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Rhabdomyolysis in an obese patient secondary to the use of limb tourniquet
- Olumuyiwa A Bamgbade, Shyahani R DeSilva, Ramesh Ekambaram (26 February 2007)
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Olumuyiwa A Bamgbade, Consultant Anaesthetist Central Manchester University Hospital, Manchester, UK, Shyahani R DeSilva, Ramesh Ekambaram
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The case report of rhabdomyolysis in an obese patient, by Karcher et al, is very interesting; but the discussion is highly debatable (1). There is an association between morbid obesity and perioperative rhabdomyolysis especially following prolonged or major surgery. However, rhabdomyolysis is an undesirable event that should be prevented especially in obese patients, who usually have a high prevalence of co-morbidities and predisposition to perioperative complications (2). The use of a thigh tourniquet appears to be the major cause of rhabdomyolysis in the case reported by Karcher et al. Although the tourniquet was applied for a relatively short period of 50 minutes, it seems likely that direct pressure injury of the muscles occurred from the tourniquet because of the excessive inflation pressure of 350 mmHg and probably the total thigh area under tourniquet pressure. It would be interesting to know the width of the tourniquet relative to the length and circumference of the patient’s thigh. It would also be informative to know the initial systolic blood pressure or any other basis for such excessive tourniquet inflation pressure. Compression injury of the thigh is a known cause of perioperative rhabdomyolysis (3). The muscle injury was not detected in the early postoperative period partly because the patient did not report thigh pain due to analgesia from the femoral nerve block. The muscle injury would have caused inflammatory swelling and pain, which if detected earlier would have prompted better postoperative fluid management and monitoring; and limit the hepatorenal sequelae. Although the patient’s preoperative renal function tests were normal, she possibly had undetected preoperative mild renal impairment secondary to diclofenac use and diabetes. Ischaemia-reperfusion injury in skeletal muscle is associated with severe microvascular and inflammatory processes that may lead to muscle damage or rhabdomyolysis (4). This may have contributed to rhabdomyolysis in the case reported; and the risk of microvascular injury was possibly increased by the pathology of diabetes and obesity. The risk of ischaemic or hypoxic tissue injury is increased in obese patients because of reduced tissue oxygenation in these patients (5). Although the case reported by Karcher et al had previous uneventful anaesthesia, it may be useful to rule out undetected myopathy which may be associated with muscle inflammatory injury following the use of inhalational anaesthetics such as sevoflurane (6). References: 1) Karcher C, Dieterich H-J, Schroeder TH. Rhabdomyolysis in an obese patient after total knee arthroplasty. Br J Anaesth 2006; 97: 823-824. 2) Bamgbade OA, Rutter TW, Nafiu OO, Dorje P. Postoperative complications in obese and nonobese patients. World J Surg 2006 Aug: Epub. 3) Prabhu M, Samra S. An unusual cause of rhabdomyolysis following surgery in the prone position. J Neurosurg Anesthesiol 2000; 12:359-63. 4) Blaisdell FW. The pathophysiology of skeletal muscle ischemia and the reperfusion syndrome: a review. Cardiovasc Surg 2002; 10:620-630. 5) Fleischmann E, Kurz A, Niedermayr M, et al. Tissue oxygenation in obese and non-obese patients. Obes Surg 2005; 15:813-9. 6) Takahashi H, Shimokawa M, Sha K, et al. Sevoflurane can induce rhabdomyolysis in Duchenne’s muscular dystrophy. Masui 2002; 51:190-192. Conflict of Interest:None declared |
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