RHABDOMYOLYSISINDUCED ACUTE RENAL FAILURE AFTER METHADONEDIAZEPAM OVERDOSE case
RHABDOMYOLYSIS-INDUCED ACUTE RENAL FAILURE AFTER METHADONE-DIAZEPAM OVERDOSE (case report) B. Pavlovski, L. Milosevska, A. Cibisev, D. Petrovski, F. Licoska, A. Babulovska Clinic of Toxicology and Urgent Internal Medicine, UCC. Skopje, R. Macedonia
BACKGROUND RHABDOMYOLYSIS – GENERAL VIEW Rhabdomyolysis is a syndrome caused by injury to skeletal muscles and the resultant leakage of muscle cell contents (myoglobin, potassium, phosphate, etc. ) into the plasma.
TOXIC CAUSES RHABDOMYOLYSIS HAS BEEN ASSOCIATED WITH A VARIETY OF TOXINS AND DRUGS. THEY CAN EITHER EXERT A DIRECT TOXIC EFFECT ON MUSCLES (METABOLIC POISONS) OR INDIRECTLY PREDISPOSE TO RHABDOMYOLYSIS. DIRECT TOXIC EFFECT: Amatoxins Carbon monoxide Colchicine Ethylene glycol Snakebite
INDIRECT EFFECT: EXCESSIVE MUSCULAR HYPERACTIVITY OR RIGIDITY PROLONGED SEIZURES HYPERTERMIA MUSCULAR COMPRESSION FROM PROLONGED IMMOBILITY (COMA) NON-TOXIC CAUSES COMA OR PROLONGED IMMOBILITY FROM ANY CAUSE DIRECT MUSCLE INJURY ISCHAEMIC MUSCLE INJURY CRUSH INJURY VASCULAR OCCLUSION
• IN THIS STUDY WE AIMED TO DESCRIBE ONE CASE WHO DEVELOPED ACUTE RENAL FAILURE AFTER RECENT INTRAVENOUS METHADONE-DIAZEPAM ABUSE • OBJECTIVE: • A 30 -years old man, known to be a heroin addict, was found at work place, totally unrousable, bent on his hips in the lotus position. • On admission (18. April, 2007), in General Hospital in Ohrid he was in coma state with miosis and acute respiratory depression, respiratory failure requiring intubation and artificial ventilation
• AT THE RECEPTION AT OUR CLINIC, HE WAS STILL IN SOPOROUS STATE WITH MIOSIS AND HYPOTENSION AND PROLONGED IMMOBILITY • ROUTINE BIOCHEMICAL TESTS WERE DETERMINED: Blood tests, serum transaminases, • ALT, AST, GGT, AF, LDH, CPK, CRP, bilirubine, coagulation factors, proteins, lipids, electrolytes, urine, alkali-acid status and markers of Hepatitis A, B, C and HIV
Hourly, urine output were measured. Liver ECHO, RTG-Chest and the CT scan of the brain were made also. Urine concentrations of Opiates and Benzodiazepines were determined using TLC and EMIT technique.
RELEVANT INVESTIGATIONS • A SERUM CREATINE PHOSPHOKINASE ACTIVITY GREATER THAN FIVE TIMES THE NORMAL VALUE (IN THE ABSENCE OF HEART AND BRAIN DISEASE) IS THE MOST SENSITIVE INDICATOR OF RHABDOMYOLYSIS • MYOGLOBINAEMIA WAS THE REASON FOR A VISIBLE DISCOLORATION OF THE URINE (REDBROWN). WE DID NOT HAVE A POSSIBILITY TO DO A ORTHOTOLUIDINE REACTION (Hematest) to confirm the presence of myoglobinuria • Kalaemia, calcaemia, phosphataemia, uricaemia, urea, serum creatinine, AST, ALT, LDH activities
THE MAIN CLINICAL FINDINGS: INDURATION OF UPPER AND LOWER LIMB SUGGESTED RHABDOMYOLYSIS. SKIN CNANGES DUE TO ISCHAEMIC TISSUE INJURY (DISCOLORATION, BLISTERS) WERE PRESENTED ON THE AFFECTED AREA. DARK (RED-BROWN) URINE WAS A CLASSICAL MANIFESTATION OF RHABDOMYOLYSIS. SIGNS RELATED TO COMPLICATIONS OF RHABDOMYOLYSIS – HYPERKALAEMIA, ACUTE RENAL FAILURE, METABOLIC ACIDOSIS WERE NOTED.
