Acute renal failure due to rhabdomyolysis associated with the extreme lithotomy position

Foot drop secondary to rhabdomyolysis: improved foot dorsiflexion and gait after neurolysis and distal nerve transfer-a case series and literature review

Rhabdomyolysis is a triad syndrome of myalgia, muscle weakness and myoglobinuria due to muscle necrosis. Trauma, exertions, strenuous exercise, infections, metabolic and electrolyte disorders, drug overdoses, toxins and genetic defects are the most common causes of rhabdomyolysis. The etiologies of foot drop are diverse. A few cases of rhabdomyolysis-associated foot drop are reported in the literature. We present five patients with foot drop secondary to rhabdomyolysis; two underwent neurolysis and distal nerve transfer (superficial peroneal nerve to the deep peroneal nerve) surgeries and follow-up evaluations. We found five-foot drop patients secondary to rhabdomyolysis among the 1022-foot drop patients who consulted our clinic since 2004, representing a 0.5% incidence. In two patients, rhabdomyolysis was caused by drug overdose and abuse. In the other three patients, the causes were an assault with a hip injury, a prolonged hospitalization due to multiple illnesses, and an unknown cause with compartment syndrome. Pre-operatively, a 35-year-old male patient had aspiration pneumonia, rhabdomyolysis and foot drop resulting from prolonged ICU hospitalization and a medically induced coma due to a drug overdose. The second patient (a 48-year-old male) had no history of trauma but had a sudden onset of right foot drop after compartment syndrome following the insidious onset of rhabdomyolysis. Both patients had difficulty dorsiflexing their involved foot and walked with a steppage gait before surgery. In addition, the 48-year-old patient had foot slapping while walking. However, both patients had strong plantar flexion (5/5). After 14 and 17 months of surgery, both patients had improved foot dorsiflexion to an MRC grade of 4/5 with an improved gait cycle and walked with no or minimal slapping, respectively. Distal motor nerve transfers in the lower limb facilitate faster recovery and less surgical dissection because of the shorter regeneration distance from the donor axons to the targeted motor end plates through residual neural network connections and descending motor signals.

[Rhabdomyolysis after radical nephrectomy in the lateral decubitus position: report of 2 cases]

Rhabdomyolysis is a rare perioperative complication, however, potentially lead to fatal outcome. We experienced 2 cases of rhabdomyolysis after radical nephrectomy and nephroureterectomy in the lateral decubitus position. (Case 1) A 40-years old man was seen in our hospital because of asymptomatic grosshematuria. Computed tomography revealed right renal pelvic cancer, cT3N0M0. Right radical nephroureterectomy, lymph node dissection, partial cystectomy was underwent, and the operation was finished without any trouble. At the post-operative day 1, serum creatinine level was elevated to the point of 4.2 mg/dl, and serum creatine kinase was 1,945 IU/l. Continuous hemodiafiltration (CHDF) was done at intensive-care unit (ICU), and serum creatinine and creatine kinase level were decreased. At the post-operative day 1, urine myoglobin level was prominently elevated (2,943.7 ng/ml), so we diagnosed acute renal failure due to rhabdomyolysis. (Case 2) A 40-years old man was incidentally pointed out of right renal tumor that was seen as renal cell carcinoma, cT1aN0M0. Open partial nephrectomy was underwent, and there was no trouble during the operation. After recovering from anesthesia, the patient felt left thigh pain strongly. Serum creatine kinase was 888 IU/L after the operation. At the postoperative day 1, serum creatine kinase level was markedly increased (31,138 IU/L). Serum creatinine level was 1.34 mg/dl. Urine and serum myoglobin level was prominently elevated (89,000 ng/ml and 8,634 ng/ml, respectively). We diagnosed it rhabdomyolysis, and he received large amount of fluid intravenously at intensive-care unit. Serum creatine kinase was peak out at the post-operative day 3 (20,709 IU/L), and hemodialysis was not performed.

Rhabdomyolysis and myogloginuric acute renal failure in the lithotomy/exaggerated lithotomy position of urogenital surgeries

OBJECTIVE

To evaluate rhabdomyolysis and it's management in lithotomy and the exaggerated lithotomy positions during urogenital surgeries.

DESIGN

Retrospective study

SETTING

Institute of Post Graduate Medical Education and Research (IPGME & R), Kolkata, India.

