A Case of Rhabdomyolysis Associated with Use of a Pneumatic Tourniquet during Arthroscopic Knee Surgery

이용구,박웅,김상훈,정훈,윤상필,양동호,김형종 대한내과학회 2010 The Korean Journal of Internal Medicine Vol.25 No.1

The common causes of rhabdomyolysis include trauma, hypoxia, drugs, toxins, infections and hyperthermia. Operative insults, including direct trauma and ischemia, have the potential to cause the development of rhabdomyolysis. Pneumatic tourniquets used during arthroscopic knee surgery to prevent blood loss have led to many complications such as nerve paralysis and vascular injuries. Rhabdomyolysis can also be caused by prolonged pneumatic tourniquet application without a midapplication release, and also from an increased application pressure, but the actual incidence of this is low. In order to prevent rhabdomyolysis, the clinicians must be aware of such risks and follow strict guidelines for the application time, the midapplication release and also the inflation pressure. Vigorous hydration and postoperative patient surveillance are helpful to prevent rhabdomyolysis. We have recently experienced a case of rhabdomyolysis after the arthroscopic knee surgery, and the rhabdomyolysis could have been associated with the use of a pneumatic tourniquet. (Korean J Intern Med 2010;25:105-109) The common causes of rhabdomyolysis include trauma, hypoxia, drugs, toxins, infections and hyperthermia. Operative insults, including direct trauma and ischemia, have the potential to cause the development of rhabdomyolysis. Pneumatic tourniquets used during arthroscopic knee surgery to prevent blood loss have led to many complications such as nerve paralysis and vascular injuries. Rhabdomyolysis can also be caused by prolonged pneumatic tourniquet application without a midapplication release, and also from an increased application pressure, but the actual incidence of this is low. In order to prevent rhabdomyolysis, the clinicians must be aware of such risks and follow strict guidelines for the application time, the midapplication release and also the inflation pressure. Vigorous hydration and postoperative patient surveillance are helpful to prevent rhabdomyolysis. We have recently experienced a case of rhabdomyolysis after the arthroscopic knee surgery, and the rhabdomyolysis could have been associated with the use of a pneumatic tourniquet. (Korean J Intern Med 2010;25:105-109)

간경변 환자에 발생한 비외상 횡문근융해증의 임상 특성

김민정 ( Min Jeong Kim ),이홍식 ( Hong Sik Lee ),김경진 ( Kyung Jin Kim ),정록선 ( Rok Son Choung ),임형준 ( Hyung Joon Yim ),이상우 ( Sang Woo Lee ),최재현 ( Jai Hyun Choi ),김창덕 ( Chang Duck Kim ),류호상 ( Ho Sang Ryu ),현진해 대한소화기학회 2005 대한소화기학회지 Vol.46 No.3

