Predictive Factors for Rhabdomyolysis after Bariatric Surgery

Lagandré, S; Arnalsteen, Laurent; Vallet, B.; Robin, Emmanuel; Jany, T.; Onraed, Brigitte; Pattou, F.; Lebuffe, Gilles

doi:10.1381/096089206778663643

Cited by 92 publications

(87 citation statements)

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“…In a prospective cohort study involving 49 obese patients undergoing bariatric surgery, the authors described prolonged surgery (more than four hours), extreme surgical positions, ASA physical status III-IV, and Preop = preoperative; PO = postoperative; POD = postoperative day; Hb = hemoglobin; CK = serum creatinine kinase the presence of diabetes or hypertension as risk factors associated with development of RML. 6 These findings confirm earlier studies in animals that showed the occurrence of myonecrosis when an intracompartmental pressure of 30 mmHg was applied for four to eight hours. 9 The previous reports of RML described its occurrence in bariatric surgery involving mainly muscles of the gluteal region, as these procedures were performed in the supine position over a lumber pad.…”

Section: Discussionsupporting

confidence: 90%

“…9 The previous reports of RML described its occurrence in bariatric surgery involving mainly muscles of the gluteal region, as these procedures were performed in the supine position over a lumber pad. 6 Our patient developed RML involving shoulder girdle muscles and upper arms probably due to morbid obesity, maintenance of a 15°Trendelenburg position over six hours, and prolonged unrelieved pressure by excessive fat over shoulder girdle and upper arm muscles. The occurrence of microangiopathy with increased platelet aggregation and altered arteriolar permeability as seen in diabetic patients could have increased the risk of muscular ischemia in our patient.…”

Section: Discussionmentioning

confidence: 74%

“…Mortality secondary to RML in the postoperative period has been rarely described after bariatric surgery. 2,6 Perioperative complications frequently occur in morbidly obese patients. 7,8 The excessive weight increases the compressive pressure leading to skeletal muscle ischemic necrosis and the release of muscle toxins into systemic circulation.…”

Section: Discussionmentioning

confidence: 99%

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Case report: Rhabdomyolysis in morbidly obese patients: anesthetic considerations

Ankichetty

Angle

Margarido

et al. 2012

Can J Anesth/J Can Anesth

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Purpose We report the presentation and management of rhabdomyolysis involving shoulder girdle and upper arm muscles in a morbidly obese patient after prolonged laparoscopic surgery. Clinical features A 41-yr-old morbidly obese woman presented for laparoscopic abdominal hysterectomy. She had hypertension and type II diabetes which were controlled on regular medications. She also had obstructive sleep apnea. Her clinical examination and investigations revealed no abnormality except morbid obesity (body mass index 54 kgÁm -2 ) and left ventricular hypertrophy on transthoracic echocardiogram. Standard general anesthesia was administered under baseline non-invasive monitors. Succinylcholine was used to secure the airway during anesthetic induction. Surgery was performed with the patient positioned with a 15°head-down tilt, and it took six hours to complete the procedure as technical difficulty was encountered due to her body habitus. Her trachea was extubated and she was transferred to the postanesthetic care unit (PACU) without incident.In the PACU, the patient complained of severe bilateral arm pain and weakness an hour after surgery. On physical examination, she exhibited limited movement of her arms against gravity while complaining of tenderness in her shoulder girdle muscles and both arms. Clinical suspicion of rhabdomyolysis based on her signs and symptoms was confirmed by an elevated serum creatinine kinase (CK) of 18,392 IUÁL -1 and serum potassium of 5.3 mmolÁL -1 . Intravenous crystalloids and mannitol were administered for 24 hr for renal protection, and her clinical symptoms and serum CK levels improved over seven days. The patient was discharged to home on the tenth postoperative day, and she continued to improve over the three-month followup period. Conclusions Morbidly obese patients who undergo prolonged surgery are at risk for rhabdomyolysis, and early diagnosis and therapy are required to prevent severe complications. RésuméObjectif Nous rapportons la pre´sentation et la prise en charge d'un cas de rhabdomyolyse touchant la ceinture scapulaire et les muscles des bras supe´rieurs d'une patiente obe`se morbide apre`s une chirurgie laparoscopique prolonge´e. É léments cliniques Une femme obe`se morbide de 41 ans s'est pre´sente´e pour une hyste´rectomie abdominale par laparoscopie. Elle souffrait d'hypertension et de diabe`te de type II, lesquels e´taient contrôle´s par un traitement me´dicamenteux re´gulier. Elle souffrait e´galement d'apne´e obstructive du sommeil. L'examen clinique et les analyses n'ont re´ve´le´aucune anomalie hormis une obe´site´morbide (indice de masse corporelle 54 kgÁm -2

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 74%

Section: Discussionmentioning

confidence: 99%

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Case report: Rhabdomyolysis in morbidly obese patients: anesthetic considerations

Ankichetty

Angle

Margarido

et al. 2012

Can J Anesth/J Can Anesth

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“…There are also other factors that are discussed to lead to CK rise. While the influence of obesity remains controversial 3,14 , superobesity is regarded as major risk factor in literature 14,19 . However, neither obesity (BMI>25 kg/m2) nor super-obesity (BMI>30 kg/m2) showed influence on CK levels in our study.…”

