Rhabdomyolysis and anesthesia: a report of two cases and review of the literature

Postoperative weakness and anesthetic-associated rhabdomyolysis in a pediatric patient: a case report and review of the literature

Background

Anesthesia-associated rhabdomyolysis is a rare complication of surgery that causes postoperative myalgia, weakness, and potential renal failure if not managed promptly. Predisposing conditions that may lead to this complication include muscular dystrophies and myopathies.

Case presentation

This rare case describes a pediatric non-Indigenous Australian patient developing this complication, with no known predisposing risk factors, and no clear etiology. A 9-year-old child with a background of asthma underwent an elective removal of keloid scar on her chest wall. The procedure was brief and uncomplicated, with an uneventful induction of anesthesia. During the emergence period, she developed acutely raised airway pressures with bronchospasm and laryngospasm requiring the use of salbutamol and suxamethonium with good effect. In the initial postoperative period, the patient complained of generalized myalgia and muscle weakness and was unable to mobilize independently. There was transient recovery to normal function; however, a recurrence of symptoms the following day with associated myalgias warranted admission to hospital. She was found to have rhabdomyolysis that was managed conservatively with a full recovery of several weeks. She was thoroughly investigated for any underlying cause, including genetic testing for malignant hyperthermia susceptibility (she had a variant of unknown significance but was negative for the known genetic abnormalities that cause malignant hyperthermia).

Conclusion

This case report demonstrates the importance of considering anesthesia-associated rhabdomyolysis as a differential for acute postoperative weakness, and outlines an investigative approach. To the best of our knowledge, it is the first case described in the pediatric literature to report biphasic progression of symptoms.

Succinylcholine-Induced Rhabdomyolysis in Adults: Case Report and Review of the Literature

PURPOSE

A case of succinylcholine (SCh) and sevoflurane as a probable cause of rhabdomyolysis in an adult is presented, along with a review of the relevant literature and strategies for prevention.

SUMMARY

A nondiabetic, morbidly obese 32-year-old female developed rhabdomyolysis after administration of SCh and sevoflurane for diagnostic procedures of 30 minutes' duration. Thirty-three hours following anesthesia, the patient developed diffuse muscle tenderness and progressive weakness with a creatinine kinase (CK) of 4319 U/L. Urinalysis findings indicated contamination, a white blood cells of 12.1 × 10³/μL was stress induced, while all other labs were normal. Following 26 hours of intravenous fluids, the patient's CK decreased to 1243 U/L, with pain responsive to acetaminophen and improved mobility, resulting in discharge. With a lack of reasonable alternative causes and a temporal association of symptoms, procedural medication-induced rhabdomyolysis was suspected. Based on Naranjo scale evaluation, SCh and sevoflurane were probable causes of rhabdomyolysis. We reviewed the literature for SCh-induced rhabdomyolysis among adults and found 10 cases. The majority of patients received halogenated anesthesia (HA) and prophylaxis for SCh myopathy, with no known personal or family history of neuromuscular disorders (NMD) reported.

CONCLUSION

Rhabdomyolysis was observed in a woman following the administration of SCh and sevoflurane for diagnostic procedures lasting 30 minutes. While avoidance is possible in adults with histories of NMDs, a high index of suspicion for occurrence of rhabdomyolysis is needed whenever combining SCh with HA in all adults.

Case Report: Red Urine After Day Care Strabismus Surgery

In the absence of surgery on the urinary tract, the emission of red urine after anesthesia should be considered as a diagnostic emergency because it can be a sign of hematuria, hemoglobinuria, blood transfusion reaction, significant myoglobinuria, or porphyria.This case describes the management of a 12-year-old boy who presented red urine at the day care unit after strabismus surgery.

Orthodontic treatment in a patient with unilateral open-bite and Becker muscular dystrophy. A 5-year follow-up

INTRODUCTION:

Becker muscular dystrophy is an X-chromosomal linked anomaly characterized by progressive muscle wear and weakness. This case report shows the orthodontic treatment of a Becker muscular dystrophy patient with unilateral open bite.

METHODS:

To correct patient's malocclusion, general anesthesia and orthognathic surgery were not considered as an option. Conventional orthodontic treatment with intermaxillary elastics and muscular functional therapy were employed instead.

RESULTS:

After 36 months, open bite was corrected. The case remains stable after a 5-year post-treatment retention period.

