a 51-year - old man ( height 183 cm , weight 96 kg ) was admitted for radical nephrectomy with the diagnosis of renal cell carcinoma .
he had undergone surgery for varicose veins under general anesthesia 3 months prior ; his tobacco use was 1 pack / day for 30 years and alcohol consumption was soju 1 bottle / day , 3 - 4 days / week .
a preoperative chest x - ray revealed multiple hematogenous metastatic nodules and emphysema on both lung fields .
he had no history of dyspnea and no wheezing sounds on his lung exam , however .
preoperative laboratory results were the following : hemoglobin was 13.5 g / dl , hematocrit was 42.3% , ast / alt were 10/20 iu , and bun / creatinine were 12.8/0.8 mg / dl .
his preoperative blood pressure was 120/80 mmhg and heart rate was 72 beats / minute .
after arriving at the operating theater , ecg , noninvasive blood pressure measurement , pulse oximeter , and capnography were applied .
initial vital signs in the operation room were blood pressure 110/73 mmhg , heart rate 65 beats / min , respiratory rate 18 breaths / min . for the induction of anesthesia ,
propofol 120 mg and rocuronium bromide 50 mg were injected intravenously , and 6 l / min of o2 and desflurane were inhaled .
anesthesia was maintained with o2 and n2o ( fio2 50% ) , desflurane 5.0 - 7.0% , and an intravenous target controlled infusion of remifentanil with a target of 2.0 - 3.0 ng / ml .
after arterial catheterization , the patient was placed in a lateral decubitus position with a kidney rest on the lower part of the iliac crest .
the operation table was flexed by 30 degrees , and the patient 's buttocks were fastened with a hip strap , with careful attention paid to prevent the femur head from encountering pressure . after a trocar was inserted via a retroperitoneal approach , pneumoperitoneum was produced until the abdominal insufflation pressure was 11 mmhg , and 3 port laparoscopic radical nephrectomy was performed .
there was no change in vital signs at initiation of the surgery , and vital signs during surgery were maintained , with blood pressure 90 - 100/55 - 65 mmhg , heart rate 60 - 75 beats / min , respiratory rate 12 - 15 breaths / min , peak inspiration pressure 18 cmh2o , end tidal co2 38 mmhg , and sao2 97% .
two branches of the right renal artery and one branch of the right renal vein were ligated .
four hours after initiation of surgery , the operating procedure was changed to open nephrectomy , because one branch of the right renal artery entered into the back of the kidney .
after ligation of the right renal artery , the right kidney and the oncologic mass were resected , and the peritoneal wall was closed . during the operation ,
an arterial blood gas analysis was performed and hemoglobin , hematocrit , and electrolytes were checked .
at one hour and 20 minutes after laparotomy , labs showed a hemoglobin level of 7.8 g / ml and hematocrit of 23.0% , so 420 ml of packed red blood cells were transfused .
the mean operative time was 7 hours , and blood loss and urine output were 800 ml and 400 ml , respectively .
the total amounts of fluids administered were 2,100 ml of crystalloid solution and 500 ml of colloid solution .
after reversing muscle relaxation and making sure the patient had an adequate amount of spontaneous breathing , the endotracheal tube was removed .
the patient was transported to the postanesthetic care unit . after awakening , he complained of back pain on the left side
. examination showed slight redness on his flank that extended to the buttocks , but localized swelling and warmth were not observed . due to the postoperative low back pain , patient control analgesia ( pca )
was administered in doses of 1 ml . an arterial blood gas analysis was performed while the patient was spontaneously breathing with mask oxygenation at 8 l / min .
the results of the blood gas analysis showed a ph of 7.40 , paco2 of 43.1 mmhg , pao2 of 98 mmhg , and hco3 of 22.6
his vital signs were stable , and the patient was transferred to the icu . on postoperative day 1 , laboratory tests revealed ast / alt of 497/175 iu , bun / creatinine of 27/3.5 mg / dl , creatinine phospokinase ( cpk ) of 21,817 iu / l , and lactate dehydrogenase ( ldh ) of 1,973 iu / l .
the patient 's urine output decreased to 83 ml during 24 hours and did not respond to diuretics .
