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Monthly CDI Discussion – Rhabdomyolysis

June 6, 2019

Topic: Traumatic Rhabdomyolysis with Acute Kidney Injury due to Acute Tubular Necrosis

Scenario:

  • 50 year old female admitted after a motor vehicle accident where she was the restrained driver
  • Patient with abdominal pain, nausea, tachycardia, muscle pain
  • Patient sustained a fractured fibula/tibia of right leg
  • Fractured ulna left arm
  • Multiple contusions and abrasions
  • Creatinine on admission 1.5 followed by an increase to 2.8 within 12 hours of admission
  • Subsequent Creatinine levels 2.5 > 2.3 > 2.1 > 1.9 > 1.7 > 1.5 on day 7
  • BUN level 35mg/dl on admission, repeat levels 30 > 23 > 20
  • Creatine Phosphokinase (CPK) elevated at 8725 on admission, repeat daily CPK levels 7210 > 5200 > 4800 > 2678 > 1292
  • Myoglobin noted in urine on admit
  • Sodium level 124 on admission, repeat NA levels 130 > 135
  • Urine sodium concentration 50meq/L, fractional excretion of sodium 4%
  • Treatment NS bolus 1000ml followed by NS @ 125 ml hour, daily CPK levels

Question: Is there a query opportunity based on the scenario stated above?

Discussion:

  • Patient was admitted with fracture of fibula/tibia right leg, ulna fracture left arm, Hyponatremia, Dehydration, Acute Kidney Injury (AKI)
  • Rhabdomyolysis is muscle necrosis with release of creatine kinase (CK) and myoglobin
  • Traumatic Rhabdomyolysis is more than immobility related to a fall. It is characterized by severe soft tissue/muscle injury due to significant trauma
  • Severe cases of Rhabdomyolysis may cause Acute Kidney Injury (AKI) due to Acute Tubular Necrosis (ATN)
  • Circulation of Myoglobin in the blood results from the release of muscle fiber which obstructs kidney structures
  • Myoglobin may not be detected in urine and/or blood serum due to rapid elimination
  • ATN is AKI due to dysfunction or damage to the renal tubules due to toxic or ischemic injury
  • If patient has severe ATN it could take weeks or months for renal function to return to baseline
  • ATN causes include IV contrast, prolonged hypotension, sepsis, major surgery, shock, Rabdomyolysis with myoglobinuria, tumor lysis syndrome, drugs, and toxins

UASI Recommends:

  • For chart accuracy, query for a diagnosis/specificity of Rhabdomyolysis (Traumatic)
  • Query for Acute Tubular Necrosis
  • M62.82 0 Rhabdomyolysis is a CC
  • T79.6XXA – Traumatic Rhabdomyolysis is a non CC
  • N17.0 Acute Kidney Failure with Tubular Necrosis is a MCC

CDI Education Tips:

Query indicators in patients meeting Traumatic Rhabdomyolysis

  • CK > 1,500 units/L up to 100K+
  • Myoglobin in urine
  • Muscle pain in 50% of cases

Query indicators in patients meeting Acute Tubular Necrosis

  • Acute Tubular Necrosis (ATN) must meet diagnostic criteria for Acute Kidney Injury (AKI). Additionally look for other indicators of ATN such as high ph, granular casts, iron and sodium levels, etc.
  • Renal function takes more than 72 hours to return to baseline (measured by creatinine)

This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.