Allison KliewerDecember 19, 2012

Case: Rhabdomyolysis

› Introduction

› Patient Profile

› Disease background

› Admission

› Nutrition Care Process

› Summary and Reflection

Outline

› Exertional rhabdomyolysis is a muscle injury the results in the lysis of skeletal muscle and the release of celllular components into the circulation

› In severe cases can lead to death› Rhabdomyolysis affects 1/10,000

people in the US per year

(Boutaud and Robert, 2010 and Stella and Shariff, 2012)

Introduction

› 28 year old African American Male

› Admission: 9/03/12 Discharge: 9/13/12

› Initial DX: heat exhaustion and cramps

› Admit through ER from soccer tournament

› PMH: heat exhaustion requiring IV fluids 2 at soccer tournament 2 years prior

› Family HX: insignificant

› Single, lives with roommate

Patient Profile

› Native to Florida where he currently lives

› Has been a Civil Servant for >4 years in the Air Force as a Systems Engineer

› Currently completing his undergraduate degree

› Position: Right back

› Been playing soccer for 23 years

Patient Profile

› Ht: 71 in - 6’ 11”

› Wt: 91.17 kg – 200 lbs

› No previous wt gain/loss

› No difficulty swallowing/chewing or BM

› Denies any substance abuse

› Previously healthy individual

Patient Profile

› Numbers 11: 31-35

› 1812 during Napoleon’s rein

› 1941 during WWII after the Blitz of London referred to as “crush syndrome”

(Elsayed and Reilly, 2010)

Rhabdomyolysis

› Breakdown of skeletal muscle resulting in the release of intracellular contents

› Leakage of contents can become severe and life threatening

(Khan, 2009)

Rhabdomyolysis

› Acute Renal Failure: abrupt decrease in renal function sufficient enough to result in retention of nitrogenous waste and disrupt fluid and electrolyte homeostasis

(Anderson, 2009)

Diagnosis

› Illicit drug use, alcohol abuse, muscle disease, trauma, seizures and immobility

› Sporadic strenuous exercise can cause exertional rhabdomyolysis

› Excess heat increases risk

› Hypokalemia

› Hyponatremia

(Bruso, 2010)

Etiology

› Myocyte is muscle cell

› Sarcomlemma is a thin membrane that encloses striated muscle fibers and electrochemical gradients

› Intercellular Na is maintained at 10 mEq/L by active transport

› Interior of cell is negatively charged and can pull Na to interior for Ca exchange

(Khan, 2009)

Physiology

› Low levels of intracellular Ca allows for increased actin-myosin muscle contraction

› Na/K-ATPase pump and Ca-ATPase pump

› Every electrochemical pump requires ATP

› ATP depletion = Pump dysfunction resulting in rhabdomyolysis

(Kahanov et al, 2012)

Physiology

› Destruction of myocytes› Dysfunction of the electrochemical pumps located in the sacrolemma membrane

› Altered ATP = Na in cytoplasm = intracellular Ca

› Proteases and phospholipases activate = destruction of myofibrillar cytoskeletal membrane proteins

(Bosch, 2009 and Khan 2009)

Pathogenesis

› Muscle cell breaks down, K, aldolase, phosphorus, myoglobin, creatine kinase, lactate dehydrogenase, urate, apsertate dehydrogenase are released into circulation

› >100 g of muscle breaks down - myoglobin releases into the circulation

› myoglobin leads to renal tubular obstruction, nephrotoxicity, and ARF

(Khan, 2009)

Pathogenesis

› Muscle damage can increase from 2-12 hrs after injury

› Peak values at 24-72 hrs

› Creatine Kinase (CK) 5 x normal value is accepted for dx

› Myoglobin might become visible in the urine

(Kahanov et al, 2012)

Symptoms

› Hypovolaemia: fluid into necrotic muscle

› Compartment syndrome: ischemia and swelling

› Hepatic dysfunction

› Lactic acidosis

› Acute Renal Failure ~ 33% of rhabdomyolysis

(Kahanov et al, 2012)

