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Obesity Surgery, 17, 525-532
Rhabdomyolysis: Diagnosis and Treatment
in Bariatric Surgery
João E.M.T.M. Ettinger, MD1,2; Carlos A. Marcílio de Souza, MD, PhD1;
Paulo V. Santos-Filho2; Euler Azaro, MD, PhD2; Carlos A.B. Mello, MD2;
Edvaldo Fahel, MD, PhD2; Paulo B.P. Batista, MD, PhD3
1Postgraduate Course of Medicine and Human Health, Escola Bahiana de Medicina, 2BariatricSurgery Division, Department of Surgery, Hospital São Rafael (HSR) and Hospital Cidade,3Nephrology Division HSR, Salvador, Bahia, Brazil Background: Rhabdomyolysis (RML) and subsequent
Abbreviations:
acute renal failure can be serious problems following
bariatric operations. Early diagnosis and treatment
are important to avoid the complications of RML.
CPK = Creatine phosphokinaseAST= Aspartate aminotransferase Methods: This review was achieved by searching
the key words: Rhabdomyolysis, diagnosis, treatment
and bariatric surgery. We included prospective, retro-
spective, case reports and review articles.
Results: RML diagnosis can be done by: signs and
symptoms, physical evaluation, laboratory findings
and imaging examinations. Muscle weakness, myal-
gia, decubitus ulcer, proteinuria and myoglobinuria
CVVH = Continuous Venovenous Hemofiltration BIC/MAN = Bicarbonate and Mannitol are the more mentioned findings. Elevation of CPK
CPK MM = Creatine phosphokinase MM-isoenzyme (muscle type) levels is the most sensitive diagnostic evidence of
CPK MB = Creatine phosphokinase MB-isoenzyme (cardiac type) RML. Treatment is geared toward preserving renal
function by avoiding dehydration, hypovolemia, tubu-
lar obstruction, aciduria, and free radical release.
Early recognition allows the administration of fluids,
Introduction
bicarbonate, and mannitol.
Conclusion: Prophylactic measures and early diag-
nosis and treatment of rhabdomyolysis in bariatric
Rhabdomyolysis (RML) can be defined as a disorder surgery are imperative to prevent the potential fatal
that consists of striated muscle disintegration resulting complications of this condition.
in the release of muscle toxic cell constituents into theextracellular fluid and systemic circulation.1-7 Key words: Rhabdomyolysis, bariatric surgery, diagnosis,treatment, morbid obesity, acute renal failure, CPK Damaged skeletal muscle fibers break down and loseintegrity of the sarcolemmal membrane, releasingtheir contents and challenging the kidney’s filteringsystem. RML and subsequent acute renal failure Correspondence to: João Ettinger, Av. Princesa Leopoldina, 21, (ARF) can be serious complications resulting from apt. 1304, Graça, Salvador, Bahia, Brazil CEP: 40 150 080.
