Banner Clinical Practice Rhabdomyolysis ZACHARY SPRAGUE DO BETHANY

Banner Clinical Practice: Rhabdomyolysis ZACHARY SPRAGUE, DO BETHANY BRUZZI, DO JUNE 7, 2018

Prevalence United Stated: approximately 26, 000 cases annually Approximately 7 to 10% of all cases of acute kidney injury in the United States are due to myoglobinuria associated AKI. The incident of AKI in rhabdomyolysis has been reports to range between 13 to 50% but is difficult to establish a true rate due to varying definitions and clinical scenarios

Why Do We Need a Standard of Care? The primary purpose of these guidelines is to decrease morbidity and mortality rates of rhabdomyolysis by presenting recommendations for clinical management that can be applied to individual cases if deemed appropriate by the treating physician.

Patient Population Inclusion Criteria Adults great than 18 years of age Signs and symptoms (H&P) consistent with diagnosis of Rhabdomyolysis Exclusion Criteria Younger than 18 years of age History of End Stage Renal Disease History of Chronic Heart Failure

Admission Criteria 1. Creatinine Kinase greater than five times the upper limit of normal 6(Observation is appropriate for anyone who meets greater than 5 x upper limit normal (1000) to 5000, and did not correct despites IV fluids. Admit to inpatient if greater than 10 K. Consider Inpatient status for anyone 5001 -9999 and rising. ) 2. Continuously increasing CK despite intravenous fluid protocol 3. Laboratory finding consistent with AKI or electrolyte abnormalities(such ranges that would warrant obs/inpt for those diagnosis (ex) creatinine at least 1. 5 x baseline) 4. Concern for oliguria(<0. 5 ml of urine per kilogram per hour for 12 hours), anuria, or volume overload 5. Need for Renal Replacement Therapy 6. Clinical signs of compartment syndrome

Treatment Intravenous Fluids: Intravenous hydration should be initiated immediately upon clinical suspicion as the delay of treatment can lead to oliguric renal failure and eventually anuric renal failure. 13 An initial 1 -2 L bolus of normal saline should be given followed by a intravenous fluid rate of 400 ml/hr titrated to a urine output of 200300 ml/hr. 6, 31 Mannitol and Loop diuretics are not effective

Complications AKI/ARF Hyperkalemia Hypocalcemia and hypercalcemia Hyperphosphatemia Hyperuricemia Hypovolemia

Discharge Criteria ED 1. Creatinine Kinase downtrending 2. Creatine Kinase less than 1, 000. 3. Urine dipstick negative for “blood” 6(Unlikely to be positive with values less than 1000, if high pos on dipstick, may consider observation with risk of increased values though rather than discharge) 4. Electrolytes within normal ranges 5. No clinical signs of compartment syndrome 6. Clinically euvolemic

Discharge Criteria Medicine 1. Creatinine Kinase downtrending 2. Creatine Kinase less than 10, 0009, 15, 36 3. Urine dipstick negative for “blood” 6 4. Electrolytes within normal ranges 5. No clinical signs of compartment syndrome 6. Clinically euvolemic

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