Complications

› Depends on underlying cause

› If treated early and aggressively, good prognosis

› 80% have recovered renal function

› 1,500 die of rhabdomyolysis per year

(Thoenes, 2010)

Prognosis

› Weightlifting, sprinting, contact practices, noncontact practices, running and swimming

› Good physical shape

› Outside and in air conditioned environments

Exertional Rhabdomyolysis

Article Sport/Event

Suspect Cause Diagnosis Outcome

Bruso, 2010 161 km ultra marathon

over hydration 5 cases of rhabdomyolysis3 with ARF

Full recovery

Casares and Marull, 2008

Heavy weight leg workout

Unconditioned muscle group

Exertional RhabdoCK 1,454,952

8 days after d/c CK < 1,000

Stella and Shariff, 2012

Recreational swimming

Unconditioned Ecertional rhabdoCK 112,400

Full recovery

Thoenes, 2010

Spin class Strenuous repetitive exercise

Exertional rhabdo myoglobinuria

Full recovery

Kuklo et al, 2000

Army Physical Fitness test

Strenuous exerciseDehydrationundernourished

MyoglobinuriaAcidosisAR insuffieciencyElevated CK

Multisystem failureexpired

Katerina et al, 2006

246-km continuous running race

Continuous muscle strain

39 possible rhabdomyolysis

Not reported on

Parmar et al, 2012

Spin class Sudden increase in training /s proper training

2 cases of rhabdomyolysis

Lab values within normal limits at F/U

Kahanov et al, 2012

Div I NCAA football

Eccentric exercise Rhabdomyolysis Increased CK for 18 days6 week recovery period

› Pt initial diagnosis was heat exhaustion with cramps, then later the primary diagnosis changed to Rhabdomyolysis with Acute Renal Failure

› Pt was hospitalized for 10 days

› Pt expressed a lack of understanding related to his condition

Application to Pt

› Pt was treated with aggressive hydration and electrolyte replacement

› Made a gradual recovery

› 3rd day- decreased muscle cramps, soreness

› 4th day- CK began to trend down

› 7th day- ARF was resolved

› 10th day- CK 1106

Treatment

2817

2050020500

13993

12135

7188

45253508 2352

1643 1106

CK

CK

Normal reference range 20-230 UI/L

› BMI: 26

› 76-100% intake

› No complaints

› Nutritional parameters within normal limits as evidence by BMI, labs, and % intake

Intervention

Calories: 2,560 - 2,985 (30-35 kcal/kg)

Protein: 102 – 136g (1.2-1.6 g/kg)

CHO: 385 – 682g (4.5 – 8 g/kg)

ESTIMATED DAILY NEEDS

Calories: 1,210

Protein: 77g

CHO: 76g

Sodium: 2,988

(Maughan, 2002)

ESTIMATED DAILY INTAKE

Application to Pt

9/01/12•79-98˚F•66% average humidity•10 mph average wind speed

9/02/12•77-99˚F•60% average humidity•11 mph average wind speed

9/03/12•76-99˚F•60% average humidity•10 mph average wind speed

Environmental Factors

› Water intoxication

› < 135 mEq/L of sodium in the blood

› Excessive water intake

› Osmotic imbalance

(Bruso et al, 2010)

Hyponatremia

› Facilitates rehydration

› Sustains the thirst drive

› Promotes retention of fluids

› More rapidly restores lost plasma volume during rehydration

(Bruso et al, 2010)

Importance of Sodium

› Exercise Associated Hyponatremia (EAH)

› Facilitates rhabdomyolysis through changes in intracellular K or Ca concentration resulting in hypotonic cell swelling

› Lysis from exertion and thermal strain = spacing of fluids = facilitates EAH

(Bruso et al, 2010)

Rhabdomyolysis and hyponatremia

› risk of opportunistic infections

› Damaged tissues caused by free radicals after exercise can lead to incomplete recovery

(Maughan, 2002)

Continued Intense Training

› Higher average energy deficit = higher body fat percentage

› rate of protein catabolism

› ↓ immune function

(Deutz et al, 2000 and Maughan, 2002)