목적: 횡문근융해증은 다양한 비외상 원인에 의해 발생할 수 있고 급성신부전 등의 합병증이 동반될 수 있는 질환이다. 그러나 간경변 환자들에서 발생한 비외상 횡문근융해증은 몇몇 산별적인 보고가 있을 뿐이고 임상 특성은 잘 알려져 있지 않은 상태이다. 저자들은 알코올 및 비알코올 간경변 환자들에게 병발된 비외상 횡문근융해증의 임상 특성을 알아보았다. 대상 및 방법: 2001년 10월부터 2004년 9월까지 고려대학교 안산병원 소화기내과에 간경변으로 입원한 환자 중 외상 없이 자발적인 횡문근융해증의 소견을 보인 19예를 대상으로 임상 특성, 검사 소견 및 치료 성적을 분석 하였다. 결과: 대상 환자 19예 중 남자 14예, 여자 5예였고, 평균연령은 49.6세(32-74세)였다. 알코올 간경변에 병발한 횡문근융해증군은 알코올(50.0%)이, 비알코올 간경변에 병발한 횡문근융해증군은 분명한 원인이 없는 자발적인 경우(69.2%)가 주된 원인이었다. 알코올 간경변에 병발한 횡문근융해증군은 대체로 비특이 증상을, 비알코올 간경변에 병발한 횡문근융해증군은 전형적인 증상을 호소하는 경우가 많았다. 대상 간경변군에서는 사망한 환자가 없었으나, 비대상 간경변군에서는 8명(57.1%)이 사망하여, 비대상 변화 유무에 따른 사망률의 유의한 차이를 보였다(p=0.04). 핍뇨는 8예(42.1%), 급성신부전은 12예(63.2%)에서 발생하였고, 전체 사망 환자 수는 8예(42.1%)였다. 핍뇨와 급성신부전이 발생하였을 때 사망률이 유의하게 증가하였다. 결론: 간경변 환자에서 비외상 횡문근융해증은 치명적인 결과를 초래할 수 있는 질환으로 특히 비대상 간경변 환자와 경과 중 핍뇨와 급성신부전이 발생한 경우에서 사망률이 높았다. 따라서, 간경변증 환자에서 횡문근 융해증의 발생 가능성을 항상 염두에 두고 의심될 경우 신속히 진단하여 적극적인 치료를 시행해야 한다. Background/Aims: Rhabdomyolysis is a serious and lethal condition that can be induced not only by traumatic causes but also by a variety of nontraumatic causes. However, there are few reports about rhabdomyolysis developed in patients with liver cirrhosis. We carried out this study to elucidate the clinical characteristics and courses of rhabdomyolysis in patients with liver cirrhosis. Methods: We analyzed 19 cases of nontraumatic rhabdomyolysis in patients with liver cirrhosis who had admitted at Korea University Ansan Hospital between October 2001 and September 2004. Results: Alcohol (50%) was the main etiology of rhabdomyolysis in alcoholic liver cirrhosis patients, and the precipitating factors were not apparent (69.2%) in majority of nonalcoholic liver cirrhosis patients with rhabdomyolysis. Nonalcoholic liver cirrhosis patients had complaints of pain referable to the musculoskeletal system, but alcoholic liver cirrhosis patients had no typical complaints. Mortality of rhabdomyolysis in liver cirrhosis patients was high (42.1%), especially in decompensated liver cirrhosis patients (p=0.04). In nonalcoholic liver cirrhosis patients, the development of oliguria (p=0.007) and acute renal failure (p=0.049) in the course of rhabdomyolysis increased the mortality significantly. Conclusions: In cirrhosis patients, rhabdomyolysis showed a poor prognosis, especially in nonalcoholic liver cirrhosis with oliguria, acute renal failure, or decompensated liver cirrhosis. It is believed that a high clinical suspicion for the occurrence of rhabdomyolysis in liver cirrhosis patients can lead to quicker recognition and better patient care. (Korean J Gastroenterol 2005;46:218-225)

군대 내 건강한 성인 횡문근 융해증 환자의 재발률 : 전향적 선행 관찰연구

국군수도병원 ( Yongjin Yi ) 국군의무사령부 2019 대한군진의학학술지 Vol.50 No.1

Objective; Rhabdomyolysis is a syndrome caused by rapid breakdown of skeletal muscle. Toxic cellular contents leaking to bloodstream would lead to acute kidney injury, compartmental syndrome, or disseminated intravascular coagulation. There was little evidence of recurrence rate of rhabdomyolysis due to lack of observational study performed in prospective manner. This study is prospective, observational study to assess recurrent rate of rhabdomyolysis in young, male military subjects. Method; From September 2016 to August 2017, newly diagnosed rhabdomyolysis patients who treated in Armed Forces Command Hospital were asked to participate the surveillance based prospective observational study for recurrence of rhabdomyolysis. The subjects followed 3-month interval surveillance until October 2018. They asked to visit the hospital when muscular or urinary symptoms recur and laboratory tests including serum creatinine kinase (CK) test was done. Recurrent rhabdomyolysis defined as more than one symptom of rhabdomyolysis with serum CK elevation. Results; A total of 17 patients were participated in the study. Fourteen patients (82%) were exertional and three (18%) had infectious rhabdomyolysis. During median 196 days of follow-up, four (24%) of the study subjects had recurred rhabdomyolysis proved by serum CK test. All four recurred subjects’ cause of recurrence was exertion. Crude recurrence rate in the study was 34.2 per 100 person-years (95% confidence interval: 12.8-91.1). Conclusion; This prospective pilot study aimed to discover the recurrence rate of rhabdomyolysis among young, physically active participants. Compared with other retrospective observational studies, this study shows relatively high recurrence rate during follow-up period.

