Abstract
Post-operative rhabdomyolysis is a rare but life-threatening condition. Less than ten cases have been described in the otolaryngic literature and, to our knowledge, no reports exist in the setting of oral reconstructive free tissue transfer. Case report presentation. We discuss the clinical course that lead to the diagnosis of rhabdomyolysis with special consideration to simultaneous microvascular anastomosis. Serial lab values were closely followed to prevent kidney injury while preventing flap congestion. Excessive fluid resuscitation in free flap reconstruction has been associated with increased post-operative complications and flap failure. We present a cautionary case to highlight the need for early diagnosis of rhabdomyolysis, a condition that may become more prevalent in the head and neck population as obesity, the main risk factor, continues to increase worldwide.
Keywords: Rhabdomyolysis, Free tissue transfer, Obesity, Microvascular anastomosis
Introduction
Rhabdomyolysis is a potentially life-threatening condition characterized by cell damage that can cause renal failure, hyperkalemia, cardiac arrhythmias and disseminated intravascular coagulation (DIC) [1]. Obesity, surgical positioning, and surgical times have been identified as risk factors for rhabdomyolysis [2]. Rhabdomyolysis in the setting of free tissue transfer has not been described in the head and neck literature, yet it poses a critical diagnosis that is likely to become more prevalent as obesity rates continue to grow [1, 3].
Report of a Case
A 44-year-old female with past medical history of morbid obesity (BMI of 70.7), hypertension, type two diabetes mellitus, non-healing lower back decubital ulcers and obstructive sleep apnea was noted to have a T2N2bM0 squamous cell carcinoma of the oral tongue based on NCCN guidelines. After preoperative cardiopulmonary clearance, she underwent tracheostomy, composite resection with partial glossectomy and modified radical neck dissection. Reconstruction was achieved using a radial forearm fasciocutaneous flap with an inset using the ipsilateral facial artery and vein and external jugular vein for second venous anastomosis. Operative time was recorded as 5 h and 20 min. The patient remained hemodynamically stable during the surgery without the need for intraoperative transfusion or vasopressors. She was given 5000 milliliters of crystalloid and was transferred to the Neurosurgical Intensive Care Unit (ICU) post-operatively.
In the first day postoperatively, she became oliguric with dark brown, turbid discoloration of her urine despite weight-based intravenous (IV) fluid hydration with 0.9% normal saline. The patient noted a new onset of radiating lower back pain that was distinct from her prior lower back decubitus ulcers. Initial laboratory work-up revealed normal hemoglobin levels, leukocytosis (19.2 × 109/L), elevated serum potassium (5.9 mmol/L) and serum creatine (2.15 mg/dl with a baseline of 0.9 mg/dl) and decreased calculated glomerular filtration rate of 20. On further evaluation, a significantly elevated serum creatinine kinase (CK) (18,170 U/L) and urine myoglobin (1305 ng/ml) were found. The combination of these findings and clinical symptoms prompted the diagnosis of rhabdomyolysis. The patient was treated in the ICU with the help of the intensivist and nephrology teams. Because of concerns for flap compromise with tissue edema secondary to aggressive hydration, IV hydration was set at 200 ml/h of 0.9% normal saline, with concomitant dextrose 5% bicarbonate drip for urine alkalization, and Lasix diuresis titrated to maintain adequate urine output. Arterial line, urinary catheter, serial arterial blood gases, chemistry lab draws, and hourly external flap Dopplers were used to monitor the patient clinically (Fig. 1). The patient did not require hemodialysis and at discharge her renal function was back to baseline. The patient was successfully discharged from the hospital on post-op day thirteen. Throughout the treatment course, the flap was edematous but remained viable (Fig. 2).
Fig. 1.
a Serial monitoring of serum creatinine in mg/dL. b Serial monitoring of serum creatinine kinase in U/L
Fig. 2.
Appearance of fasciocutaneous tongue reconstruction after initial healing period
Discussion
Rhabdomyolysis is a potentially life-threatening condition that is rarely described in the otolaryngic literature [2]. In the last decades the prevalence of obesity, a well-known risk factor of rhabdomyolysis, has increased in alarming rates [4]. As this trend continues, the incidence of rhabdomyolysis in microvascular surgeries is likely to because more prevalent.
