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Intraoperative Rhabdomyolysis: Simulation Case Scenario

2011; Lippincott Williams & Wilkins; Volume: 6; Issue: 5 Linguagem: Inglês

10.1097/sih.0b013e318208101e

1559-713X

Pablo Gavazza, Abraham Rosenbaum, Cecilia Canales, Nathan Kudrick, Sharon Lin,

Cardiac, Anesthesia and Surgical Outcomes

DEMOGRAPHICS Case Title: Diego Milito's Dorsi Flap Patient Name: Diego Milito Case Description and Diagnosis: 36-year-old male undergoing a latissimus dorsi flap to the forearm develops anemia, hypotension, and hyperkalemia shortly after handoff (handover) of care and tourniquet release. Date of Development: November 2008 Target Audience: Anesthesiology residents (PGY2–PGY4) Anesthesiologists in practice Certified Registered Nurse Anesthetists CURRICULAR INFORMATION Educational Rationale This case provides an opportunity to discuss the handoff of patient care as well as crisis resource management (Table 1). This is a rare and interesting case that requires prompt diagnosis and timely management of the conditions associated with rhabdomyolysis including hyperkalemia, acidemia, acute renal failure, and hemoconcentration. Hyperkalemia is a frequent cause of mortality in hospitalized patients, and the prompt recognition and treatment of this condition is essential for patient survival. This scenario emphasizes and requires the learner to identify and manage electrocardiogram (EKG) changes, diagnose and treat hyperkalemia, and practice leading a code situation while reviewing Advanced Cardiac Life Support protocols. In addition, the experience of leading a health care team during a crisis highlights the principles of crisis resource management and managing any crisis in the operating room, such as utilizing all available resources, calling for help early enough to make a difference, and effective communication with the health care team.Table 1: Simulation Events TableTable 1: (Continued)TABLE 1: (Continued)ACGME Core Competencies (1) Patient care (PC), (2) medical knowledge (MK), (3) practice-based learning and improvement (PLI), (4) interpersonal and communication skills (CS), (5) professionalism (PR), and (6) systems-based practice (SBP). Learning Objectives Discuss how to ensure a comprehensive handoff of patient care (PC, CS, PR, SBP). Discuss the differential diagnosis for hypotension and tachycardia in a trauma patient (PC, MK). Describe the diagnosis and treatment of hyperkalemia (PC, MK). Describe the differential diagnosis and management of intraoperative oliguria (PC, MK). Discuss how to prioritize tasks and delegate tasks in a time of crisis (PC, CS, PLI, SBP). Describe the treatment of stable and unstable ventricular tachycardia (PC, MK). Discuss the various etiologies of rhabdomyolysis (MK). Describe the pathophysiology and treatment of rhabdomyolysis (PC, MK). Simulation Performance Objectives Communicate diagnosis to health care team promptly to initiate collaborative action. Recognize EKG changes including peaked T waves and wide QRS interval. Order hemoglobin, electrolyte panel, and arterial blood gas. Recognize hemodynamic instability and request arterial line monitoring. Establish additional intravenous access and/or central venous access. Recognize abnormal urine output. Call for assistance during medical emergency. Manage and treat hyperkalemia appropriately. During cardiac arrest, discontinue inhalational anesthetic agent, switch to 100% oxygen, and initiate cardiopulmonary resuscitation. Delegate tasks appropriately utilizing all available personnel. Transfer patient to intensive care unit with trachea intubated. Guided Study Questions What are the essential elements of effective handoff communication (SBAR—situation, background, assessment, recommendation—technique)? What patients are at risk for crush injury and rhabdomyolysis? What is the pathophysiology of crush injury and rhabdomyolysis? References Used Malinoski DJ, Slater MS, Mullins RJ. Crush injury and rhabdomyolysis. Crit Care Clin 2004;20:171–192. Gonzalez D. Crush syndrome. Crit Care Med 2005;33:S34–S41. Khan FY. Rhabdomyolysis: a review of the literature. Neth J Med 2009;67:272–283. Karcher C, Dieterich HJ, Schroeder TH. Rhabdomyolysis in an obese patient after total knee arthroplasty. Br J Anaesth 2006;97:822–824. Palmer SH, Graham G. Tourniquet-induced rhabdomyolysis after total knee replacement. Ann R Coll Surg Engl 1994;76:416–417. Gaba DM, Fish KJ, Howard SK. Crisis Management in Anesthesiology. New York: Churchill Livingstone; 1994:153–155. Didactics None. Assessment Instruments None. PREPARATION