독시라민 중독 환자에서 독시라민의 혈중 농도와 횡문근융해증 발생의 관계

안남규,한승백,김준식,백진휘,정현민,김지혜 대한응급의학회 2010 大韓應急醫學會誌 Vol.21 No.5

Purpose: The relationship between plasma concentration of doxylamine and rhabdomyolysis in doxylamine overdose has not yet been reported. The aim of this study was to determine if the plasma concentration of doxylamine can predict the occurrence of rhabdomyolysis. Methods: We reviewed the medical records of patients whose plasma concentration of doxylamine were checked during a state of doxylamine overdose. Variables, including the measured concentration (Ct) of drug, were compared between the rhabdomyolysis and the non-rhabdomyolysis group. We calculated the hypothetical initial concentration (C0) based on first order pharmacokinetics and measurement of each patient's plasma concentration of doxylamine (Ct). C0 values were compared based on the occurrence of rhabdomyolysis. Results: A total of 41 blood samples were taken; all were taken more than two hours after the ingestion of doxylamine. Of the 41, 14 of the subjects showed rhabdomyolysis and 15 of the subjects did not. The rest were excluded from the study. Average values of Ct and C0 in the rhabdomyolysis and non-rhabdomyolysis groups were, respectively,4.18±5.17 mg/L Vs 4.18±2.23 mg/L, for Ct; 6.21±7.92 mg/L Vs 15.53±17.97 mg/L for C0. Ct levels between the two groups were not different (p=1.00), but the difference in C0 was marginally significant (p=0.08). Blood sampling time showed a significant difference between the two groups (p=0.03). Conclusion: We can not confirm a relationship of plasma doxylamine concentration and rhabdomyolysis but it appears that the development of rhabdomyolysis in doxylamine overdose has a tendency to increase at high plasma concentration.

Case report : A Case of Rhabdomyolysis Associated with Use of a Pneumatic Tourniquet during Arthroscopic Knee Surgery

( Yong Gu Lee ),( Woong Park ),( Sang Hoon Kim ),( Sang Pil Yun ),( Hun Jeong ),( Hyung Jong Kim ),( Dong Ho Yang ) 대한내과학회 2010 The Korean Journal of Internal Medicine Vol.25 No.1

The common causes of rhabdomyolysis include trauma, hypoxia, drugs, toxins, infections and hyperthermia. Operative insults, including direct trauma and ischemia, have the potential to cause the development of rhabdomyolysis. Pneumatic tourniquets used during arthroscopic knee surgery to prevent blood loss have led to many complications such as nerve paralysis and vascular injuries. Rhabdomyolysis can also be caused by prolonged pneumatic tourniquet application without a midapplication release, and also from an increased application pressure, but the actual incidence of this is low. In order to prevent rhabdomyolysis, the clinicians must be aware of such risks and follow strict guidelines for the application time, the midapplication release and also the inflation pressure. Vigorous hydration and postoperative patient surveillance are helpful to prevent rhabdomyolysis. We have recently experienced a case of rhabdomyolysis after the arthroscopic knee surgery, and the rhabdomyolysis could have been associated with the use of a pneumatic tourniquet. (Korean J Intern Med 2010;25:105-109)

운동 후 발생한 횡문근융해증의 임상적 고찰

김경곤,김준형,김성민,전규락,김영욱,이호학,박상준,김윤권,김소연,김영중,조민구,이권전 대한내과학회 2002 대한내과학회지 Vol.63 No.6

Background : It is important to recognize rhabdomyolysis in clinical settings, because 10~30% of rhabdomyolysis patients develop acute renal failure as a complication and patients with such complication have risk of high mortality. Recently, there have been frequent reports about healthy people who developed rhabdomyolysis after heavy exercise, but few prospective studies on exercise-induced rhabdomyolysis have been reported. Methods : To evaluate the degree of muscle cell necrosis during the regular combat-police training, we examined the level of creatine kinase, plasma myoglobin and bone scan in 173 combat-police before the training and on fourth day after the training. Average ambient temperature and humidity during the study were 25℃ and 78%, respectively. Results : From the laboratory findings, 98 out of 173 combat-police were diagnosed as having rhabdomyolysis. Upon regressional analysis, an increase in amount of exercise correlated with the elevation of the levels of plasma creatine kinase and myoglobin. Among variables related to rhabdomyolysis only the levels of myoglobin, aspartate aminotransferase were significantly elevated. The level of plasma creatinine was elevated along with the elevation of plasma myoglobin. Bone scan not only provided detailed information on the location and degree of muscle cell damage, but also could be of diagnostic value in patients whose creatine kinase had been normalized. Conclusion : In people who developed rhabdomyolysis after heavy exercise, the level of plasma creatinine was elevated along with the elevation of plasma myoglobin. So early diagnosis of rhabdomyolysis and early detection of acute renal failure may be useful with monitoring of plasma myoglobin level.(Korean J Med 63:675-681, 2002) 목적 : 저자들은 전투 경찰에서 흔히 실시되는 훈련 후 횡문근융해증과의 연관성을 알아보고자 하였다. 방법 : 전투경찰 173명을 대상으로 6일간 평균 매일 8시간에 걸쳐 PT체조훈련이 시행하였고, 설문조사를 통해 개인당 훈련량을 조사하였다. 결과 : 검사 결과 173명 중 98명에서 횡문근융해증을 진단 할 수 있었다. 혈중 마이오글로빈은 훈련량이 증가함에 따라 상승하는 소견을 보였다. 시간 경과에 따른 진행 과정을 볼 때, CPK, AST, 혈중 마이오글로빈은 자연 치유되는 경향을 보여 주었으며, 다른 검사가 정상으로 되어도 골주사 검사는 병력이나 이학적 검사로는 알 수 없는 근육 손상의 정도나 위치를 알 수 있었으며 생화학 검사가 정상화된 환자에서도 횡문근융해증의 진단에 유용한 정보를 제공하였다.

