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    A kliewer case_1_pp A kliewer case_1_pp Presentation Transcript

    • Allison KliewerDecember 19, 2012
    • › Introduction› Patient Profile› Disease background› Admission› Nutrition Care Process› Summary and Reflection
    • › Exertional rhabdomyolysis is a muscleinjury the results in the lysis of skeletalmuscle and the release of celllularcomponents into the circulation› In severe cases can lead to death› Rhabdomyolysis affects 1/10,000people in the US per year(Boutaud and Robert, 2010 and Stella and Shariff, 2012)
    • › 28 year old African American Male› Admission: 9/03/12 Discharge: 9/13/12› Initial DX: heat exhaustion and cramps› Admit through ER from soccertournament› PMH: heat exhaustion requiring IV fluids2 at soccer tournament 2 years prior› Family HX: insignificant› Single, lives with roommate
    • › Native to Florida where he currentlylives› Has been a Civil Servant for >4 years inthe Air Force as a Systems Engineer› Currently completing hisundergraduate degree› Position: Right back› Been playing soccer for 23 years
    • › Ht: 71 in - 6’ 11”› Wt: 91.17 kg – 200 lbs› No previous wt gain/loss› No difficulty swallowing/chewing or BM› Denies any substance abuse› Previously healthy individual
    • › Numbers 11: 31-35› 1812 during Napoleon’s rein› 1941 during WWII after the Blitz ofLondon referred to as “crush syndrome”(Elsayed and Reilly, 2010)
    • › Breakdown of skeletal muscle resultingin the release of intracellular contents› Leakage of contents can becomesevere and life threatening(Khan, 2009)
    • › Acute Renal Failure: abrupt decrease inrenal function sufficient enough to resultin retention of nitrogenous waste anddisrupt fluid and electrolyte homeostasis(Anderson, 2009)
    • › Illicit drug use, alcohol abuse, muscledisease, trauma, seizures and immobility› Sporadic strenuous exercise can causeexertional rhabdomyolysis› Excess heat increases risk› Hypokalemia› Hyponatremia(Bruso, 2010)
    • › Myocyte is muscle cell› Sarcomlemma is a thin membrane thatencloses striated muscle fibers andelectrochemical gradients› Intercellular Na is maintained at 10 mEq/L byactive transport› Interior of cell is negatively charged and canpull Na to interior for Ca exchange(Khan, 2009)
    • › Low levels of intracellular Ca allows forincreased actin-myosin musclecontraction› Na/K-ATPase pump and Ca-ATPasepump› Every electrochemical pump requiresATP› ATP depletion = Pump dysfunctionresulting in rhabdomyolysis(Kahanov et al, 2012)
    • › Destruction of myocytes› Dysfunction of the electrochemicalpumps located in the sacrolemmamembrane› Altered ATP = Na in cytoplasm =intracellular Ca› Proteases and phospholipases activate= destruction of myofibrillar cytoskeletalmembrane proteins(Bosch, 2009 and Khan 2009)
    • › Muscle cell breaksdown, K, aldolase, phosphorus, myoglobin, creatine kinase, lactatedehydrogenase, urate, apsertatedehydrogenase are released intocirculation› >100 g of muscle breaks down -myoglobin releases into the circulation› myoglobin leads to renal tubularobstruction, nephrotoxicity, and ARF(Khan, 2009)
    • › Muscle damage can increase from 2-12hrs after injury› Peak values at 24-72 hrs› Creatine Kinase (CK) 5 x normal value isaccepted for dx› Myoglobin might become visible in theurine(Kahanov et al, 2012)
    • › Hypovolaemia: fluid into necroticmuscle› Compartment syndrome: ischemia andswelling› Hepatic dysfunction› Lactic acidosis› Acute Renal Failure ~ 33% ofrhabdomyolysis(Kahanov et al, 2012)
    • › Depends on underlying cause› If treated early and aggressively, goodprognosis› 80% have recovered renal function› 1,500 die of rhabdomyolysis per year(Thoenes, 2010)
    • › Weightlifting,sprinting, contactpractices,noncontactpractices, runningand swimming› Good physicalshape› Outside and in airconditionedenvironments
    • Article Sport/Event Suspect Cause Diagnosis OutcomeBruso, 2010 161 km ultramarathonover hydration 5 cases ofrhabdomyolysis3 with ARFFull recoveryCasares andMarull, 2008Heavy weightleg workoutUnconditionedmuscle groupExertionalRhabdoCK 1,454,9528 days after d/c CK <1,000Stella andShariff, 2012RecreationalswimmingUnconditioned Ecertional rhabdoCK 112,400Full recoveryThoenes,2010Spin class Strenuousrepetitive exerciseExertional rhabdomyoglobinuriaFull recoveryKuklo et al,2000Army PhysicalFitness testStrenuous exerciseDehydrationundernourishedMyoglobinuriaAcidosisAR insuffieciencyElevated CKMultisystem failureexpiredKaterina etal, 2006246-kmcontinuousrunning raceContinuous musclestrain39 possiblerhabdomyolysisNot reported onParmar et al,2012Spin class Sudden increase intraining /s propertraining2 cases ofrhabdomyolysisLab values within normallimits at F/UKahanov etal, 2012Div I NCAAfootballEccentric exercise Rhabdomyolysis Increased CK for 18 days6 week recovery period
    • › Pt initial diagnosis was heat exhaustionwith cramps, then later the primarydiagnosis changed to Rhabdomyolysiswith Acute Renal Failure› Pt was hospitalized for 10 days› Pt expressed a lack of understandingrelated to his condition
