Journal of Clinical Anesthesia (2007) 19,64–66

Case report : another complication after prolonged

Igal Alterman MDa, Ami Sidi MDb, Leonard Azamfirei MDc, Sanda Copotoiu MDc, Tiberiu Ezri MDd,e,* aDepartment of General Intensive Care Unit, Edith Wolfson Medical Center (affiliated with the Tel Aviv University Sackler School of ), Holon 58100, Israel bDepartment of , Edith Wolfson Medical Center (affiliated with the Tel Aviv University Sackler School of Medicine), Holon 58100, Israel cDepartment of and Intensive Care, University of Medicine and , Targu-Mures, Romania dDepartment of Anesthesia, Edith Wolfson Medical Center (affiliated with the Tel Aviv University Sackler School of Medicine), Holon 58100, Israel eOutcomes Research Group, University of Louisville, Louisville, KY, USA

Received 18 October 2005; revised 13 June 2006; accepted 15 June 2006

Keywords: Abstract We present the case of a young patient who underwent a prolonged urological procedure in the Prolonged urological lateral decubitus position. The patient’s postoperative course was complicated by rhabdomyolysis surgery; manifested by elevated levels of serum creatine phosphokinase and the presence of in Lateral position; and blood. To prevent renal failure, we managed the patient in the intensive care unit with generous Rhabdomyolysis volumes of intravenous fluids, forced diuresis, and urine alkalization. Subsequently, the patient had an uneventful recovery. The linkage between surgical positioning, prolonged surgery time, and rhabdomyolysis is discussed. D 2007 Elsevier Inc. All rights reserved.

Rhabdomyolysis is a dissolution of skeletal muscles that abnormality is associated with more than 100 seemingly produces a nonspecific clinical syndrome causing extrav- unrelated disorders, including direct muscle (crush asation of toxic intracellular contents from the myocytes injury syndrome), muscle ischemia, excessive physical into the circulatory system [1]. This destruction leads to exertion, temperature extremes, infections, drugs, toxins, electrolyte disturbances, hypovolemia, metabolic acidosis, venoms, and endocrine disorders, among others [2]. coagulopathies, and myoglobinuric renal failure. This Although initially recognized solely as a posttraumatic sequela, nontraumatic causes of rhabdomyolysis are now estimated to be more frequent than traumatic causes [1]. Most patients have several risk factors [3]. In this article, * Corresponding author. Department of Anesthesia, Edith Wolfson Medical Center, Holon 58100, Israel. Tel.: +972 3 5028229; fax: +972 3 we report the case of a patient who underwent a prolonged 5028218. urological surgery in the left lateral decubitus position, and E-mail address: [email protected] (T. Ezri). which was complicated by rhabdomyolysis.

0952-8180/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2006.06.002 Rhabdomyolysis after prolonged surgery 65