MATERIALS AND METHODS

Patients undergoing urogenital surgeries (lithotomy and the exaggerated lithotomy positions).

INTERVENTION(S)

All four cases of rhabdomyolysis which occurred after such positional urogenital surgeries were treated with conservative management for prolonged period with hemodialysis. One case which developed compartment syndrome underwent fasciotomy and also managed with conservative approach as other cases.

MAIN OUTCOME MEASURE

Rhabdomylysis is now a rare complication in any open or laparoscopic surgery. But prolonged lithotomy or exaggerated lithotomy position surgeries have been shown to expose patients to the risk of rhabdomylysis and acute renal failure.

RESULTS

In our institute patients undergoing urogenital surgeries in lithotomy and the exaggerated lithotomy positions only developed rhabdomyolysis and myogloginuric acute renal failure. All procedures were of prolonged duration (mean five hours and ten minutes). Three patients developed rhabdomyolysis and acute renal failure without compartmental syndrome and one with compartmental syndrome. Rhabdomyolysis with the appearance of acute renal failure is discussed.

CONCLUSION

Overall, our cases showed that rhabdomyolysis and acute renal failure can develop in such operative positions even in the absence of compartmental syndrome, and that duration of surgery is the most important risk factor for such complications. So we should be careful regarding duration of surgery in lithotomy procedure to prevent such morbid complications.

Rhabdomyolysis and acute renal failure following minimally invasive spine surgery

Minimally invasive spine surgery is increasingly used to treat various spinal pathologies with the goal of minimizing destruction of the surrounding tissues. Rhabdomyolysis (RM) is a rare but known complication of spine surgery, and acute renal failure (ARF) is in turn a potential complication of severe RM. The authors report the first known case series of RM and ARF following minimally invasive lateral spine surgery.

The authors retrospectively reviewed data in all consecutive patients who underwent a minimally invasive lateral transpsoas approach for interbody fusion with the subsequent development of RM and ARF at 2 institutions between 2006 and 2009. Demographic variables, patient home medications, preoperative laboratory values, and anesthetic used during the procedure were reviewed. All patient data were recorded including the operative procedure, patient positioning, postoperative hospital course, operative time, blood loss, creatine phosphokinase (CPK), creatinine, duration of hospital stay, and complications.

Five of 315 consecutive patients were identified with RM and ARF after undergoing minimally invasive lateral transpsoas spine surgery. There were 4 men and 1 woman with a mean age of 66 years (range 60–71 years). The mean body mass index was 31 kg/m2 and ranged from 25 to 40 kg/m2. Nineteen interbody levels had been fused, with a range of 3–6 levels per patient. The mean operative time was 420 minutes and ranged from 315 to 600 minutes. The CPK ranged from 5000 to 56,000 U/L, with a mean of 25,861 U/L. Two of the 5 patients required temporary hemodialysis, while 3 required only aggressive fluid resuscitation. The mean duration of the hospital stay was 12 days, with a range of 3–25 days

Rhabdomyolysis is a rare but known potential complication of spine surgery. The authors describe the first case series associated with the minimally invasive lateral approach. Surgeons must be aware of the possibility of postoperative RM and ARF, particularly in morbidly obese patients and in procedures associated with prolonged operative times.

Bilateral sciatic and femoral neuropathies, rhabdomyolysis, and acute renal failure caused by positioning during radical retropubic prostatectomy

In the hyperlordotic position, the patient's hips are above the feet and head. We present a case of rhabdomyolysis, acute renal failure, and bilateral femoral and sciatic neuropathies caused by this position.

[Anaesthesia and prostate surgery]

OBJECTIVES

To review the current data about anaesthetic management in prostate surgery with special regards on analysis and prevention of specific risks, appropriate anaesthetic procedure keeping with surgery and patient, recognition and treatment of adverse events.

DATA SOURCES AND EXTRACTION

The Pubmed database was searched for articles (1990-2004) combined with references analysis of major articles on the field.