Section: Other Reasons For Ck Rise In the Literaturementioning

confidence: 99%

“…During prolonged surgery, diffuse local muscle compression with ischemia and subsequent reperfusion injury is inevitable, despite utilization of modern operating tables and padding 9,10 . Different manifestations after various surgical procedures ranging from simple serum CK rise to rhabdomyolysis with complex organ failure have been reported in literature 4,8,[11][12][13][14] . With limited direct surgical trauma to the musculature during craniotomies, we hypothesize that postoperative CK excess is, among other factors, related to patient positioning.…”

Section: Introductionmentioning

confidence: 99%

Enhanced Serum Creatine Kinase after Neurosurgery in Lateral Position and Intraoperative Neurophysiological Monitoring

Woernle

Sarnthein

Foit

et al. 2012

J Neurol Surg A Cent Eur Neurosurg

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OBJECTIVE: Several cases of highly elevated serum levels of creatine kinase (CK) after surgical interventions have been described in the literature. A consensus on possible risk factors is still lacking. We therefore studied CK-levels in a large population of patients undergoing neurosurgical interventions and sought to determine possible risk factors. METHODS: We retrospectively analyzed 150 elective neurosurgical interventions where pre-and postoperative CK serum levels were determined. The cases were selected such that 50 patients were operated in lateral position and 100 in prone or supine position. During the hospital stay, routine clinical diagnostics were conducted, including medical status and laboratory examinations. RESULTS: In the patient group (median age 50, 63 male) there were 129 cranial and 21 spinal interventions. In 55 cases, intraoperative neurophysiological monitoring (IONM) was performed so that in these patients muscles were not relaxed pharmacologically. In a linear regression model, the maximal postoperative CK-level increased compared to baseline (p<0.001). While age and obesity were not identified as risk factors, the CK-level was enhanced after surgery in lateral position (p<0.001) and if IONM was performed (p=0.04). CONCLUSIONS: The strong association of postoperative serum CK-level with intraoperative positioning and IONM may be related to the elevated body pressure on the operating table in the lateral position, in particular if muscles are not relaxed pharmacologically, which was the case if intraoperative monitoring was performed. In these cases special care has to be taken for the positioning and during the peri-operative management. ResultsIn the patient group (median age 50, 63 male) there were 129 cranial and 21 spinal interventions. In 55 cases, Intraoperative Neurophysiological Monitoring (IONM) was performed so that in these patients muscles were not relaxed pharmacologically. In a linear regression model, the maximal postoperative CKlevel increased compared to baseline (p<0.001). While age and obesity were not identified as risk factors, the CK-level was enhanced after surgery in lateral position (p<0.001) and if IONM was performed (p=0.04). ConclusionsThe strong association of postoperative serum CK-level with intraoperative positioning and IONM may be related to the elevated body pressure on the operating table in the lateral position, in particular if muscles are not relaxed pharmacologically, which was the case if intraoperative monitoring was performed. In these cases special care has to be taken for the positioning and during the peri-operative management.3

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Spectrum and Risk Factors of Complications After Gastric Bypass

Campos

Ciovica²,

Rogers³

et al. 2007

Arch Surg

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Main Outcome Measures: Complications were stratified by grade: grade I, only bedside procedure; grade II, therapeutic intervention but without lasting disability; grade III, irreversible deficits; and grade IV, death. Data were analyzed using logistic regression to identify independent risk factors of complications after GBP. Predictors investigated were age, race, sex, marital and insurance status, body mass index, obesity-associated comorbidities, American Society of Anesthesiologists Physical Status Class, operating room time, open or laparoscopic approach, and surgeon experience. Results: Of the 404 morbidly obese patients who underwent consecutive open (n = 72) or laparoscopic (n = 332) GBP, 74 (18.3%) experienced 107 complications. Grade I and II complications were more frequent after open GBP (grade I, 19.4% after open vs 3.9% after laparoscopic operations, PϽ .001; grade II, 20.8% after open vs 8.4% after laparoscopic operations, PϽ.001), and 55% were wound related. Grades III and IV complications occurred in only 4 patients (1%), and frequency was similar for open and laparoscopic cases. Three factors were independently predictive of complications: diabetes mellitus

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Predictive Factors for Rhabdomyolysis after Bariatric Surgery

Abstract: After surgery for obesity, the risk of RML increases with prolonged surgery (>4 hours) and in diabetic obese patients with BMI >40 kg/m(2). In such patients, CK could be systematically measured to verify the presence of muscle injuries.

Cited by 92 publications

References 20 publications

Case report: Rhabdomyolysis in morbidly obese patients: anesthetic considerations

Case report: Rhabdomyolysis in morbidly obese patients: anesthetic considerations

Enhanced Serum Creatine Kinase after Neurosurgery in Lateral Position and Intraoperative Neurophysiological Monitoring

Spectrum and Risk Factors of Complications After Gastric Bypass

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