E-mail: [email protected] operative position compression of bariatric opera- Obesity Surgery, 17, 2007 525
tions. The incidence varies from 6 to 75%.2,8 Table 1. Clinical features of rhabdomyolysis
Postoperative RML occurs due to the prolongedmuscle compression in many non-physiological sur- Local features
Systemic features
gical positions, but mainly in procedures longer than 49 to 58,10 hours. In bariatric surgery, the excessive weight, the presence of diabetes, an ASA physical status >II,9 and prolonged surgical time lead to RML.10 Full recovery can be expected with early diagnosis and treatment of the many complications that can develop in patients with this syndrome.11 Materials and Methods
Rhabdomyolysis. Am Fam Physic 2002; 65: 907-12.11 PubMed, Medline, Bireme, Scielo and Lilacs libraries besides textbooks, specialized journals and Although history and physical examination can pro- the internet were searched between December 2005 vide clues, the actual diagnosis of RML is con- and January 2006. The work includes prospective, firmed by laboratory studies.5,10,15 Once RML is retrospective, case reports and review articles in suspected, the diagnosis can be confirmed by iden- Portuguese and English languages. A total of 52 tifying high levels of creatine phosphokinase (CPK). Serum CPK 5 times the normal value is con-sidered as a biochemical diagnosis of RML.2 Theelevation in CPK levels is the most sensitive diag- Published Results
nostic evidence of muscle injury8,11,14 and is presentin 100% of RML cases.10 When the RML syndrome is present, extreme quantities of CKMM are released into the blood system and peak concentra-tions of 100,000 IU/ml or more are not unusual. No Clinical Findings and Physical Evaluation other condition will cause such extreme CPK eleva- The initial expression of RML can be sudden, and tions.10 Small amounts of CKMB may also be pres- an early diagnosis requires a high degree of suspi- ent.16 Serum CPK peak values occur 4 to 7 days cion.10 The syndrome has local and systemic fea- after injury and remain elevated for up to 12 days.13 tures. Local signs and symptoms are non-specific In some cases, the CPK isoenzymes MM and MB and may include muscle pain, tenderness, swelling, are measured to distinguish a cardiac from a skele- bruising and weakness. Systemic features include tal source.7 An electrocardiogram must also be done tea-colored urine, fever, malaise, nausea, emesis, to differentiate RML from myocardial infarction.2 confusion, agitation, delirium and anuria11 (Table 1).
Urinary myoglobin provokes a typical reddish- During the physical examination, decubitus ulcer brown color. Myoglobin can be detected in urine and eruptions can be present in pressure zones, when these values exceed 1500 to 3000 ng/m.16 Kim mainly at the hips, limbs and buttocks.12,13 et al15 found in a prospective study that a urine myo- Usually, the first systemic clinical sign is the globin concentration >300 ng/ml was associated appearance of urine with altered color that can range with an increased risk of RML and ARF. Urinalysis from pink, to brown, and black.7,10,11 Myoglobinuria in patients with RML will also reveal the presence is suspected with the presence of altered urine color7 of protein, brown casts in tubules and uric acid crys- and requires differential diagnosis among several tals and may reflect electrolyte wasting consistent 526 Obesity Surgery, 17, 2007
Rhabdomyolysis: Diagnosis and Treatment In a retrospective analysis, Grover et al18 studied the lack of clinical utility of urine myoglobin detec- Radiographic evaluation can also be valuable for diag- tion by microconcentrator ultrafiltration in the diag- nosing RML when clinical findings and physical exam- nosis of RML. They concluded that this method has ination are not elucidating (Table 2). Magnetic a poor and clinically inadequate sensitivity in detec- Resonance Imaging (MRI) and Computed Tomography (CT) are helpful in the diagnosis of RML.22 When RML is present, there is generally an increase MRI accurately identifies muscular edema in the in blood urea nitrogen and creatinine due to prerenal affected muscle groups. In Lamminen’s et al23 causes of ARF from dehydration and myoglobin- prospective study, MRI had a higher sensitivity in uria.19 Both ARF and increased release of creatine the detection of abnormal muscles than CT or ultra- from skeletal muscle cause the serum concentration of sound (US) (100%, 62% and 42% respectively). CT urea nitrogen and creatinine to increase in RML. evaluation can reveal muscle necrosis and calcifica- A classical pattern of