Generally, treatment goals are focused on prevention of further renal injury by adequate volume replacement. Volume expansion with normal saline increases renal blood flow and thus increases glomerular filtration rate allowing for excretion of myoglobulin precipitate. Goal infusion rate is aimed at maintaining a urine output of 200–1000 ml/h which, in general, translates to a normal saline infusion of 400 ml/h [5, 6]. Even though these well-established treatment guidelines exist, the treatment paradigm needs adjustments as excessive fluid resuscitation has been associated with increased post-operative complications in free flap reconstruction [1, 5, 7]. While the exact pathophysiology is unclear, aggressive fluid resuscitation induces flap edema with increased wound tension and higher anastomotic failure rates [1, 3]. Miller et al. discuss the importance of optimizing fluid management by utilizing various arterial line parameters such as cardiac output, stroke volume and pulse pressure variation [7].
Conclusion
Rhabdomyolysis is a potentially life-threatening condition characterized by the breakdown of skeletal muscle with a reported incidence of 0.074-2% of annually admitted patients [8]. In the setting of new microvascular anastomosis, we recommend management by a multidisciplinary team with close cardiac and renal monitoring. As in majority of post-operative free flap patients, net fluid balance is crucial despite the need for hydration, highlighting the utility of adequate diuresis and urine alkalinization. Ultimately, special consideration should be paid to any new physical exam findings or patient complaints in the immediate post-operative period as they can be harbingers of rare post-operative complications.
Compliance with Ethical Standards
Conflict of interest
All authors declare that they have no conflict of interest.
Ethical Approval
This article does not contain any studies with human participants performed by any of the authors.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
References
- 1.Cervellin G, Comelli I, Lippi G. Rhabdomyolysis: historical background, clinical, diagnostic and therapeutic features. Clin Chem Lab Med. 2010;48(6):749–756. doi: 10.1515/CCLM.2010.151. [DOI] [PubMed] [Google Scholar]
- 2.Dequanter D, Vercruysse N, Shahla M, Paulus P, Lothaire P. Rhabdomyolysis in head and neck surgery. B-ent. 2014;10(3):171–173. [PubMed] [Google Scholar]
- 3.Farwell DG, Reilly DF, Weymuller EA, Jr, Greenberg DL, Staiger TO, Futran NA. Predictors of perioperative complications in head and neck patients. Arch Otolaryngol Head Neck Surg. 2002;128(5):505–511. doi: 10.1001/archotol.128.5.505. [DOI] [PubMed] [Google Scholar]
- 4.Seidell JC, Halberstadt J. The global burden of obesity and the challenges of prevention. Ann Nutr Metab. 2015;66(Suppl 2):7–12. doi: 10.1159/000375143. [DOI] [PubMed] [Google Scholar]
- 5.Ferrandez O, Urbina O, Luque S, Espona M, Berenguer N, Grau S. Normalization of creatine kinase values in a case of rhabdomyolysis during daptomycin treatment. Indian J Pharmacol. 2013;45(2):193–194. doi: 10.4103/0253-7613.108321. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Hofer CK, Cannesson M. Monitoring fluid responsiveness. Acta Anaesthesiol Taiwan Off J Taiwan Soc Anesthesiol. 2011;49(2):59–65. doi: 10.1016/j.aat.2011.05.001. [DOI] [PubMed] [Google Scholar]
- 7.Miller TE, Roche AM, Mythen M. Fluid management and goal-directed therapy as an adjunct to enhanced recovery after surgery (ERAS). Canadian journal of anaesthesia = J Can D’anesth. 2015;62(2):158–168. doi: 10.1007/s12630-014-0266-y. [DOI] [PubMed] [Google Scholar]
- 8.Zutt R, van der Kooi AJ, Linthorst GE, Wanders RJ, de Visser M. Rhabdomyolysis: review of the literature. Neuromuscul Disord NMD. 2014;24(8):651–659. doi: 10.1016/j.nmd.2014.05.005. [DOI] [PubMed] [Google Scholar]