Hyperkalemia and Rhabdomyolysis With Succinylcholine Used for Rapid Sequence Intubation

Objective: Succinylcholine, a depolarizing neuromuscular blocker used during intubation, has a black box warning for use in pediatric patients due to the risk of rhabdomyolysis, hyperkalemia, ventricular arrhythmias, and cardiac arrest in patients with skeletal muscle myopathy. Though the warning does not exist for adult patients, succinylcholine is commonly used in adults, who may still be at risk for the same complications. Our objective is to present the case of an adult patient experiencing rhabdomyolysis, hyperkalemia, and cardiac arrest after the administration of succinylcholine for rapid sequence intubation. Case Summary: We describe the hospital course of a 58-year-old patient admitted for the placement of a biventricular implantable cardioverter defibrillator. The patient received etomidate, fentanyl, isoflurane, midazolam, and succinylcholine during rapid sequence intubation. During intubation for the procedure and shortly after the administration of succinylcholine, the patient went into asystole and arrested. After several arrhythmias and periods of cardiac arrest, the patient was stabilized, and the procedure completed. Shortly after the procedure, the patient developed hyperkalemia, rhabdomyolysis, and acute kidney injury and ultimately expired. Discussion: Though reports of adverse reactions to succinylcholine are less common in adults without underlying muscular disorders, this phenomenon has been reported in the literature. There is the potential that this patient may have had an underlying myopathy that was previously undiagnosed or could have experienced malignant hyperthermia. The Naranjo adverse drug reaction probability scale for this case is 5, which is considered probable. Conclusions: Though uncommon, succinylcholine is a potential cause of hyperkalemia, rhabdomyolysis, and cardiac arrest in susceptible adult patients.

Anesthesia and Duchenne or Becker muscular dystrophy: review of 117 anesthetic exposures

BACKGROUND

Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are associated with life-threatening perioperative complications, including rhabdomyolysis, hyperkalemia, and hyperthermia. Current recommendations contraindicate use of succinylcholine and volatile anesthetics; however, the latter recommendation remains controversial.

OBJECTIVE

To review the perioperative outcomes of patients with DMD and BMD.

METHODS

We reviewed records of patients with DMD or BMD who underwent anesthetic management at our institution from January 1990 through December 2011.

RESULTS

We identified 47 patients (DMD, 37; BMD, 10) who underwent 117 anesthetic exposures (DMD, 101; BMD, 16). Volatile anesthetic agents were used 66 times (DMD, 59; BMD, 7). One patient with undiagnosed BMD received succinylcholine and developed acute rhabdomyolysis and hyperkalemic cardiac arrest. All other major complications were attributed to the procedure (i.e., large bleeding), to preexisting comorbidities (i.e., respiratory failure, cardiac disease), or to both.

CONCLUSIONS

Use of succinylcholine in children with dystrophinopathy is contraindicated. These patients have significant comorbidities and are frequently undergoing extensive operations; complications related to these factors can develop, as evidenced by our series. These complications may occur with use of volatile and nonvolatile anesthetics. However, because most of our patients were older than 8 years at the time of surgery, our observation cannot be generalized to younger dystrophin-deficient children.

Changes in creatine phosphokinase (CK) concentrations after minor and major surgeries in children

BACKGROUND

During surgery, damage occurs to muscles in the area of the operation. The few studies that have examined creatine phosphokinase (CK) values after surgery have been in adults. The only study in children was after cardiac surgery. Understanding the normal enzyme pattern of change may help to differentiate malignant hyperthermia, anaesthesia-induced rhabdomyolysis and elevated CK values resulting from inherited muscle disease in cases in which these are suspected. The aim of this study was to delineate the normal rise of CK after minor and major surgery in children.

METHODS

A total of 71 patients aged 1 month-17 yr were studied. From the cohort of 71 patients, 46 underwent elective surgery (14 major, 32 minor) and in 25 the surgery was designated as an emergency surgery (21 major, 4 minor). The anaesthesia protocol was similar for both groups with halothane induction and isoflurane maintenance. Owing to its possible effect on CK, succinylcholine was avoided during the study.

RESULTS

The mean values of CK concentration before and after surgery were 63.1 iu litre(-1) and 151.5 iu litre(-1), respectively. The median CK elevation (range) for the major and minor surgery groups was 43 iu litre(-1) (4-647) and 10 iu litre(-1) (-28 to 122), respectively (P<0.0001).