on postoperative day 2 , the patient had persistent pain in the area of his left flank , and laboratory tests revealed ast / alt of 432/176 iu , bun / creatinine of 40.9/5.1 mg / dl , and his urine output was still low at 254 ml over 24 hours .
renal ultrasonography results did not show any left kidney abnormality , such as pelvicouretral dilatation indicating hydronephrosis or obstruction .
on postoperative day 3 , bun / creatinine increased to 51/6.8 mg / dl , and urine output was less than 10 ml . at that point ,
on postoperative day 4 , cpk was 7,091 iu / l , ldh was 2,161 iu / l , and serum myoglobin was more than 3,000 ng / ml .
aldose was 43.2 u / l , and the patient had persistent pain of the left flank .
on postoperative day 8 , bun / creatinine level increased to 50/10.8 mg / dl and then gradually decreased .
on postoperative day 20 , bun / creatinine level decreased to 23/2.0 mg / dl and continued to drop , and urine output returned to normal .
cpk and ldh levels also dropped to 127 iu / l and 572 iu / l on postoperative day 15 .
he was discharged 41 days after surgery and has had no problems since that time .
rhabdomyolysis can be defined as a reversible or irreversible injury due to degeneration of the cell membrane or an injury to the sarcolemma of skeletal muscle , resulting in leakage of its components into the blood or extracellular environment [ 1 - 4 ] .
injury to the sarcolemma may be caused by hypoxia , reperfusion injury , or direct injury to the cell membrane , causing leakage of intracellular proteins into the extracellular environment .
leaked substances include cpk , ldh , myoglobin , aldose , phosphate , and potassium , resulting in increased plasma concentrations of these substances .
criteria for the diagnosis of rhabdomyolysis includes the absence of myocardial ischemia , five times more than normal cpk levels ( greater than 1,000 ) , or presence of myoglobinuria .
rhabdomyolysis occurs more frequently in males , as in this case , and is prevalent in patients in their late 40s .
postoperative rhabdomyolysis is known to be associated with ruptured abdominal aortic aneurysm surgery , revascularization of vascular occlusion , and urology surgery .
risk factors include male gender , high body mass index , prolonged surgery , lateral decubitus position , and flexed lateral decubitus position .
additional risk factors include kidney disease , extracellular dehydration , and hypoperfusion of the kidney .
the most common sites include the muscles around the lumbar spine and gluteus , as in this case [ 7 - 9 ] .
symptoms of rhabdomyolysis include pain , tenderness , edema , weakness of the affected muscles , and muscle pain related to passive stretch .
myoglobinuria occurs when myoglobin levels in plasma exceed 0.5 - 1.5 mg / dl and is characterized by dark brown urine . in some cases of rhabdomyolysis , however , myoglobinuria intermittently occurs and thus myoglobin can not be detected in the urine .
urine may not test positive for myoglobin because these proteins are metabolized to bilirubin , excreted quickly and appear only temporarily in the urine . in this case , we could not grossly detect myoglobinuria , mostly likely because we could not distinguish the characteristic dark brown color of myoglobinuria from postoperative hematuria . obtaining the patient 's serum myoglobin level could not have been useful , because serum myoglobin can be increased and normalized in a short period of time .
the cpk level is known to be the most sensitive test for rhabdomyolysis , because it is increased in proportion to the amount of muscle damage . in this case , we measured cpk , ldh , ast , and alt on a daily basis and monitored the patient 's progress .
complications of rhabdomyolysis include persistent muscle weakness , atrophy , and nerve dysfunction , with acute renal failure as the most serious complication .
acute renal failure occurs in 15 - 46% of cases of rhabdomyolysis and death occurs in 3.4% of cases .
the mechanism of acute renal failure in patients with rhabdomyolysis is not clearly known , but it is thought to be a complex mechanism that includes myoglobin - induced vasoconstriction , cytotoxicity of the heme molecule , and blockage of renal tubules with precipitated myoglobin that results in reverse pressure .
dehydration and acidosis as a result of fluid loss are also a part of this phenomenon . the flexed lateral decubitus position , called the kidney position or nephrectomy position , is a position commonly used in urological surgery .