Chronic Negative Energy Balance

› Oxidation of fat and CHO for energy

› Body stores of CHO are relatively low

› Glycogen stores deplete during strenuous exercise

› CHO not replenished = decrements in training response

(Maughan, 2002)

Energy Requirements

› Low-CHO diet = difficulty in sport performance compared to high-CHO diet

› Low-CHO diet risk of injury and susceptibility to minor infections

› High-CHO might be difficult to achieve due to daily practicalities of most athletes

(Maughan, 2002)

Energy Requirements

› Adequate dietary CHO before exercise and regular CHO ingestion during exercise to minimize stress hormones that have negative effect on immunity

› Maintaining adequate dietary CHO intake is a priority

(Maughan, 2002)

Goals

› Inadequate carbohydrate intake related to food and nutrition knowledge deficit and increased energy needs due to physical activity as evidence by estimated carbohydrate intake less than recommended amounts and verbalized report of incomplete knowledge

› Basic sport nutrition education was given

Intervention

› >23 years as a soccer player with no nutritional guidance?!

› Could this have been avoided with proper dietary habits and nutrition?

› Who is responsible?

Summary and Reflection

Anderson, R. & Barry, D. (2004). Clinical and laboratory diagnosis of acute renal failure. Best Practice & Research Clinical Anesthesiology. 18(1): 1-20.

Bosch, X., Poch, E., & Grau, J. (2009). Rhabdomyolysis and acute kidney injury. The New England Journal of Medicine. 361(1): 62-74.

Bruso, J., Hoffman, M., Rogers, I., Lee, L., Towle, G., & Hew-Butler, T. (2010). Rhabdomyolysis and hyponatremia: A cluster of five cases at the 161-km 2009 Western States Endurance Run. Wilderness & Environmental Medicine. 21: 303-308.

Capacchione, J., & Muldoon, S. (2009). The relationship between exertional heat illness, exertional rhabdomyolysis, and malignant hyperthermia. Anesthesia Research Society. 109(4): 1065-1069.

Casares, P. & Marull, J. (2008). Over a million creatine kinase due to a heavy work-out: A case report. Cases Journal. 1(173): 1-4.

Deutz, R., Benardot, D., Martin, D., & Cody, M. (2000). Relationship between energy deficits and body composition in elite female gymnast and runners. Medicine and Science in Sports and Exercise. 659-678.

Falvo, M. & Bloomer, R. (2006). Review of exercise-induced muscle injury: Relevance for athletic populations. Research in Sports Medicine. 14: 65-82.

Hannah-Shmouni, F., McLeod, K., & Sirrs, S. (2012). Recurrent exercise-induced rhabdomyolysis. Canadian Medical Associations Journal. 184(4): 426-430.

Huerta-Alardin, A., Varon, J., & Marik, P. (2005). Bench –to-bedisde review: Rhabdomyolysis- an overview for clinicians. Critical Care. 9: 158-169.

Kahanov, L., Eberman, l., Wasik, M., & Alvey, T. (2012). Exertional rhabdomyolysis in a collegiate American football player after preventive cold water immersion: A case report. Journal of Athletic Training. 47(2): 228-232.

Khan, F. (2009). Review: Rhabdomyolysis: A review of the literature. The Netherlands Journal of Medicine. 67(9).Kulko, T., Tis, J., Moores, L., & Schaefer, R. (2000). The American Journal of Sports Medicine. 28(1): 117.Maughan, R. (2002). Plenary lecture: The athlete’s diet: Nutritional goals and dietary strategies. The Nutritional Society.

61:87-96Parmar, S., Chauhan, B., DuBose, J., & Blake, L. (2012). Rhabdomyolysis after spin clas? The Journal of Family Practice.

61(10): 584-586.Skenderi, K., Kavouras, S., Anastasiou, C., Yiannakouris, N., & Matalas, A. (2006). Exertional rhabdomyolysis during a 246-

km continuous running race. Americn College of Sports Medicine. 1054-1056.Thoenes, M. (2010). Rhabdomyolysis: When exercising becomes a risk. Journal of Pediatric Health Care. 24: 189-193.

References