changes in serum elec- tion that occur early in the course of RML.24 CT for trolytes occurs in RML. At the outset, serum levels the diagnosis of RML must be non-contrast of potassium and phosphate increase as these com- ponents are released from the cells, then levels 111In-labeled antimyosin monoclonal antibody decrease as they are excreted in the urine. Serum and Technetium-99m pyrophosphate (99mTc-PYP) concentration of calcium initially decreases as calci- scintigraphy have also been used to make the diag- um moves into the damaged muscle cells, then grad- nosis of RML and evaluate muscle injury.13 ually increases during the recovery phase due to the Ultrasound has also been known to have some release of calcium from injured muscle and elevated value in identifying injured musculature in RML by 1,25-dihydroxyvitamin D levels.16 Severe hyper- revealing hyperechoic areas within the muscles uricemia may develop because of the release of examined.26 Plain muscle X-ray does not have value purines from damaged muscle cells.16,19 High anion in RML.27 A muscle biopsy in the affected site can acidosis can also occur with RML.19 Clotting stud- ies are useful for detecting any indication of dis-seminated intravascular coagulation.10 Serum aspartate aminotransferase (AST), alanine aminotranferease (ALT), aldolase, troponin I andlactate dehydrogenase (LDH) enzymes can increase The treatment of RML is geared toward preserving due to muscular injury.13,19 Serum carbonic anhy- renal function, which is done by preventing factors drase III has also been suggested as a marker for the that can lead to ARF, which are dehydration, hypov- olemia, tubular obstruction, aciduria, and free radical Arterial blood gas analysis is helpful for detecting release.28 Early recognition allows the administration underlying hypoxia and metabolic acidosis and of fluid, bicarbonate, and mannitol.5,8,10,29 These monitoring sodium bicarbonate therapy.10 Muckart measures help to prevent volume depletion, tubular et al20 concluded in a prospective study that venous obstruction, aciduria, and free radical release which is bicarbonate (VBC) concentration has an important the mechanism for renal failure in rhabdomyolysis.5,8 role as a predictive factor that allows identificationof patients at risk of developing myoglobin-inducedacute renal failure. A VBC <17 mmol/L was signif- Table 2. Image examinations to detect RML and the
icantly predictive of ARF development.20 findings
In a retrospective study, Al-Shekhlee et al21 investi- gated the electromyographic (EMG) features of acute Magnetic Resonance Imaging - Muscular edemaComputed tomography - Muscle necrosis and RML. They concluded that EMG is an important diagnostic tool in the work-up of patients presenting acute or sub-acute severe muscle weakness and sig- Technetium-99m pyrophosphate scintigraphy - nificantly elevated CPK when the differential diagno- Accumulation of the radioactivity in the damaged sis includes RML and inflammatory myopathies.
Obesity Surgery, 17, 2007 527
Hypovolemia may result from sequestration of production of uric acid and also acts as a free-radical water by muscles and must be prevented by the scavenger. Another purine analog pentoxyfilline has early and aggressive administration of intravenous been considered in the management of RML because fluids.1,11,30 Expanding the intravascular volume of its capacity to enhance capillary flow and maximizes renal excretion by flushing out the tubu- decrease neutrophil adhesion and cytokine release.1 lar debris and limiting the time that nephrotoxins are Electrolyte disorders should be prevented or in contact with renal tissues.10,30 Treatment of RML promptly treated.16 Control of hyperkalemia is an requires aggressive administration of fluids to important therapeutic goal. Calcium salts and calci- ensure urine output >1.5 ml/kg/h32 or 150-300 ml/h um kayexalate (sodium polystyrene sulfanate and until myoglobinuria has ceased.5,10,11,33 Maintaining exchange resin) should be used with caution because a urine output this high may require intravenous they enhance the risk of intramuscular calcium dep- infusion of fluids between 500 and 1000 ml/h,33 and osition.1 Hypocalcemia usually does not require cor- all patients should have a urinary catheter placed in rection, particularly because this would increase the order to adequately monitor fluid output.1,34 Sinert risk of intramuscular calcium deposition.1 et al35 showed in a retrospective chart analysis that Dialysis is necessary if the kidneys no longer forced diuresis within the first 6 hours of admission respond