독시라민 중독 노인 환자에게서 횡문근융해증이 더 많이 발생하는가 ?

임용민,최한성,권오영,이종석,홍훈표,고영관,임성관,김신철,김동필 대한노인병학회 2013 Annals of geriatric medicine and research Vol.17 No.4

Background: Doxylamine is an over-the-counter drug that is popular in the treatment of insomnia. Doxylamine is relatively safe but can cause rhabdomyolysis. The aim of this study was to evaluate whether the incidence of rhabomyolysis increased in elderly patients (age≥65 years) with doxylamine overdose. Methods: This study included 108 patients admitted to an Emergency Department after doxylamine overdose between January 1, 2000, and March 31, 2013. Age, sex, time ingested before admission, amount of drug ingested, gastric lavage, tachycardia, vomiting, hematuria, blood urea nitrogen, blood creatinine, urine pH, and alcohol ingestion were investigated for the risk factors of rhabdomyolysis. Results: Forty-three patients (47.6%) developed rhabdomyolysis. Of 16 elderly patients, 11 developed rhabdomyolysis. Of the 92 patients <65 years-of-age, 34 developed rhabdomyolysis. Advanced age, alcohol ingestion, and increased blood creatinine level were significantly associated with the development of rhabdomyolysis. Conclusion: In elderly patients with doxylamine overdose, the incidence rate of rhabdomyolysis may be increased. A high index of suspicion and evaluation of rhabdomyolysis is warranted in elderly patients with doxylamine overdose. 연구배경: 독시라민은 주로 수면 유도의 용도로 쓰이는데, 의사의 처방 없이 구입 가능하기 때문에 자살을 목적으로 과용하는 경우가 많다. 독시라민은 비교적 안전한 약이지만, 과량 복용시 횡문근융해증을 일으킬 수 있다. 저자는 노인이 독시라민을 과용하였을 때 노인이 아닌 환자들에 비해서 횡문근융해증이 발생할 가능성이 높은지 알아보고자 하였다. 방법: 2000년 1월 1일부터 2013년 3월 31일까지 응급의료센터를 통해 입원한 독시라민 중독 환자 108명을 대상으로하였다. 연구 대상 환자들의 노인 여부(65세 이상), 성별, 복용후 병원을 방문하기까지 걸린 시간, 복용한 독시라민의 양, 위세척의 시행 여부, 빈맥과 구토의 유무, 초기 혈뇨의 유무, 초기 혈액 요소 질소(blood urea nitrogen), 초기 혈청 크레아티닌, 초기 요 pH, 알코올의 복용 유무 등의 인자들과 횡문근융해증의 발생의 관계를 조사하였다. 결과: 연구에 포함된 총 108명의 환자 중 45(41.7%)명에게서 횡문근융해증이 발생하였다. 65세 이상의 노인 환자는 16 명이었으며, 이 중 11명에게서 횡문근융해증이 발생하였고, 65세 미만의 인구는 92명이었으며, 이 중 34명에게서 횡문근융해증이 발생하였다. 독시라민 중독 환자에게서 노인일 경우그렇지 않은 경우보다 횡문근융해증의 발생이 유의하게 증가되는 것으로 나타났다. 이밖에 알코올을 같이 복용했는지의여부, 혈중 크레아티닌 농도가 횡문근융해증의 발생과 유의한연관성을 보였다. 결론: 독시라민 중독 환자에서 노인의 경우에 횡문근융해증의 발생의 위험이 커질 수 있다. 따라서 노인 환자가 독시라민을 과용하였을 경우, 횡문근융해증이 발생할 위험성이 더높다는 것을 알고 예방과 진단, 치료에 주의를 기울여야 할것이다.