studied the association between rhabdomyolysis and operative position and concluded that rhabdomyolysis is associated with the lateral position and long lasting surgery .
glassman et al .   suggested the possibility that placing a patient in a rotated supine position instead of the flexed lateral position would reduce the occurrence of rhabdomyolysis .
it has also been suggested that intraperitoneal co2 infusion for laparoscopic surgery resulting in abdominal pressure of 12 - 15 mmhg can further add to low perfusion pressure among the obese , so it is possible that in our case laparoscopic surgery served as one of the factors causing low perfusion .
permissive hypertension would provide improved perfusion of compressed tissue and prevent the development of rhabdomyolysis . in general
, surgeons want to establish a blood pressure that is low enough to prevent blood from disturbing the operative field and avoid fluid overload , which could cause postoperative pulmonary edema .
laparoscopic surgery and low blood pressure might be precipitating factors for rhabdomyolysis , however , because they perturb perfusion to muscles under pressure . in the anesthesiologist 's view , the disease to distinguish from postoperative rhabdomyolysis is malignant hyperthermia . in this case , increased co2 production , which is the earliest and most sensitive indicator of malignant hyperthermia , was not observed and the body temperature was normal .
also , there was no rigidity of the masseter muscle and no tachycardia , arrhythmia , and tachypnea , signs that are known to occur within 5 minutes of induction of anesthesia in malignant hyperthermia .
finally , the patient 's cpk level was higher than those of other hyperthermia cases reported in the country .
treatment of rhabdomyolysis includes aggressive fluid resuscitation with central venous pressure monitoring , use of mannitol , and infusion of sodium bicarbonate to alkalinize the urine and stop the progression of renal failure . when renal failure occurs and it is indicated , hemodialysis is important to recover renal function .
the criteria for hemodialysis in patients with rhabdomyolysis includes serum creatinine more than 1.5 mg / dl , base deficit less than -4 , serum cpk more than 5,000 iu / l , and the presence of myoglobinuria .
sharp et al .   reported that renal failure requiring dialysis occurs in 9.5% of patients with postoperative rhabdomyolysis and that mortality is 3 times higher in patients with rhabdomyolysis who need hemodialysis than in those who do not .
also , it is known that muscle swelling can delay muscle ischemia and cause a second surge of cpk , so vigilance must not be relaxed after the initial treatment .
if patients have surgery again at a later date , anesthesiologists should proceed with care , because rhabdomyolysis reoccurs in 11% of patients . in conclusion , it is important to note that anesthesiologists should pay attention to positioning during surgery , because prevention methods are critical to reduce the risk of rhabdomyolysis .
that is , appropriate pads on body parts under pressure should be installed during surgery and lowering the kidney rest could be effective even before the end of the operation .
more study is needed on the efficacy of devices that measure abdominal pressure ; studies are also needed to test how well commercial products like vacuum bean bags or gel cushioning pads , which are designed to distribute the pressure of large areas , can prevent excessive local pressure . in rhabdomyolysis
, stable hemodynamic status should be maintained , because hypotension and acidosis may act as contributing factors during anesthesia .
if possible , intentional hypertension should be tried in patients who are at risk for rhabdomyolysis .
reduction of operating time by surgeons and interruption of surgery at regular intervals to normalize flexed areas might help prevent rhabdomyolysis . in patients with the possibility of postoperative rhabdomyolysis ,
it is important to observe the patient 's progress and have an early suspicion of rhabdomyolysis , especially when the patient 's pain is out of proportion to the clinical situation and skin symptoms and an abnormal urine color are found .
 rhabdomyolysis is a rare but potentially lethal clinical syndrome that results from acute muscle fiber necrosis with leakage of muscle constituents into blood . 
 this devastating disease could be due to muscle compression caused by urologic positioning for a lengthy nephrectomy . in this 
 regard , laparoscopic renal surgery may be a risk for the development of rhabdomyolysis . 
 this phenomenon of massive muscle necrosis can produce secondary acute renal failure . 
 the risk factors have to be managed carefully during anesthetic management . here 
 , we report a case of a patient with rhabdomyolysis that developed in the flexed lateral decubitus position during laparoscopic nephrectomy . 
Case Report
Discussion