcholine.  Other neuromuscular blocking agents.

Physical examination:  body temperature, muscle rigidity, muscle pain, weakness, neurologic changes, state of consciousness.

Laboratory tests: CK, BUN/Creatinine, ABG, WBC, blood culture, urine and serum myoglobin, coagulation studies, CRP.

Disorders to consider: NMS, cardiac arrest with ischemia, ICU myopathy, propofol infusion syndrome, iatrogenic hyperthermia, toxin exposure.

Diagnostic procedures to consider for myopathies:  EMG, biopsy, genetic testing.

 Treatment of Rhabdomyolysis

Treat underlying cause: e.g. stop seizures, treat sepsis.

Maintain urine output of about 200 ml/hr in adults with fluids and diuretics.

Add bicarbonate to IV fluids such that urine pH is greater than 6.5 but less than 7.4.

Follow electrolytes and calcium levels.

Consult a nephrologist.

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