Monitors Required Noninvasive blood pressure cuff Arterial line Central venous pressure Pulmonary artery catheter 5-lead EKG Temperature probe Pulse oximeter Capnograph Foley catheter Other Equipment Required Anesthesia machine Pumps Defibrillator Nerve stimulator Transesophageal echocardiography Suction Packed red blood cells Labeled syringes Endotracheal tube Laryngoscope Normal saline Tourniquet Forced air warmer Supporting Materials Chest x-ray 12-lead electrocardiogram Preoperative history and physical Anesthesia record “Tea-colored” urine Transesophageal echocardiography: hypovolemic and hyperdynamic state Labs: VBG: pH: 7.3, pCO2 39 mm Hg, pO2 47 mm Hg, BE: −7 mmol/L, Sat: 78%. Na 135 mmol/L, K 7.2 mmol/L, Cl 107 mmol/L, HCO3 20 mmol/L, BUN 6.8 mmol/L, Cr 194.5 μmol/L, Glu 11.6 mmol/L. First Hgb/Hct: 55 g/L/0.168. CBC: WBC 14.5 × 109/L, Hgb 76 g/L, Hct 0.228, Plt 221 × 109/L. Time Duration Set-up: 15 minutes. Preparation: 10 minutes. Simulation: 15 minutes. Debrief: 30 minutes. SIMULATION EXERCISE Information for Participant Case Stem to be Read to Participants A 36-year-old male inpatient presents with an old left forearm fracture injury complicated by methicillin-resistant Staphylococcus aureus infection and is undergoing hardware removal in the left forearm with a latissimus dorsi muscle free flap. The patient height is 5′ 8″ and weight 268 lbs (173 cm, 122 kg), with well-controlled hypertension and obstructive sleep apnea. He is otherwise healthy. It is in the late afternoon and you are relieving your colleague for the day, 5 hours after the surgery started. Additional Information if Asked IV access: one peripheral IV. Urine output: 30 mL/h. Tourniquet has been inflated: 2 hours. Estimated blood loss: 2 L. Fluids received: 5 L of crystalloid over 5 hours. Blood is available: 2 U. Surgery will last at least 5 more hours. The postsurgical plan is to extubate the patient's trachea and admit to monitored bed. Information for Facilitator/Simulator Operator Only Background and Briefing Information Participant is handed over the case of a patient who has been in surgery for 5 hours. The patient has become progressively hypotensive and tachycardic with diminished urine output. After handoff of patient care, the patient develops anemia, hypotension, and hyperkalemia with EKG changes shortly after tourniquet release. Actual Course of Events and Outcomes (For Real Patient Cases) The operation performed was for removal of hardware; free right latissimus dorsi muscle flap coverage of left hand, wrist, and forearm; and split-thickness skin graft from right thigh. Surgical findings were significant crush near-amputation injury of the left upper extremity status after many operations. Significant heterotopic bone was nearly protruding from the radius in the area of the radiocarpal joint. The case occurred over the course of three handoffs between four attending anesthesiologists. The patient remained intubated, was admitted to the intensive care unit, treated for hyperkalemia, and diagnosed with a prerenal etiology for acute renal failure. The patient was extubated 24 hours later and discharged from hospital 5 days later. Discussion of Scenario In our experience with presenting this simulation scenario more than 30 times at University of California, Irvine, and at other institutions, we have found that this scenario may be easily tailored to participants of varying training levels. Although we may not advance the scenario beyond stable ventricular tachycardia for junior participants, we will progress to cardiac arrest for more senior participants. Topics for debriefing include thnd an old left forearm fracture is currently scheduled to undergo hardware removal, revision of wrist injury, and a latissimus dorsi muscle free flap. Review of Systems Central nervous system: Awake, alert and oriented before general anesthesia. Cardiovascular: Negative. Pulmonary: Negative. Renal/hepatic: Negative. Endocrine: Negative. Heme/coag: Negative. Current Medications and Allergies Hospital: hydromorphone PCA, diphenhydramine PRN, no known drug allergies. Home medications: Percocet (oxycodone with paracetamol/acetaminophen), rifampin, docusate, lisinopril. Physical Examination General: No acute distress. Weight, height: 268 lbs, 5′ 8″ (122 kg, 173 cm). VS: 118/60, P90, RR 12, SpO2 100%. Airway: Mallampati 1, neck full range of motion, thyromental distance >3 fingerbreadths. Lungs: Clear bilaterally. Heart: Regular rate and rhythm, no murmurs. Laboratory, Radiology, and Other Relevant Studies HCT: 0.036. Chest x-ray: within normal limits EKG: NSR, rate 88.