Ddx: anderson syn, Familial hypokalemic periodic paralysis, Thyrotoxic periodic paralysis, Hyper/hypo-kalemic periodic paralysis.
Clinical s/s: 20 y/M, c.c: 2 hours after pushing up, squatting and standing for 1 hour, he felt bilateral lower limb weakness. So he was brought to ER for help, where CK showed around 3000. Pt denied any associated family disease like the same symptom. And this was his first experience. He seldom exercised before. Local tenderness and pain sensation noted a few hours later. There was no tea-colored urine output and nor decreased urine amount.
Background knowledge:
1. Rhabdomyolysis造成的下肢運動weakness，通常K要低於2.0.
2. CK level >10^4, 才多會有tea-color urine. U/A: OB +, indicate myoglobinuria.
3. 在台灣常見還是一些GI drugs or lower lipid （Statin, Fibrate) drugs 所 induced。
4. 臨床上處理：大量hydration, with N/S 2L in 3-3.5L within 24hr. 以前可以回家觀察，只要有小便出來就不需太擔心。
5. 但有些Crushing造成的rhabdomyolysis處理上要小心。在移除外物送病人到救護車時，很容易就cardiac arrest. 多半是因為Crushing後死亡的細胞釋出的K在移除異物後迅速回到心臟所致。因此會有壓脈帶先綁住。或者在原地hydration, 等到有urine output再行移送。
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Q: 那何時需要緊急洗腎？acute hemodialysis?
當然小麻有AEIOU的建議, 於此掠過…
Let’s review Uptodate first:
Accepted indications for renal replacement therapy (RRT) in patients with AKI generally include:
* Refractory fluid overload
* Hyperkalemia (plasma potassium concentration >6.5 meq/L) or rapidly rising potassium levels
* Signs of uremia, such as pericarditis, neuropathy, or an otherwise unexplained decline in mental status
* Metabolic acidosis (pH less than 7.1)
* Certain alcohol and drug intoxications
About the choice of what kind of RRT(renal replacement therapy) and when?
* Among patients with life-threatening complications of acute kidney injury (AKI), we recommend the initiation of renal replacement therapy (RRT) (Grade 1A).
* It is unproven whether initiation of earlier or prophylactic dialysis offers any clinical or survival benefit. We suggest initiating dialysis prior to the development of symptoms and signs of renal failure due to AKI (Grade 2B). It is not possible to specify a specific duration of renal injury or level of azotemia at which RRT should be optimally initiated. General practice is to initiate RRT when the BUN reaches 80 to 100 mg/dL, although there is no consensus and practice patterns vary widely
We suggest the following strategies for dosage of RRT: (uptodate)
* We recommend that intermittent hemodialysis be provided on a three-times per week schedule (alternate days) with monitoring of the delivered dose of dialysis to ensure delivery of a Kt/V of at least 1.2 per treatment (Grade 1B).
* We recommend that CRRT be provided with a delivered effluent flow rate (sum of hemofiltration rate and dialysate flow rate) of at least 20 mL/kg per hour (Grade 1B). In order to ensure delivery of this flow rate, we prescribe an effluent flow rate of at least 25 mL/kg per hour
許V口述：
1. Acute pulmonary edema, when using 200q6h lasix once dose, no satisfied U/O, considering.
2. Hyerkalemia,K>5.5 (EKG: tent T), K>6.5 (p wave decreased and then junctional rhythm, pt may present with weakness), K>7.0-7.5 QRS widening Vf (K>8) ESRD or CRI (renal insufficiency)的pt, K常>5.5
If EKG QRS narrowing: could use conventional way to lower K+
a. Glu +RI transition.
b. Urine, stool passage ( H/D if no use.)
(Lasix, kayexalate enema 80mg in 80-100c.c water for 30min, let alone sorbitol for some case report for ischemic bowel)
If EKG QRS widening: Cal gluconate 1amp push for 30s continuiously. call Nephro for H/D if narrowing…
3. Metabolic Acidosis (MA) if reversible: like sepsis shock, no need) If PH<7.2 or HCO3-<15, considering.
4. Uremic pericarditis, seldom now.
5. Uremic encephalopathy. Dx by exclusion, mostly BUN>100, Cr>10
6. Intoxication: ethylene, lithium, TCA. If 有機磷：打解藥。If Paraquat: HP (吸附)
一相對的indication:
uremic s/s restless leg or induced coagulopathy.
s/s UGIB, but PES no function due to diffuse bleeding. (average BUN>100, Cr>10)
(類似影響VWF所以只有bleeding time prolong) 在H/D前的treatment:
1. 可用DDAVP twice, 4-6amp in N/S 50c.c. run 30min (pending check)
2. cryoprecipitate transplantation.
3. PRBC transfusion, until Hgb >10, or Hct>30~35%.
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so treatment of this pt:
supportive care, followed CK. however, considering pt's age, it's unusual for young men having such rhamdomyolysis caused by exercise only. Maybe some other underlying precipitating factor. Educate pt regularly taking exercise and maybe the same condition will recurrent.
Familial hypokalemic periodic paralysis, unlike pure hypokalemia by GI or Renal loss, may present with general weakness. This pt is unlikely a/c to only bilateral lower limb and no contributory family history.
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