DATA SYNTHESIS

It is strongly recommended to settle germfree urine in the preoperative period. The thromboembolic risk of radical retropubic prostatectomy for cancer parallels lower abdomen oncologic surgery and is prolonged. Preoperative evaluation of cardiovascular, respiratory, neurological and metabolic comorbidity is a source of prognostic information and an essential tool in the management of elderly patients with prostate disease. Extreme patient positioning applied in prostate surgery induces haemodynamic and respiratory changes and are associated with severe muscular and nervous injuries. The laparoscopic access for radical prostatectomy is a growing alternative to the open surgical procedure. Acute normovolaemic haemodilution is a consistent and cost-effective blood conservation strategy in reducing allogenic blood transfusion for radical retropubic prostatectomy. Whether open transvesical or transurethral prostatectomy for treatment of benign hypertrophy depends on the size of the gland: transurethral resection is safe up to 80 g. Intrathecal anaesthesia with a T9 cephalad spread of sensory block, produces adequate conditions for transurethral prostatectomy and allows a rapid diagnosis of irrigating fluid absorption syndrome. In spite of recommended preoperative antibiotic prophylaxis, bacteriemias are frequent during transurethral prostate resection.

Bench-to-bedside review: Rhabdomyolysis -- an overview for clinicians

Rhabdomyolysis ranges from an asymptomatic illness with elevation in the creatine kinase level to a life-threatening condition associated with extreme elevations in creatine kinase, electrolyte imbalances, acute renal failure and disseminated intravascular coagulation. Muscular trauma is the most common cause of rhabdomyolysis. Less common causes include muscle enzyme deficiencies, electrolyte abnormalities, infectious causes, drugs, toxins and endocrinopathies. Weakness, myalgia and tea-colored urine are the main clinical manifestations. The most sensitive laboratory finding of muscle injury is an elevated plasma creatine kinase level. The management of patients with rhabdomyolysis includes early vigorous hydration.

Crush injury and rhabdomyolysis

Crush injuries resulting in traumatic rhabdomyolysis are an important cause of acute renal failure. Ischemia reperfusion is the main mechanism of muscle injury. Intravascular volume depletion and renal hypoperfusion, combined with myoglobinuria, result in renal dysfunction. The infusion of intravenous fluids before extrication or soon after injury may lessen the severity of the crush syndrome. Serum CK levels can be used to screen patients with crush injuries to determine injury severity. Once intravascular volume has been stabilized, and the presence of urine flow has been confirmed, a forced mannitol-alkaline diuresis for prophylaxis against hyperkalemia and acute renal failure should be instituted. If an extremity compartment syndrome is suspected, one should have a low threshold for checking the intracompartmental pressures. Further studies are needed to demonstrate if any treatment regimen is truly superior to early, aggressive crystalloid infusion.

Risk of elevated creatine kinase and myoglobulinemia due to incised muscles in patients who underwent urological surgery

PURPOSE

We clarified the risk of elevated creatine kinase (CK) and myoglobulinemia during incised muscle urological operations.

MATERIALS AND METHODS

We retrospectively reviewed 58 consecutive cases of radical nephrectomy with muscle incision and 89 consecutive radical prostatectomies or radical cystectomies without muscle incision. Operations with or without muscle incision were divided into 2 groups depending on operative time (200 minutes or less and 201 to 400). Increases in CK and myoglobin were compared between the 2 groups, and between muscle incision and no muscle incision at each operative time.

RESULTS

CK and myoglobin were proportionally increased according to operative time in operations without muscle incision but not in muscle incision operations, in which high CK and myoglobin were seen even with short operative times. CK and myoglobin were more increased in muscle incision operations than in those without incision with significance at each operative time. However, maximum CK and myoglobin were 2,220 IU/L and 3,600 ng/ml, respectively, in muscle incision operations.

CONCLUSIONS

Even with short operative times surgeries with muscle incision are associated with a marked increase in CK and myoglobulinemia. However, CK and myoglobin are not sufficiently high for rhabdomyolysis with acute renal failure to develop.

Traumatic rhabdomyolysis resulting from continuous compression in the exaggerated lithotomy position for radical perineal prostatectomy

This report demonstrates a case of rhabdomyolysis as a result of the exaggerated lithotomy position during radical perineal prostatectomy. The pathogenesis, diagnosis, management, and preventive measures of rhabdomyolysis are also reviewed.

Acute renal failure in the critically ill patient

This article focuses on the epidemiology, pathogenesis, and prevention of the most common forms of acute renal failure encountered in the critically ill. These include pre-renal azotemia and acute tubular necrosis that occurs postoperatively, in patients with rhabdomyolysis, or as a complication of sepsis. In addition, some unusual causes of acute renal failure that occur predominantly in the intensive care unit are briefly discussed.