to the above-mentioned supportive measures and severe renal dysfunction has set in.2,32 Dialysis is Diuretics are also used, mainly mannitol and loop indicated not only in patients with overt hyper- diuretics. The addition of mannitol to the fluid regi- kalemia but also in patients whose serum potassium men serves several purposes: mannitol increases renal blood flow and glomerular filtration rate; man- Compartment syndrome may be an early or late nitol is an osmotic agent that attracts fluids from the complication that results mainly from direct muscle interstitial compartment, thus counterbalancing injury.10,11,16,40 This complication occurs primarily hypovolemia and reducing muscular swelling and in muscles whose expansion is limited by tight fas- nerve compression. Mannitol is an osmotic diuretic cia. Peripheral pulses may still be palpable, and in that increases urinary flow and prevents obstructive these cases, nerve deficits (mainly sensory) are the myoglobin casts, and mannitol scavenges free radi- more important finding. Compartment syndrome cals.1 Many authors assert that loop diuretics may develop or worsen during fluid resuscitation (furosemide, bumetanide, and torsemide) must be due to the development of edema of limbs and/or used if fluids and mannitol are insufficient to main- muscles. Decompressive fasciotomy, muscular tain a brisk urine output.5,33 They increase tubular debridement and escharotomies should also be con- flow and calcium losses and decrease the risk of pre- sidered in patients with evidence of neurovascular cipitation of myoglobin,1 although they may acidify compression and decubitus ulcer if the compartment the urine.1,36 However, there is no evidence that The use of sodium bicarbonate helps to correct the acidosis induced by the release of protons from dam- Discussion
aged muscles to prevent precipitation of myoglobinin the tubules and reduce the risk of hyperkalemia.1Bicarbonate and acetazolamide are used for produc- The early diagnosis of RML is especially important ing more alkaline urine when blood pH is >7.45.32 so that adequate treatment can be initiated and com- Some investigators assert that the urine must be alka- plications avoided. Features of RML can easily be linized to pH 6.0,37 6.5,38 7.0,5 or even 7.539 to pre- unrecognized in critically ill patients. Physical vent the dissociation of myoglobin into its nephro- examination in obese patients is difficult and may be toxic components. On the other hand, there are also non-contributory due to the amount of fat tissue in some concerns about the use of sodium bicarbonate areas submitted to greater pressure. Furthermore, the because it may worsen hypocalcemia or precipitate diagnosis could be delayed in obese patients due to calcium phosphate deposition in various tissues.11 postoperative analgesia, late extubation and pre- Allopurinol may be useful because it reduces the existing symptoms, which morbidly obese patients 528 Obesity Surgery, 17, 2007
Rhabdomyolysis: Diagnosis and Treatment often have in addition to myoskeletal discomfort in ing treatment or prevention have been published.
the lumbar region and gluteal musles.32,42 Laboratory The only effective treatment is the intravascular vol- and imaging tests must be done to confirm RML.
Elevation of CPK levels is present in 100% of RML Myoglobin may have direct toxic effects on the cases. CPK measurement must be done not only in tubular epithelium and this toxicity is increased the postoperative phase but also in the preoperative when nephronal flow-rates are low and urine is con- period to compare enzyme levels. The CPK level to centrated. In addition, urine pH may play a role with diagnose RML varies from each author. Some of increased toxicity when the urine is acidic. Thus, in them use CPK >1000 UI/l2. Others prefer CPK levels the early phases of RML, renal injury can be pre- >5000 UI/l13 and even >10000 UI/l7. The first one vented or diminished by maintaining adequate vol- (>1000 UI/l) is safer for making prompt diagnosis ume-repletion or even hypervolemic state with a and avoiding RML complications. Faintuch et al43 stratified the patients according to muscle pain and The use of mannitol remains controversial, and is peak serum CPK value in minor RML (inconspicu- mostly supported by experimental animal studies and ous pain and CPK <8000 UI/L) and extensive RML retrospective clinical studies.11,47 The risk of using man- (severe shoulder back or buttock pain, swelling and nitol is the occurrence of volume overload if renal fail- ure develops, in spite of the above-mentioned treatment.
