Rotation: Emergency Medicine
Title: Rhabdomyolysis in Severe COVID-19: Male Sex, High Body Mass Index, and Prone Positioning Confer High Risk
Citation: Mokhtari, A. K., Maurer, L. R., Christensen, M. A., Moheb, M. E., Naar, L., Alser, O., Gaitanidis, A., Langeveld, K., Kapoen, C., Breen, K., Velmahos, G. C., & Kaafarani, H. (2021). Rhabdomyolysis in Severe COVID-19: Male Sex, High Body Mass Index, and Prone Positioning Confer High Risk. The Journal of surgical research, 266, 35–43. https://doi.org/10.1016/j.jss.2021.03.049
Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8023200/
Study Design: Prospective Cohort
The purpose of this article was to prospectively study critically ill patients with COVID-19 (admitted to the ICU) to determine the incidence, associated variables, and outcomes of rhabdomyolysis in patients with COVID-19. Included in this study were COVID patients with serum CK levels greater than 1000 who were diagnosed with rhabdomyolysis. Patients were then classified as having moderate rhabdomyolysis (CK 1000-4999) or severe rhabdomyolysis (CK at 5000 or above). Univariate and multivariate analyses were done to identify the outcomes and variables associated with the development of rhabdomyolysis.
The study explain that when studying CK levels, most rhabdomyolysis patients (>80%) did not have a serum CK concentration of 1000 or above on admission, but instead developed elevated CK levels later during their admission. However, the CK levels of patients who did develop rhabdomyolysis were significantly greater on admission than those who did not. While many patients returned to serum CK of below 1000 within 3 days of treatment, the range of days required to return to normal concentrations was 1-23 days. Additionally, patients with rhabdomyolysis were more likely to require mechanical ventilation, prone positioning, pharmacologic paralysis to optimize respiratory support, initiation of dialysis, and ECMO. They also had longer total ICU and hospital days. However, the rates of mortality were actually similar between those with and without rhabdomyolysis. Regarding systematic complications, rhabdomyolysis patients were more likely to experience thrombosis, pulmonary complications, GI complications, renal complications, and shock. Regarding AKI, 82.5% of patients with rhabdomyolysis had their ICU course complicated by AKI. The treatment in this study for rhabdomyolysis included cessation of statin use, fluid resuscitation, and some patients required diuresis.
The results of the study showed that male sex, patients with morbid obesity, SOFA score (Sequential Organ Failure Assessment – a mortality prediction score) and prone positioning were all indecently associated with rhabdomyolysis. Essentially this means that male patients with morbid obesity who were placed into prone positioning were significantly more likely to develop rhabdomyolysis. Whether rhabdomyolysis was the result of critical illness, or directly related to COVID itself, remains unclear warranting further studies.
*Prone positioning is a strategy used to increase alveolar recruitment and increase gas exchange and oxygenation in patients with ARDS.
*The most common etiologies of rhabdomyolysis are crush injuries, drug toxicity, extreme physical exertion, metabolic myopathies, viral infection, and electrolyte abnormalities. COVID-19 itself as well as the sequelae secondary to the viral infection (e.g. coagulopathy, cardiac dysfunction, sepsis) could have resulted in rhabdomyolysis.
