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A “crush” course on rhabdomyolysis: risk stratification and clinical management update for the perioperative clinician

  • Review Article
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Abstract

Rhabdomyolysis, the release of myoglobin and other cellular breakdown products from necrotic muscle tissue, is seen in patients with crush injuries, drug overdose, malignant hyperthermia, muscular dystrophy, and with increasing frequency in obese patients undergoing routine procedures. For the perioperative clinician, managing the resultant shock, hyperkalemia, acidosis, and myoglobinuric acute kidney injury can present a significant challenge. Prompt recognition, hydration, and correction of metabolic disturbances may reduce or eliminate the need for long-term renal replacement therapy. This article reviews the pathophysiology and discusses key issues in the perioperative diagnosis, risk stratification, and management of rhabdomyolysis.

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Abbreviations

ADP:

Adenosine diphosphate

AKI:

Acute kidney injury

ASA:

American Society of Anesthesiologists

AST:

Aspartate transaminase

ATN:

Acute tubular necrosis

ATP:

Adenosine triphosphate

BMI:

Body mass index

CABG:

Coronary artery bypass grafting

CK:

Creatine kinase

CRRT:

Continuous renal replacement therapy

DHPR:

Dihydropyridine receptor

DIC:

Disseminated intravascular coagulation

DKA:

Diabetic ketoacidosis

ICU:

Intensive care unit

IV:

Intravenous

LR:

Lactated Ringer’s solution

LSD:

Lysergic acid diethylamide

MAOI:

Monoamine oxidase inhibitor

MDMA:

3,4-Methylenedioxymethamphetamine

MH:

Malignant hyperthermia

NMS:

Neuroleptic malignant syndrome

NS:

Normal saline

PCP:

Phencyclidine

PLA2:

Phospholipase A2

POD:

Postoperative day

PRIS:

Propofol infusion syndrome

PT:

Prothrombin time

ROS:

Reactive oxygen species

RRT:

Renal replacement therapy

RYR1:

Ryanodine receptor 1

SERCA:

Sarcoendoplasmic reticulum calcium transport ATPase

SSRI:

Selective serotonin reuptake inhibitor

TCA:

Tricyclic antidepressant

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Authors and Affiliations

  1. Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA

    Devan R. Cote

  2. Department of Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA

    Eva Fuentes

  3. Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Tufts University School of Medicine, 800 Washington Street, Boston, MA, 02111, USA

    Ali H. Elsayes & Sadeq A. Quraishi

  4. Department of Anesthesiology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA, USA

    Jonathan J. Ross

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  1. Devan R. Cote
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  2. Eva Fuentes
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  3. Ali H. Elsayes
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  5. Sadeq A. Quraishi
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SAQ conceived the project and critically revised the manuscript. DRC wrote major sections of the manuscript and prepared tables and figures. EF, AHE, and JJR helped review the literature and draft parts of the manuscript.

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Correspondence to Sadeq A. Quraishi.

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Cote, D.R., Fuentes, E., Elsayes, A.H. et al. A “crush” course on rhabdomyolysis: risk stratification and clinical management update for the perioperative clinician. J Anesth 34, 585–598 (2020). https://doi.org/10.1007/s00540-020-02792-w

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