1. Case report Blood chemistry revealed a steep elevation in total serum CPK values, up to 10800 U/L (normal, V200 U/L); the A 22-year-old, ASA physical status II, overweight CPK/MB fraction was 5%. (height, 180 cm; weight, 94 kg; body mass index, 29 kg/ In the PACU, arterial blood gas analysis, with the patient 2 m ) man was scheduled for ureterocalicostomy. He was breathing through a face mask, showed the healthy, apart from having nephrolithiasis and ureteral following levels: pH, between 7.35 and 7.38; Paco2, stricture that was a complication of a similar (ureter- between 36 and 39 mmHg; base excess, between À3 and ocalicostomy) surgery that he had undergone as a child. one mEq; standard bicarbonate, between 20 and 22 mEq; Physical examination of the head, neck, heart, lungs, and and Pao2, between 120 and 145 mmHg. other organs/systems revealed normal findings. Preopera- Under these circumstances, a muscle injury of the left tive urinalysis and measurements of complete blood thigh as a result of pressure of the thigh against the table count, serum electrolytes, blood urea nitrogen, serum from the prolonged lateral position was suspected. , blood creatine phosphokinase (CPK), and A diagnosis of rhabdomyolysis was made, and the liver enzymes yielded outcomes that were within normal patient was managed with fluid replacement using between limits. The patient did not receive any nephrotoxic 500 and 600 mL/h of lactated Ringer’s solution and 20 mg medication (eg, aminoglycosides or nonsteroidal anti- of IV furosemide, followed by a dose of 0.5 mg/kg per inflammatory drugs). hour to maintain a urine output greater than 1.5 to 2 mL/kg The procedure was a repeat ureterocalicostomy that per hour. In the first hour, urine output was 80 mL and its lasted for 9 hours as a result of technical difficulties in color was darker. Urine alkalinization was initiated with approaching the kidney and extracting the stone. Open 25 mEq/h of sodium bicarbonate. The goal was to surgery was performed during general anesthesia with the maintain urine pH at a level higher than 7, and this goal patient placed in the left lateral decubitus position, with a was attained. wedge placed under the dependent iliac crest. The patient was subsequently transferred to the intensive Monitoring included ASA standard monitors, direct care unit (ICU) for further observation and treatment. arterial pressure monitoring via the radial artery, and central During that time, the patient continued to complain of pain venous pressure (CVP) monitoring via the right internal in his left flank and thigh. An orthopedic surgeon ruled out jugular vein. Urinary output was measured hourly. the possibility of compartment syndrome after measuring The patient was hemodynamically stable [heart rate (HR), normal pressures in the gluteal compartment. 62-88 bpm; mean arterial pressure (MAP), 70-100 mmHg; In the ICU, the following measurements were noted: CPK, CVP, 3-8 mmHg], with all the ventilation and oxygenation 12000 U/L; serum creatinine, between 1.1 and 1.3 mg/dL; variables preserved within normal limits. Total fluid input and blood urea, between 30 and 40 mg/dL. The plasma was 6000 mL, and total amount of urine over the procedure myoglobin level was initially 90 ng/mL, but it was was 1350 mL. Core (nasopharyngeal) temperature ranged subsequently measured as 70 ng/mL (the normal myoglobin between 36.68C and 378C. During surgery, the patient did values in our laboratory range from 7 to 70 ng/mL). In not require blood transfusion. addition, urinalysis revealed the presence of myoglobin. Red Findings from intraoperative arterial blood gas analyses, blood cells were not seen on microscopic examination. performed every two hours, were normal. Forced diuresis with volume expansion, furosemide At the end of surgery, the residual neuromuscular block (0.5 mg/kg per hour), and alkalinization of urine were was reversed with 2.5 mg of neostigmine and one mg continued, and myoglobinuria subsequently disappeared by of atropine, the patient’s trachea was extubated unevent- the patient’s second day in the ICU. Twenty-four hours later, fully, and he was transferred to the postanesthesia care the CPK level started to decline, followed by gradual unit (PACU). clinical improvement. In the PACU, the patient’s vital signs remained stable The patient was transferred to the urology ward and was (HR, 90-102 bpm; MAP, 95-110 mmHg; respiratory rate, discharged home one week later with normal laboratory 20-26 breaths/min; CVP, 5-10 mmHg; rectal temperature, measurements. The thigh swelling improved over the first 36.18C-378C). However, he complained of severe pain in postoperative week. his left thigh region, which was edematous and reddish. The thigh was tender to touch and firm. All pulses were palpable. The anatomical location of these erythematous 2. Discussion areas corresponded to the region that was in contact with the operating table during surgery, for which the patient was in ischemia can be caused by localized the lateral position. compression. Sources include intraoperative use of tourni- For pain control, the patient received intravenous (IV) quets, tight dressings, or casts, particularly in patients with morphine, tramadol, and dipyrone as required to maintain hypotension [4,5]. the visual analog pain (VAS) score lower than 4 (on a VAS Rhabdomyolysis can be caused by tissue compression as a scale of 0-10). result of extended periods of immobilization, including 66 I. Alterman et al. immobilization related to intraoperative positioning [6,7]. If a diagnosis of rhabdomyolysis is confirmed, aggressive Other cases of intraoperative rhabdomyolysis involve malig- treatment of the disturbances produced by rhabdomyolysis nant hyperthermia, hypoperfusion, urological surgical pro- should be initiated. Prevention may be aided by focusing on cedures (especially nephrectomy), intense vasospasm during intraoperative padding and positioning, observing intraoper- hypertensive crisis, and bariatric surgery, among others. ative repositioning when feasible, and limiting the duration of Compartment syndrome is both a cause and a complica- an operation. tion of rhabdomyolysis. As pressure within the fascial compartment increases, blood flow decreases, tissues become necrotic, and dying muscle cells release osmotically References active particles that draw additional water into the compart- ment, further worsening the condition [8]. 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Rhabdomyolysis after require IV infusions of 500 to 1000 mL/h of fluid [20]. The nephrectomy in the lateral flexed decubitus position. Masui 2003;52: urine is alkalinized by adding sodium bicarbonate to achieve a 882-5. [18] Bostanjian D, Anthone GJ, Hamoui N, Crookes PF. Rhabdomyolysis pH level higher than 7 [1,5,21] in preventing the dissociation of gluteal muscles leading to renal failure: a potentially fatal com- of myoglobin into its nephrotoxic components. Mannitol may plication of surgery in the morbidly obese. Obes Surg 2003;13:302-5. be given to promote diuresis, keep the kidneys flushed, and [19] Kuang W, Ng CS, Matin S, Kaouk JH, El-Jack M, Gill IS. prevent formation of casts in the tubules [5], and furosemide Rhabdomyolysis after laparoscopic donor nephrectomy. Urology can also be added. When the kidneys do not respond to 2002;60:911. [20] Abassi ZA, Hoffman A, Better O. 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