Case rhabdo


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Case rhabdo

  1. 1. Allison KliewerDecember 19, 2012
  2. 2. › Introduction› Patient Profile› Disease background› Admission› Nutrition Care Process› Summary and Reflection
  3. 3. › 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)
  4. 4. › 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
  5. 5. › 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
  6. 6. › 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
  7. 7. › 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)
  8. 8. › Breakdown of skeletal muscle resultingin the release of intracellular contents› Leakage of contents can becomesevere and life threatening(Khan, 2009)
  9. 9. › Illicit drug use, alcohol abuse, muscledisease, trauma, seizures and immobility› Sporadic strenuous exercise can causeexertional rhabdomyolysis› Excess heat increases risk› Hypokalemia› Hyponatremia
  10. 10. › 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)
  11. 11. › 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
  12. 12. › 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)
  13. 13. › Muscle cell breaks down, K, aldolase,phosphorus, myoglobin, creatinekinase, lactate dehydrogenase, urate,apsertate dehydrogenase are releasedinto circulation› >100 g of muscle breaks down -myoglobin releases into the circulation› myoglobin leads to renal tubularobstruction, nephrotoxicity, and ARF(Khan, 2009)
  14. 14. › 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
  15. 15. › Hypovolaemia: fluid into necroticmuscle› Compartment syndrome: ischemia andswelling› Hepatic dysfunction› Lactic acidosis› Acute Renal Failure ~ 33% ofrhabdomyolysis
  16. 16. › Depends on underlying cause› If treated early and aggressively, goodprognosis› 80% have recovered renal function› 1,500 die of rhabdomyolysis per year
  17. 17. › 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
  18. 18. › Pt experienced exertionalrhabdomyolysis after playing a soccertournament
  19. 19. › Weightlifting,sprinting, contactpractices,noncontactpractices, runningand swimming› Good physicalshape› Outside and in airconditionedenvironments
  20. 20. Total Daily Calories: 1,210Sodium: 2,988Fat: 61Protein: 77CHO: 76
  21. 21. Calories: 2,560 - 2,985Sodium:Fat:Protein: 102 – 136g(1.2-1.6 g/kg)CHO: 385 – 682g (4.5 –8 g/kg)ESTIMATED DAILYNEEDSCalories: 1,210Sodium: 2,988Fat: 61Protein: 77gCHO: 76gESTIMATED DAILYINTAKE
  22. 22. › Facilitates rehydration› Sustains the thirst drive› Promotes retention of fluids› More rapidly restores lost plasmavolume during rehydration
  23. 23. › Water intoxication› < 135 mEq/L of sodium in the blood› Excessive water intake› Osmotic imbalance
  24. 24. › Acute Renal Failure: abrupt decrease inrenal function sufficient enough to resultin retention of nitrogenous waste anddisrupt fluid and electrolyte homeostasis(Anderson, 2009)
  25. 25. › 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 = AVP secretion andfacilitates EAH(Bruso, 2010)
  26. 26. › Higher average energy deficit = higherbody fat percentage› rate of protein catabolism› ↓ immune function(Deutz et al, 2000 and Maughan, 2002)
  27. 27. › 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)
  28. 28. › 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)
  29. 29. › risk of opportunistic infections› Damaged tissues caused by freeradicals after exercise can lead toincomplete recovery(Maughan, 2002)
  30. 30. › 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)