    • › Pt was treated with aggressivehydration and electrolyte replacement› Made a gradual recovery› 3rd day- decreased musclecramps, soreness› 4th day- CK began to trend down› 7th day- ARF was resolved› 10th day- CK 1106
    • 281720500205001399312135718845253508 23521643 1106CKCK
    • › BMI: 26› 76-100% intake› No complaints› Nutritional parameters within normallimits as evidence by BMI, labs, and %intake
    • Calories: 2,560 - 2,985(30-35 kcal/kg)Protein: 102 – 136g(1.2-1.6 g/kg)CHO: 385 – 682g (4.5 –8 g/kg)ESTIMATED DAILYNEEDSCalories: 1,210Protein: 77gCHO: 76gSodium: 2,988(Maughan, 2002)ESTIMATED DAILYINTAKE
    • 9/01/12• 79-98˚F• 66%averagehumidity• 10 mphaveragewindspeed9/02/12• 77-99˚F• 60%averagehumidity• 11 mphaveragewindspeed9/03/12• 76-99˚F• 60%averagehumidity• 10 mphaveragewindspeed
    • › Water intoxication› < 135 mEq/L of sodium in the blood› Excessive water intake› Osmotic imbalance(Bruso et al, 2010)
    • › Facilitates rehydration› Sustains the thirst drive› Promotes retention of fluids› More rapidly restores lost plasmavolume during rehydration(Bruso et al, 2010)
    • › Exercise Associated Hyponatremia (EAH)› Facilitates rhabdomyolysis throughchanges in intracellular K or Caconcentration resulting in hypotonic cellswelling› Lysis from exertion and thermal strain =spacing of fluids = facilitates EAH(Bruso et al, 2010)
    • › risk of opportunistic infections› Damaged tissues caused by freeradicals after exercise can lead toincomplete recovery(Maughan, 2002)
    • › Higher average energy deficit = higherbody fat percentage› rate of protein catabolism› ↓ immune function(Deutz et al, 2000 and Maughan, 2002)
    • › Oxidation of fat and CHO for energy› Body stores of CHO are relatively low› Glycogen stores deplete duringstrenuous exercise› CHO not replenished = decrements intraining response(Maughan, 2002)
    • › Low-CHO diet = difficulty in sportperformance compared to high-CHOdiet› Low-CHO diet risk of injury andsusceptibility to minor infections› High-CHO might be difficult to achievedue to daily practicalities of mostathletes(Maughan, 2002)
    • › Adequate dietary CHO before exerciseand regular CHO ingestion duringexercise to minimize stress hormonesthat have negative effect on immunity› Maintaining adequate dietary CHOintake is a priority(Maughan, 2002)
    • › Inadequate carbohydrate intakerelated to food and nutritionknowledge deficit and increasedenergy needs due to physical activityas evidence by estimatedcarbohydrate intake less thanrecommended amounts andverbalized report of incompleteknowledge› Basic sport nutrition education wasgiven
    • › >23 years as a soccer player with nonutritional guidance?!› Could this have been avoided withproper dietary habits and nutrition?› Who is responsible?
    • Anderson, R. & Barry, D. (2004). Clinical and laboratory diagnosis of acute renal failure. Best Practice & ResearchClinical Anesthesiology. 18(1): 1-20.Bosch, X., Poch, E., & Grau, J. (2009). Rhabdomyolysis and acute kidney injury. The New England Journal ofMedicine. 361(1): 62-74.Bruso, J., Hoffman, M., Rogers, I., Lee, L., Towle, G., & Hew-Butler, T. (2010). Rhabdomyolysis and hyponatremia:A cluster of five cases at the 161-km 2009 Western States Endurance Run. Wilderness & EnvironmentalMedicine. 21: 303-308.Capacchione, J., & Muldoon, S. (2009). The relationship between exertional heat illness, exertionalrhabdomyolysis, and malignant hyperthermia. Anesthesia Research Society. 109(4): 1065-1069.Casares, P. & Marull, J. (2008). Over a million creatine kinase due to a heavy work-out: A case report. CasesJournal. 1(173): 1-4.Deutz, R., Benardot, D., Martin, D., & Cody, M. (2000). Relationship between energy deficits and bodycomposition in elite female gymnast and runners. Medicine and Science in Sports and Exercise. 659-678.Falvo, M. & Bloomer, R. (2006). Review of exercise-induced muscle injury: Relevance for athletic populations.Research in Sports Medicine. 14: 65-82.Hannah-Shmouni, F., McLeod, K., & Sirrs, S. (2012). Recurrent exercise-induced rhabdomyolysis. CanadianMedical Associations Journal. 184(4): 426-430.Huerta-Alardin, A., Varon, J., & Marik, P. (2005). Bench –to-bedisde review: Rhabdomyolysis- an overview forclinicians. Critical Care. 9: 158-169.Kahanov, L., Eberman, l., Wasik, M., & Alvey, T. (2012). Exertional rhabdomyolysis in a collegiate Americanfootball player after preventive cold water immersion: A case report. Journal of Athletic Training. 47(2): 228-232.Khan, F. (2009). Review: Rhabdomyolysis: A review of the literature. The Netherlands Journal of Medicine. 67(9).Kulko, T., Tis, J., Moores, L., & Schaefer, R. (2000). The American Journal of Sports Medicine. 28(1): 117.Maughan, R. (2002). Plenary lecture: The athlete’s diet: Nutritional goals and dietary strategies. The NutritionalSociety. 61:87-96Parmar, S., Chauhan, B., DuBose, J., & Blake, L. (2012). Rhabdomyolysis after spin clas? The Journal of FamilyPractice. 61(10): 584-586.Skenderi, K., Kavouras, S., Anastasiou, C., Yiannakouris, N., & Matalas, A. (2006). Exertional rhabdomyolysisduring a 246-km continuous running race. Americn College of Sports Medicine. 1054-1056.