1、肌肉溶解综合症（Lysis syndrome）The pathophysiology and diagnosis of rhabdomyolysis: Su Lei, Meng FansuChinese Journal of emergency medicine, 2007, eleventhRhabdomyolysis (rhabdomyolysis, RM) refers to a series of factors affecting striated muscle cell membrane, membrane channel and its energy supply of mult
2、iple genetic or acquired diseases resulting in striated muscle injury. The change of cell membrane integrity, the leakage of cellular contents, including myoglobin (myoglobin, Mb), creatinekinase (creatine pphos-phokinases, CPK) and other enzymes, ions and small molecules of toxic substances, often
3、accompanied by the threat of metabolic disorders and acute renal failure life (ARF). In 1881 Fleche first reported by muscle caused by compression of rhabdomyolysis after 1970s reported stroke, poisoning and infection causes of non traumatic rhabdomyolysis (NRM).1 etiologyRhabdomyolysis caused by tr
4、auma has been referred to as gap syndrome and crush syndrome. Compartment syndrome refers to a limb due to trauma or by local performance after extrusion osteofascial compartment pressure caused by increased muscle ischemia; and crush syndrome refers to systemic muscle injury caused by the direct fl
5、ow of trauma or ischemia - reperfusion. Broadly speaking, rhabdomyolysis is caused by destruction of skeletal muscles leading to release of cell contents into the blood and excretion of urine. In addition to trauma factors, non traumatic factors, including genetic etiology, excessive exercise, muscl
6、e extrusion, ischemic metabolic abnormalities, extreme body temperature, drugs, poisons, infections, and other factors can lead to rhabdomyolysis.1.1 traumaAny major cause of muscle damage or ischemia can lead to rhabdomyolysis, including direct and indirect injuries.1.2 non traumaticAlthough rhabdo
7、myolysis was first found in trauma patients, rhabdomyolysis, at least, is more than 5 times more traumatic than rhabdomyolysis.(1) excessive exertion due to impaired substrate utilization or lack of exertional rhabdomyolysis caused by energy metabolism occurs frequently in strenuous exercise, such a
8、s military training, weight lifting, and marathon running.(2) muscle ischemia due to shock, carboxyhemoglobinemia, asthma, drowning caused by generalized muscle ischemia; local dressing too tight, long time use of anti shock garment and air splint caused by local muscle ischemia; the braking time ca
9、used by long time surgery and spinal cord injury; in addition, due to the blocking of heparin induced gas the thrombus, diving causes embolism, vasculitis caused by arterial and venous.(3) excessive high temperature and low temperature, frostbite or overheating can cause rhabdomyolysis.(4) electroly
10、te and osmotic pressure changes and metabolic diseases and electrolyte disorders (low potassium, low phosphorus), severe edema, diabetic ketoacidosis, hyperosmolar diabetic coma, hypothyroidism and other metabolic disorders can lead to rhabdomyolysis, there are not many reports, but can be fatal.(5)
11、 genetic and autoimmune disease genetic disorder caused by glycogen and lipid metabolism disorders can cause rhabdomyolysis, mainly in the family history, high incidence of children, Yi Fufa, has nothing to do with the sports can not associated with muscle necrosis, myoglobinuria, including muscle a
12、trophy, polymyositis, dermatomyositis, McArdledisease, palm carnitine acyl transferase deficiency and respiratory chain enzyme deficiency caused by rhabdomyolysis.Drug and alcohol according to the literature, drug-induced rhabdomyolysis amounted to more than 150 kinds of statins (simvastatin, lovast
13、atin, pravastatin) caused by rhabdomyolysis is clear; if statins and other drugs (erythromycin, clarithromycin, azithromycin, itraconazole, warfarin, digoxin, dicoumarin, non Kyrgyzstan Betsey, cyclosporine, chlorzoxazone, etc.) rhabdomyolysis combined to increase the chance of occurrence of alcohol
