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
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