Anesthesia for radical prostatectomy, cystectomy, nephrectomy, pheochromocytoma, and laparoscopic procedures

This article presents some of the more salient aspects of the anesthetic management of the common major renal surgical procedures and discusses the physiology and anesthetic implications of minimally invasive laparoscopic urologic surgery.

The patient at risk for acute renal failure. Recognition, prevention, and preoperative optimization

Despite major advances in critical care medicine and extracorporeal renal support, the treatment of established postoperative ARF remains unsatisfactory and costly. The essential elements of perioperative renal preservation are early recognition of high-risk patients, preoperative optimization of fluid status and cardiovascular performance, intraoperative maintenance of renal perfusion, and avoidance of nephrotoxins. Pharmacologic interventions directed at preventing postoperative ARF are under intense investigation but presently are limited to renal transplant surgery.

Survey of neuromuscular injuries to the patient and surgeon during urologic laparoscopic surgery

OBJECTIVES

Laparoscopy may be complicated by neuromuscular injuries, both to the patient and to the surgeon. We used a survey to estimate the incidence of these injuries during urologic laparoscopic surgery, to assess risk factors for these injuries, and to determine preventive measures.

METHODS

A survey of neuromuscular injuries associated with laparoscopy submitted to 18 institutions in the United States was completed by 18 attending urologists from 15 institutions.

RESULTS

From among a total of 1651 procedures, there were 46 neuromuscular injuries in 45 patients (2.7%), including abdominal wall neuralgia (14), extremity sensory deficit (12), extremity motor deficit (8), clinical rhabdomyolysis (6), shoulder contusion (4), and back spasm (2). Neuromuscular injuries were twice as common with upper retroperitoneal as with pelvic laparoscopy (3. 1% versus 1.5%). Among patients with neuromuscular injuries, those with rhabdomyolysis were heavier (means 91 versus 80 kg) and underwent longer procedures (means 379 versus 300 minutes), and those with motor deficits were older (means 51 versus 42 years of age). Of the surgeons, 28% and 17% reported frequent neck and shoulder pain, respectively.

CONCLUSIONS

Although not common, neuromuscular injuries during laparoscopy do contribute to morbidity. Abdominal wall neuralgias, injuries to peripheral nerves, and joint or back injuries likely occur no more frequently than during open surgery, but risk of rhabdomyolysis may be increased. Positioning in a partial rather than full flank position may reduce the incidence of some injuries. Measures to reduce neuromuscular strain on the surgeon during laparoscopy should be considered.

Myoglobinuria

Myoglobinuria refers to an abnormal pathologic state in which an excessive amount of myoglobin is found in the urine, imparting a cola-like hue, usually in association with myonecrosis and a clinical picture of weakness, myalgias, and edema. Myoglobinuria is produced by multiple causes: any condition that accelerates the use or interferes with the availability of oxygen or energy substrates to muscle cells can result in myoglobinuria, as can events that produce direct muscle injury, either mechanical or chemical. Acute renal failure is the most serious complication, which can be prevented by prompt, aggressive treatment. In patients surviving acute attacks, recovery of muscle and renal function is usually complete.

Rhabdomyolysis and acute renal failure following radical perineal prostatectomy

Rhabdomyolysis and acute renal failure can be a rare but serious complication resulting from compromising operative positions following some urologic and gynecologic procedures. We report a lethal case of rhabdomyolysis following radical perineal prostatectomy. The possibility of this complication must be considered prior to performing any operation in the exaggerated lithotomy position. Prevention, early diagnosis, and aggressive treatment are the keys to a successful recovery.

Rhabdomyolysis following spinal cord injury: case report

Rhabdomyolysis is commonly seen in association with multisystem trauma. We report an unexpected case of rhabdomyolysis and subsequent renal insufficiency after spinal cord injury unassociated with acute muscular injury. Immobilization, in conjunction with mild systemic hypoperfusion, was the suspected cause. Due to the likelihood of muscle catabolism, the difficulties of diagnosing soft tissue injury, and the impact of any decrease in renal reserve in patients with spinal cord injuries, surveillance for laboratory evidence of rhabdomyolysis in patients with neurologically complete spinal cord injuries appears warranted.