FOCAL POINTS IN THE TREATMENT: • THE FIRST AIM OF TREATMENT WAS TO SUPPORT VITAL FUNCTIONS • CARDIO-PULMONARRY AND CEREBRAL PHARMACOLOGICAL SUPPORT AND CONTROL OF FLUIDS, ELECTROLYTES AND ALKALI-ACID STATUS • HAEMODIALYSIS • Antibiotics, Vitamins, Corticosteroids, Infusions, Calcium salts, Diuretics, Sodium Bicarbonate, were given following laboratory findings.
RESULTS: DURING THE TREATMENT IN THE INTENSIVE CARE UNIT SIX HAEMODIALYSIS WERE MADE LABORATORY VALUES BEFORE THE STARTING DIALYTIC TREATMENT AND AFTER THE SIXTH HAEMODIALYSIS
LABORATORY FINDINGS CPK------ 2764 U/L--Last results -19. 05. 07 ---173 U/L Urea------ 42, 9 mmol/L-------------- 9, 7 mmol/L Creatinin----- 825 micmol/L-------------86 micmol/L Na------- 136 mmol/L---------------140 mmol/L Potassium----- 5, 0 mmol/L--------------4, 8 mmol/L Ca ------- 2, 2 mmol/L--------------2, 2 mmol/L AST-------406 U/L-----------------36 U/L ALT-------439 U/L----------------47 U/L LDH-------1353 U/L----------------586 U/L AF--------73 U/L-----------------120/U/L
BLOOD VALUES DURING THE TREATMENT AT THE CLINIC Hb—------111— 94— 92 ---- 90 -----90 g/L Er--------3, 7 ---- 3, 0— 2, 67 --- 3, 0 -----3, 0 (x 10¹²/L) Hct-------0, 30 --- 0, 27— 0, 26 ------0, 28 Tr—-------226 ----- 257 -------277(x 109/L) Le--------29, 2 ---22, 6 ----15, 8 Fe--------13, 0(ųmol/L) TIBC------ 39, 8(ųmol/L) 13, 6 ----8, 0(x 109/L)
URINE OUTPUT - diuresis From 100 ml per day from 26 April. 07, slowly increase to 6300 ml per day on 05 May. Last results from 19 May-1500 ml per day
IN OUR DAILY TOXICOLOGICAL PRACTICE WE HAVE HAD MANY RHABDOMYOLYSIS AFTER HEROIN OVERDOSE AT HEROIN ADDICTS DIALYTIC TREATMENT – NECESSARY AND SUCCESSFUL IN CORRECTION HYDROELECTROLYTIC IMBALANCE AND RENAL FUNCTION ALTERATIONS AND IT MAY BE A PATHOGENETIC THERAPY BY MYOGLOBIN REMOVAL FROM THE PLASMA
ALTHOUGHT RENAL RECOVERY WAS EXPECTED, LONG –TERM IMMOBILITY CAUSED ONE POTENCIAL SERIOUS COMPLICATION AS A DEEP PHLEBOTHROMBOSIS ON THE LEFT HAND THE LEFT LEG
THE PATIENT WILL CONTINUE WITH FURTHER TREATMENT WITH METHADONE MAINTENANCE THERAPY AND FRAHEPAN, LMWH, ( Low molecular weight heparin), AND REHABILITATION TREATMENT IN “SVETI ERAZMO” HOSPITAL IN OHRID
- Slides: 18