RHABDOMYOLYSIS-INDUCED ACUTE RENAL FAILURE AFTER METHADONE-DIAZEPAM OVERDOSE (case report) B.Pavlovski, L.Milosevska, D.Petrovski, A.Cibisev, F.Licoska, A.Babulovska

1
RHABDOMYOLYSIS-INDUCED ACUTE RENAL FAILURE
AFTER METHADONE-DIAZEPAM OVERDOSE (case
report) B.Pavlovski, L.Milosevska, A. Cibisev, D.
Petrovski, F. Licoska, A. Babulovska Clinic of
Toxicology and Urgent Internal Medicine, UCC.Skopj
e, R. Macedonia
2
(No Transcript)
3
BACKGROUND RHABDOMYOLYSIS GENERAL
VIEW Rhabdomyolysis is a syndrome caused by
injury to skeletal muscles and the resultant
leakage of muscle cell contents (myoglobin,
potassium, phosphate, etc.) into the plasma.
4
TOXIC CAUSES RHABDOMYOLYSIS HAS BEEN ASSOCIATED
WITH A VARIETY OF TOXINS AND DRUGS. THEY CAN
EITHER EXERT A DIRECT TOXIC EFFECT ON MUSCLES
(METABOLIC POISONS) OR INDIRECTLY PREDISPOSE TO
RHABDOMYOLYSIS. DIRECT TOXIC EFFECT Amatoxins

Carbon monoxide
Colchicine
Ethylene glycol
Snakebite
5
INDIRECT EFFECT EXCESSIVE MUSCULAR HYPERACTIVITY
OR RIGIDITY PROLONGED SEIZURES HYPERTERMIA MUSCULA
R COMPRESSION FROM PROLONGED IMMOBILITY
(COMA) NON-TOXIC CAUSES COMA OR PROLONGED
IMMOBILITY FROM ANY CAUSE DIRECT MUSCLE
INJURY ISCHAEMIC MUSCLE INJURY CRUSH
INJURY VASCULAR OCCLUSION
6

• IN THIS STUDY WE AIMED TO DESCRIBE ONE CASE WHO
  DEVELOPED ACUTE RENAL FAILURE AFTER RECENT
  INTRAVENOUS METHADONE-DIAZEPAM ABUSE
• OBJECTIVE
• A 30-years old man, known to be a heroin addict,
  was found at work place, totally unrousable, bent
  on his hips in the lotus position.
• On admission (18.April, 2007), in General
  Hospital in Ohrid he was in coma state with
  miosis and acute respiratory depression,
  respiratory failure requiring
  intubation and artificial ventilation

7

• AT THE RECEPTION AT OUR CLINIC, HE WAS STILL IN
  SOPOROUS STATE WITH MIOSIS AND HYPOTENSION AND
  PROLONGED IMMOBILITY
• ROUTINE BIOCHEMICAL TESTS WERE DETERMINED Blood
  tests, serum transaminases,
• ALT, AST,GGT,AF,LDH,CPK,CRP, bilirubine,coagulatio
  n factors, proteins, lipids, electrolytes, urine,
  alkali-acid status and markers of Hepatitis
  A,B,C and HIV

8
Hourly, urine output were measured.Liver ECHO,
RTG-Chest and the CT scan of the brain were made
also.Urine concentrations of Opiates and
Benzodiazepines were determined using TLC and
EMIT technique.
9

• RELEVANT INVESTIGATIONS
• A SERUM CREATINE PHOSPHOKINASE ACTIVITY GREATER
  THAN FIVE TIMES THE NORMAL VALUE (IN THE ABSENCE
  OF HEART AND BRAIN DISEASE) IS THE MOST SENSITIVE
  INDICATOR OF RHABDOMYOLYSIS
• MYOGLOBINAEMIA WAS THE REASON FOR A VISIBLE
  DISCOLORATION OF THE URINE (RED-BROWN).WE DID NOT
  HAVE A POSSIBILITY TO DO
• A ORTHOTOLUIDINE REACTION (Hematest) to
  confirm the presence of myoglobinuria
• Kalaemia,calcaemia,phosphataemia,uricaemia,urea,se
  rum creatinine,AST,ALT,LDH activities

