Rhabdomyolysis in a chronic kidney disease patient after lung surgery

Corresponding author: Woo-Jong Shin, M.D., Ph.D., Department of Anesthesiology and Pain Medicine, Hanyang University Guri Hospital, 249-1, Gyomun-dong, Guri 471-701, Korea. Tel: 82-31-560-2390, Fax: 82-31-563-1731, E-mail: [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC Rhabdomyolysis is the rapid lysis of the rhabdomyoma due to muscular tissue damage, which leads to circulation of myoglobin, which causes nonspecific clinical syndromes [1]. Rhabdomyolysis can occur post-traumatically or from metabolic derangements [1]. Rhabdomyolysis is a well-known cause of acute renal failure (ARF), but in patients with chronic kidney disease (CKD), the characteristic symptoms of rhabdomyolysis are not so obvious and variations in biochemical tests can be similar to CKD patients [2]. We report a CKD patient who developed rhabdomyolysis after a lung surgery under general anesthesia. The patient was a diabetic 64-year-old male who was receiving intermittent hemodialysis after being diagnosed with CKD a year ago. He was taking aspirin and clopidogrel due to a right thalamic infarction; irbesartan, isosorbide dinitrate, and nifedipine for high blood pressure; and insulin due to diabetes. After one year observation of a 2 cm nodule discovered in his left lingular segment at the time of CKD diagnosis, small cell lung carcinoma and adenoma was diagnosed. A left lingular segmentectomy of upper lobe by thoracotomy was scheduled. Patient received hemodialysis 36 hours before surgery, and laboratory data showed a Ca level of 8.5 mg/dl, K 5.6 mEq/L, phosphate 5.1 mg/dl, urea 58 mg/dl, creatine 11.0 mg/dl, albumin 4.1 g/dl, uric acid 8.7 mg/dl, and CK 91 U/L (Table 1). There were no signs of K elevation in electrocardiogram. Tracheal intubation was done with a left sided double lumen tube using pentothal sodium 250 mg. Atracurium 30 mg, 1% lidocaine 80 mg and fentanyl 100 μg. Anesthesia was maintained using 2.0-6.0 vol% desflurane with 100% oxygen and remifentanil. Mechanical ventilation was started with a tidal volume of 450 ml at a frequency of 15 per minutes. Total time under general anesthesia was 285 minutes; systolic blood pressure was maintained between 100 and 130 mmHg and diastolic blood pressure was maintained between 60 and 80 mmHg. Body temperature was kept around 36.0C. To maintain muscle relaxation during surgery, injection of atracurium was started 15 minutes after intubation. About 30 minutes after one lung ventilation, the patient’s SpO2 suddenly decreased. Arterial blood gas analysis (ABGA) showed a pH of 7.39, PaCO2 32 mmHg, PaO2 51 mmHg, BE -5.1 mEq/L, Na 137 mEq/L, K 7.15 mEq/L and Ca 1.11 mg/dl. One gram of calcium gluconate, 5 units of insulin, and 40 mEq of sodium bicarbonate were immediately injected to prevent side effects from hyperkalemia. Results of additional ABGA showed pH 7.41, PaCO2 30 mmHg. PaO2 72 mmHg, BE -3.9 mEq/L, Na 139 mEq/L, K 6.30 mEq/L, Ca 1.08 mg/dl, and blood sugar test at 187. One gram of calcium gluconate, 5 units of insulin, and 40 mEq of sodium bicarbonate were additionally administered. Operation time was 210 minutes. After surgery, patient was moved to intensive care unit (ICU) and 2 hours after surgery (operative day), his K level measured 5.6 mEq/L. Nine hours later (postoperative day 1), it increased to 8.9 mEq/ L, so calcium gluconate and polystyrene sulfonate calcium were administered and kalimate enema was done (Table 1). Eleven hours after surgery, K level increased again (8.9 mEq/L), thus, continuous renal replacement therapy (CRRT) was done. At the