Since degradation of CPKMM is slow and the Bicarbonate administration to elevate urine alkalinity enzyme is not removed by the kidneys or dialysis, the and help solubility of myoglobin casts is often recom- plasma concentration of CPK remains elevated for mended, although the benefits from this treatment have much longer and in a more consistent fashion than not been conclusively demonstrated.16 The only draw- that of myoglobin. Consequently, CPK is more reli- back of bicarbonate administration is the decrease of able than myoglobin in assessing the presence and serum ionized calcium1 and its deposition in soft tisues.
intensity of damage to the muscles.1 Serum levels of If bicarbonate is used, calcium levels should be careful- myoglobin also increase markedly in RML, but this ly monitored because hypocalcemia may be aggravated increase is not a reliable indicator of RML because by this therapy.16 Homsi et al48 showed in a retrospective myoglobin is rapidly cleared from the plasma.10 study that progression to establish ARF following RML In their reviews, Wiltshire et al13 and Lane et al44 could be totally avoided with prophylactic treatment in stated that the laboratory values >300 ng/ml and which volume repletion was achieved, using saline >250 ng/ml were compatible with myoglobinuria, alone, and the use of bicarbonate and mannitol was unnecessary. In another retrospective study, Brown et Li et al45 established a poor correlation between al49 state that bicarbonate and mannitol therapies do not CPK peak and cardiac troponin I peak levels in a prevent ARF and the need of dialysis or mortality in retrospective study. They found a prevalence of 17% of false positive troponin I levels in Emergency Treatment of compartment syndrome by means of fasciotomy is controversial. Some physicians advise When a CT scan is utilized, the iodinated radio- immediate decompression of the muscles by surgi- contrast should not be used due to renal toxicity, and cal intervention, thereby decreasing the pressure in it is limited to patients weighing <140 kg in our the injury region. However, this creates a potential institution. MRI is an excellent method for diagno- sis of RML, but is it not regularly utilized due to its Some authors have suggested that immediate hemodialysis may be useful for patients with RML Aggressive treatment must be done after diagno- and serum CPK >10,000 U/L before the develop- sis of RML to avoid complications. The first step is ment of customary biochemical and clinical indica- to preserve the affected zones and avoid RML in new areas of pressure, encouraging early ambula- The last measure is the maintenance of therapy and tion and the use of special mattresses or pneumatic the monitoring of clinical and laboratory data. The beds.46 Early and adequate treatment of RML is CPK level should be determined every 6 to12 hours, imperative. However, no randomized trials concern- and all patients with RML require continuous elec- Obesity Surgery, 17, 2007 529
trocardiographic monitoring for signs of hyper- Conclusion
kalemia or cardiac irritability. This also includessequential monitoring of urine output to guide fur- Early diagnosis and treatment of rhabdomyolysis in ther fluid resuscitation. Patients should be monitoredclosely to avoid the development of oliguric renal bariatric surgery is imperative to prevent the potential failure and to prevent fluid overload that can lead to fatal complications of this condition. The bariatric the development of pulmonary edema and conges- surgeon must be attentive and must know all clinical, tive heart failure. Patients with RML may benefit biochemical and image examinations that indicate from invasive arterial and pulmonary artery pressure postoperative RML and should also establish early monitoring, which enables cognizance of the circu- treatment for this syndrome. The treatment still has latory volume status. Other interventions include many controversies that will only be solved with limiting the use of nephrotoxic antibiotics (e.g.
aminoglycosides and amphotericin), non-steroidal prospective, controlled and multi-centered trials.
anti-inflammatory drugs and iodinated radiocontrastto minimize further kidney damage10 (Figure 1).
Risk factors for ARF from RML
Prevention of RML in bariatric Surgery
Aggressive fluid replacement peri-operativelyEarly ambulation Intraoperative prevention
Bariatric Surgery
Hydration >13 ml/kg/hMaintain diuresis >2.3 ml/kg/hOperative time <2 hr FIRST POST-OP DAY
Discolored UrineMyoglobinuriaUrinary outputDecubitus Ulcer CPK >1000 iU/L
+ Myoglobinuria >250 ng/ml
Urine output >1.5 ml/kg/hr
Figure 1. Algorithm for diagnosis and treatment of rhabdomyolysis in bariatric surgery.
530 Obesity Surgery, 17, 2007
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Prevention of rhabdomyolysis in bariatric surgery.
(Received November 12, 2006; accepted December 18, 2006) 532 Obesity Surgery, 17, 2007

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