10
THE MAIN CLINICAL FINDINGS INDURATION OF UPPER
AND LOWER LIMB SUGGESTED RHABDOMYOLYSIS. SKIN
CNANGES DUE TO ISCHAEMIC TISSUE INJURY
(DISCOLORATION, BLISTERS) WERE PRESENTED ON THE
AFFECTED AREA. DARK (RED-BROWN) URINE WAS A
CLASSICAL MANIFESTATION OF RHABDOMYOLYSIS. SIGNS
RELATED TO COMPLICATIONS OF RHABDOMYOLYSIS
HYPERKALAEMIA, ACUTE RENAL FAILURE, METABOLIC
ACIDOSIS WERE NOTED.
11

• FOCAL POINTS IN THE TREATMENT
• THE FIRST AIM OF TREATMENT WAS TO
• SUPPORT VITAL FUNCTIONS
• CARDIO-PULMONARRY AND CEREBRAL
• PHARMACOLOGICAL SUPPORT AND CONTROL
• OF FLUIDS, ELECTROLYTES AND ALKALI-ACID
• STATUS
• HAEMODIALYSIS
• Antibiotics,Vitamins,Corticosteroids,Infusions,
  Calcium
• salts,Diuretics,Sodium Bicarbonate, were given
  
• following laboratory findings.

12
RESULTS DURING THE TREATMENT IN THE INTENSIVE
CARE UNIT SIX HAEMODIALYSIS WERE MADE LABORATORY
VALUES BEFORE THE STARTING DIALYTIC TREATMENT AND
AFTER THE SIXTH HAEMODIALYSIS
13
LABORATORY FINDINGS
CPK----------- 2764U/L--Last results
-19.05.07---173U/L Urea-----------
42,9mmol/L---------------------------
9,7mmol/L Creatinin----- 825micmol/L------------
--------------86micmol/L Na--------------
136mmol/L-----------------------------140mmol/L Po
tassium----- 5,0 mmol/L---------------------------
-4,8mmol/L Ca -------------- 2,2
mmol/L----------------------------2,2mmol/L AST---
----------406U/L---------------------------------3
6U/L ALT-------------439U/L-----------------------
---------47U/L LDH-------------1353U/L------------
-------------------586U/L AF---------------73U/L--
--------------------------------120/U/L
14
BLOOD VALUES DURING THE TREATMENT AT THE CLINIC
Hb------------111 94 92----
90-----90g/L Er----------------3,7---- 3,0
2,67--- 3,0-----3,0 (x10¹²/L) Hct--------------0,3
0--- 0,27 0,26------------0,28 Tr-------------2
26---------- 257-------------277(x109/L) Le---
-------------29,2---22,6----15,8-
13,6----8,0(x109/L) Fe----------------13,0(umol/L)
TIBC----------- 39,8(umol/L)
15
URINE OUTPUT - diuresis From 100 ml per day from
26 April.07, slowly increase to 6300 ml per day
on 05 May. Last results from 19 May-1500ml per day
16
IN OUR DAILY TOXICOLOGICAL PRACTICE WE HAVE HAD
MANY RHABDOMYOLYSIS AFTER HEROIN OVERDOSE AT
HEROIN ADDICTS DIALYTIC TREATMENT NECESSARY AND
SUCCESSFUL IN CORRECTION HYDROELECTROLYTIC
IMBALANCE AND RENAL FUNCTION ALTERATIONS AND IT
MAY BE A PATHOGENETIC THERAPY BY MYOGLOBIN
REMOVAL FROM THE PLASMA
17
ALTHOUGHT RENAL RECOVERY WAS EXPECTED, LONG TERM
IMMOBILITY CAUSED ONE POTENCIAL SERIOUS
COMPLICATION AS A DEEP PHLEBOTHROMBOSIS ON THE
LEFT HAND AND THE LEFT LEG
18
THE PATIENT WILL CONTINUE WITH FURTHER TREATMENT
WITH METHADONE MAINTENANCE THERAPY AND FRAHEPAN,
LMWH, ( Low molecular weight heparin), AND
REHABILITATION TREATMENT IN SVETI ERAZMO
HOSPITAL IN OHRID