CONCLUSIONS

CK concentrations in the major surgery group were significantly higher than the minor surgery group. This profile can contribute to the evaluation of patients who present with the possibility of malignant hyperthermia, anaesthesia-induced rhabdomyolysis and underlying muscle disease. Any rise of CK concentration above what is expected should prompt further investigation.

Hyperkalemic cardiac arrest after cardiopulmonary bypass in a child with unsuspected duchenne muscular dystrophy

Adverse reactions to volatile anesthetics and depolarizing muscle relaxants can occur in patients with Duchenne muscular dystrophy (DMD) resulting in acute rhabdomyolysis and hyperkalemia. We report a case of hyperkalemic cardiac arrest after cardiac surgery using cardiopulmonary bypass in a child with unsuspected DMD. Early diagnosis and management of hyperkalemia resulted in a successful outcome. Genetic testing confirmed the diagnosis of DMD. We recommend a thorough preoperative investigation, including creatine kinase estimation, in children with a history of unexplained motor delay.

Muscle relaxants

Studies on the toxic effects of muscle relaxants are difficult to design because of the need for mechanical ventilation and, consequently, concomitant administration of anaesthetic drugs which may influence the results. The following overview shows that muscle relaxants are weak toxic agents with regard to their teratogenicity, carcinogenicity and cytotoxic effects (including tissue- and organ-damaging effects). Moreover, this chapter presents other side-effects of muscle relaxants under the broad heading of toxicity: the succinylcholine-triggered cytotoxic effects on skeletal muscle cells with different aetiology, for example, or persistent muscle weakness after long-term administration of non-depolarizing muscle relaxants. Receptor stimulation in the central nervous system may cause acute excitement and seizures. Muscle relaxants and their metabolites may interact with muscarinic and nicotinic receptors in other organs and the ganglionic system, for example in the cardiovascular system. Direct stimulation of mast cells, with consequent release of histamine, after administration of muscle relaxants may clinically impose as toxic reactions.

Acute pediatric rhabdomyolysis

Rhabdomyolysis is a relatively common condition that may occur intermittently in chronic and inflammatory myopathy, muscular dystrophy, and metabolic myopathy. Rhabdomyolysis can also present acutely in otherwise healthy individuals. The list of etiologies for acute muscle cell lysis is enormous, with new causes described yearly. Series on acute pediatric rhabdomyolysis have not yet been published. This article describes a retrospective review of children admitted to the authors' institution during an 8-year period in whom rhabdomyolysis was recognized as a complication during their hospital stay. Patients with intermittent or relapsing rhabdomyolysis were excluded. Nineteen children were identified. Trauma (five cases), nonketotic hyperosmolar coma (two cases), viral myositis (two cases), dystonia (two cases), and malignant hyperthermia-related conditions (two cases) were the most common causes of rhabdomyolysis. Acute renal failure was the most frequent complication, occurring in 42% of cases. The mean age of renal failure patients was 13.9 years, compared to 8 years for non-renal failure children. Careful assessment of the initial urinalysis would have suggested a diagnosis of rhabdomyolysis in 9 of 16 patients tested.

Recombinant activated factor VII in children with acute bleeding resulting from liver failure and disseminated intravascular coagulation

Recombinant activated factor VII (rFVIIa) was given to three children with acute bleeding resulting from liver failure and disseminated intravascular coagulation. Cases I and II (girls aged 3 years and 6 years, respectively) were diagnosed with Dengue hemorrhagic fever and prolonged shock. Case III, a boy aged 9 months, underwent left lobe hepatectomy for a hepatoblastoma, during which 60% of his liver was removed. This case was complicated by myoglobinuria, liver and renal impairment and early disseminated intravascular coagulation. All three patients exhibited active bleeding. Cases I and II received rFVIIa combined with other blood component replacement, while Case III received rFVIIa as the only hemostatic agent. A bolus of 40-180 microg/kg b.w. was administered followed by 16.5-33 microg/kg b.w. per h continuous infusion. As a result, bleeding was controlled, the prothrombin time was shortened and FVII clotting activity was significantly increased. In conclusion, rFVIIa has shown some efficacy in controlling acute bleeding in children with liver failure and disseminated intravascular coagulation.