Exertional rhabdomyolysis and heat stroke: Beware of volatile anesthetic sedation

Abstract

In view of the enormous popularity of mass sporting events such as half-marathons, the number of patients with exertional rhabdomyolysis or exercise-induced heat stroke admitted to intensive care units (ICUs) has increased over the last decade. Because these patients have been reported to be at risk for malignant hyperthermia during general anesthesia, the intensive care community should bear in mind that the same risk of life-threatening rhabdomyolysis is present when these patients are admitted to an ICU, and volatile anesthetic sedation is chosen as the sedative technique. As illustrated by the three case studies we elaborate upon, a thorough diagnostic work-up is needed to clarify the subsequent risk of strenuous exercise, and the anesthetic exposure to volatile agents in these patients and their families. Other contraindications for the use of volatile intensive care sedation consist of known malignant hyperthermia susceptibility, congenital myopathies, Duchenne muscular dystrophy, and intracranial hypertension.

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“…Common risk factors for rhabdomyolysis include high body temperature, seen in individuals working in outdoor and hot environments like forge and smelter workers, roofers, and asphalt pavers. Other risk factors encompass muscle overuse during high levels of physical exertion or intense workouts leading to muscle necrosis, physical damage to muscles from crush injuries or fall from heights, illicit drug use (cocaine and methamphetamine), excessive alcohol consumption, infections (flu, cytomegalovirus, Epstein-Barr virus, HIV, bacterial, fungal, and parasitic infections), inflammatory and autoimmune muscle conditions (e.g., polymyositis), and certain underlying medical conditions (uncontrolled diabetes, sickle cell disease, thyroid disorders) [15][16][17]. Medications such as antibiotics, antidepressants, cholesterol-lowering agents (statins), and cold and allergy medications are also associated with an increased risk.…”

Repetitive Bouts of Exhaustive Exercise Induces a Systemic Inflammatory Response and Multi-Organ Damage in Rats

“…While this response is important for muscle regeneration following normal exercise, excessively damaging or exhaustive exercise induces a larger, systemic inflammatory response with release of a variety of cytokines and chemokines which can induce multi-organ effects (Yang and Hu, 2018). As such, beyond the direct damage to skeletal muscle, exhaustive exercise is known to induce systemic phenomena such as heat stress (American College of Sports Medicine et al, 2007;Heytens et al, 2017), visceral organ ischemia via splanchnic hypoperfusion (van Wijck et al, 2012), and alterations in blood cell counts and inflammatory mediator levels (Gannon et al, 1997;Weinstock et al, 1997;Ronsen et al, 2001).…”