Case report: Rhabdomyolysis in morbidly obese patients: anesthetic considerations

Abstract

Purpose We report the presentation and management of rhabdomyolysis involving shoulder girdle and upper arm muscles in a morbidly obese patient after prolonged laparoscopic surgery. Clinical features A 41-yr-old morbidly obese woman presented for laparoscopic abdominal hysterectomy. She had hypertension and type II diabetes which were controlled on regular medications. She also had obstructive sleep apnea. Her clinical examination and investigations revealed no abnormality except morbid obesity (body mass index 54 kgÁm -2 ) and left ventricular hypertrophy on transthoracic echocardiogram. Standard general anesthesia was administered under baseline non-invasive monitors. Succinylcholine was used to secure the airway during anesthetic induction. Surgery was performed with the patient positioned with a 15°head-down tilt, and it took six hours to complete the procedure as technical difficulty was encountered due to her body habitus. Her trachea was extubated and she was transferred to the postanesthetic care unit (PACU) without incident.In the PACU, the patient complained of severe bilateral arm pain and weakness an hour after surgery. On physical examination, she exhibited limited movement of her arms against gravity while complaining of tenderness in her shoulder girdle muscles and both arms. Clinical suspicion of rhabdomyolysis based on her signs and symptoms was confirmed by an elevated serum creatinine kinase (CK) of 18,392 IUÁL -1 and serum potassium of 5.3 mmolÁL -1 . Intravenous crystalloids and mannitol were administered for 24 hr for renal protection, and her clinical symptoms and serum CK levels improved over seven days. The patient was discharged to home on the tenth postoperative day, and she continued to improve over the three-month followup period. Conclusions Morbidly obese patients who undergo prolonged surgery are at risk for rhabdomyolysis, and early diagnosis and therapy are required to prevent severe complications. RésuméObjectif Nous rapportons la pre´sentation et la prise en charge d'un cas de rhabdomyolyse touchant la ceinture scapulaire et les muscles des bras supe´rieurs d'une patiente obe`se morbide apre`s une chirurgie laparoscopique prolonge´e. É léments cliniques Une femme obe`se morbide de 41 ans s'est pre´sente´e pour une hyste´rectomie abdominale par laparoscopie. Elle souffrait d'hypertension et de diabe`te de type II, lesquels e´taient contrôle´s par un traitement me´dicamenteux re´gulier. Elle souffrait e´galement d'apne´e obstructive du sommeil. L'examen clinique et les analyses n'ont re´ve´le´aucune anomalie hormis une obe´site´morbide (indice de masse corporelle 54 kgÁm -2

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

“…Our patient received prophylaxis for SCh myopathy with propofol and lidocaine, which have demonstrated an ability to moderately reduce SCh-associated myalgia (NNT ¼ 3-6). 19 In comparison, our literature search found 6 of 10 patients with SCh-induced rhabdomyolysis received medication prophylaxis for myalgia, including midazolam, 21,27 propofol, 19,24 rocuronium, 27 or atracurium, 22 while 1 patient received prophylaxis with 2 or more medications. 24 Whether multiple medication prophylactic measures to decrease myalgia also reduce the infrequent occurrence of rhabdomyolysis remains to be evidenced.…”

“…With a median age of 42, we found 10 cases that met our criteria. [19][20][21][22][23][24][25][26][27][28] Patients were almost entirely male, with median CK of 48,697 IU/L, resulting in myoglobinuria and renal failure in 6 cases and cardiac arrest in 2 individuals. None of these patients had a known history of NMD, while 5 patients had a confounding cause of rhabdomyolysis.…”

“…None of these patients had a known history of NMD, while 5 patients had a confounding cause of rhabdomyolysis. 19,21,22,24 (Table 2). With a mean dose of SCh of 100 mg and surgical duration of just over 2 hours (133 minutes), the majority of patients received HA.…”

Neurosurgery in morbidly obese patients

“…There are numerous cases of rhabdomyolysis occurring in morbidly obese patients reported in literature. [30][31][32][33] Hence, vigilance during positioning is critical during prolonged neurosurgical procedures.…”

Postoperative rhabdomyolysis following pars-plana vitrectomy under general anesthesia

“…Postoperative rhabdomyolysis is a rare complication of general anesthesia 1–3. Myoglobinuria can lead to renal failure, which is associated with up to 20% mortality 4.…”