Incidence, Etiology, and Outcomes of Rhabdomyolysis in a Single Tertiary Referral Center

박재석,이은영,서민숙,길효욱,홍세용 대한의학회 2013 Journal of Korean medical science Vol.28 No.8

We have encountered numerous cases of rhabdomyolysis associated with acute pesticide intoxication; however, the cause, incidence, and treatment outcomes of rhabdomyolysis have not been studied. The current study involved 2,125 patients hospitalized with acute chemical poisoning. Based on clinical and laboratory parameters and treatment outcomes,we found that overall incidence of rhabdomyolysis in our hospital was 0.06% (93 of 143,830 patients admitted), but the incidence associated with acute pesticide intoxication was 1.8% (33 of 1,793 cases). The incidence of rhabdomyolysis after pesticide intoxication was significantly higher in men than in women (P = 0.010). The amount of pesticide ingested was significantly higher in rhabdomyolysis patients than that in those who did not develop rhabdomyolysis (mean ± SD, 114.1 ± 79.5 mL vs 74.1 ± 94.2 mL, P = 0.010). Our results show that pesticide intoxication is a frequent cause of rhabdomyolysis and is more common among men than women. The volume of pesticide ingested, and not the degree of human toxicity, is the main factor influencing the incidence of rhabdomyolysis.

횡문근융해를 동반한 고혈당성 응급상태 환자의 임상적 특징

김수경,백종하,이경주,함종렬,정정화,김희진,김호수,김성수,정순일,정태식 대한내분비학회 2011 Endocrinology and metabolism Vol.26 No.4

Background: The purpose of this study was to investigate the prevalence of rhabdomyolysis and its association with both clinical course and prognosis and to evaluate the factors associated with rhabdomyolysis in patients with hyperglycemic emergencies. Methods: We reviewed the medical records of patients with hyperglycemic emergencies who visited our hospital from May 2003to April 2010. We assessed the clinical characteristics, biochemical profiles and clinical course of patients and analyzed these data according to the presence of rhabdomyolysis. Results: The prevalence of rhabdomyolysis was 29 patients (28.4%) among 102 patients. Mean serum osmolarity, glucose and serum creatinine levels were higher in patients with rhabdomyolysis than those without rhabdomyolysis. Patients with rhabdomyolysis had higher rates of hemodialysis and mortality than those without the condition. The factors associated with rhabdomyolysis in the hyperglycemic emergency state were increased serum osmolarity and APACHE II score on admission (P < 0.05). Conclusion: Rhabdomyolysis commonly occurred in patients with hyperglycemic emergencies and this could aggravate their clinical course and increase mortality.

상용량의 아세트아미노펜 복용 후 발생한 횡문근융해에 의한 급성신부전

김형진(Heung Jin Kim),김일두(Il Doo Kim),황영훈(Yeoung Hoon Whang),배용목(Yong Mock Bae),서길동(Gil Dong Seo),김명준(Myong June Kim),김수형(Soo Heung Kim),이인상(In Sang Lee) 대한신장학회 2000 Kidney Research and Clinical Practice Vol.19 No.1

A 21-year-young man had an episode of myalgia and chilling 3 days prior to hospital admission. He had consumed common doses of acetaminophen for one day, and was presented in the sauna room for an hour. On the next morning, he complained of dyspnea and was admitted. He presented in rhabdo-myolysis and acute renal failure with increased up-take in the proximal muscles by (99m)Tc-MPD bone scan. He was treated by hemodialysis and discharged on the twenty-eighth hospital day. Rhabdomyolysis has the variable causes. The causes of this case are two, the first cause is common doses of acetaminophen. But, there is no reports for rhabdomyolysis by common doses of acetaminophen only. However, we should consider that acetaminophen is a contributing factor in this case. The second cause is viral infection. Our patient had myalgia and chilling prior to hospital admission. Heat- stroke is well known cause of rhabdomyolysis. The mechnisms for rhabdomyolysis in this disease are hypovolemia, total body potassium deficit, and increased variable cytokines. Sauna, the last cause of our rhabdomyolysis case may have the same mechanisms with heatstroke. Our case had two causative factors, common doses of acetaminophen and sauna. These factors might be cooperated in our case of rhabdomyolysis and acute renal failure.