14、ism, is also one of the reasons causing rhabdomyolysis.(7) infection is one of the causes of rhabdomyolysis, and influenza viruses are the most common viruses causing rhabdomyolysis,Herpes simplex virus, EB virus, Coxsackie virus and HIV infection caused by RM have been reported, but the exact mecha
15、nism is still not very clear; Legionella bacteria are the most common cause of rhabdomyolysis, also Streptococcus, Salmonella and other reports.2 diagnostic criteria2.1 clinical and laboratory features(1) muscle swelling and limb weakness in varying degrees;(2) black, brown, urine suggesting myoglob
16、in;(3) the creatine kinase and other muscle enzymes (AST, aldolase, lactate dehydrogenase) were increased;(4) creatinine, urea, uric acid; high, low or high share K + Ca +, Pa3 + and high metabolic acidosis (lactic acid);(5) thrombocytopenia or DIC;Some can be hot and the white blood cells rise;(7)
17、30% patients with acute renal failure;Trauma is often associated with low blood volume shock, metabolic disturbances, and heart damage.2.2 laboratory testing methods and evaluation(1) creatinephosphokinase (CK) and its isoenzymes as a major muscle enzyme, when muscle cell injury or death when CK rel
18、eased into blood plasma CK1000 U/L showed that the muscle damage, when the CK20 000 U/L appear myoglobinuria, caused by the exclusion of other causes of injury can be diagnosed with muscle injury. There are CK in myocardium, skeletal muscle and brain. In order to further identify the source of CK, i
19、sozyme analysis is often performed. Normal CK-MB/CK1000 IU, myoglobinuria (brown, 61.6%). All these examinations help diagnose, but are not conclusive.= = = = = = = = = = = =Diagnostic examination of MHPatients with the following characteristics should undergo a diagnostic examination* strabismus* a
20、thletic myalgia* easy to generate heatMB* muscular disease* intolerance to caffeineGold standard for diagnostic tests: halothane-caffeine contracture test (85% specificity and 100% sensitivity). The muscles of the biopsy (usually vastus lateralis 2G) were soaked in 1-3%, halothane and caffeine solut
21、ions, increasing the rate and tension of muscle contractions.Creatine phosphokinase (CPK) increased and screened in 70% of the patientsThe treatment of MHThe early diagnosis and treatment of MH can lead to a mortality rate of 0.Dantrolene is a specific drug that can effectively control calcium depen
22、dent muscle contraction and high metabolic status.Malignant hyperthermia (MH) is a genetic disease occurring in skeletal muscle 1, which is autosomal dominant 3. Often caused by a halogen containing volatile anesthetic or depolarizing muscle relaxant 1. In the past, mortality rates were very high du
23、e to lack of awareness and specificity of treatment. In recent years, several studies have shown that the ryanodine receptor (calcium release channel) in skeletal muscle sarcoplasmic reticulum is closely related to the occurrence of MH, and the gene mutation that determines the transcription of ryan
24、odine receptor protein can lead to the onset of disease 1.The main symptom of MH: petCO2 increased and paO2 decreased, tachycardia and arrhythmias, muscle stiffness, shortness of breath, fever and cyanosis.Laboratory examination: blood gas (metabolic and respiratory acidosis), hyperkalemia, hypercal
25、cemia, hyperphosphatemia, CK 1000 IU, myoglobinuria. If not diagnosed or treated in time, the mortality rate exceeds 70% 1. Early diagnosis and specific treatment can make the mortality rate of -15), there were no similar cases reported in china. We believe that adequate organ support, especially ea
26、rly CVVH treatment, is the key to successful salvage after ICU. CVVH can not only maintain the stability of hemodynamics, remove solutes and metabolites, replace renal function, but also reduce tissue oxygen consumption, balance the balance of water and electrolyte, and also create conditions for nu
27、tritional support. At the same time, effective respiratory function support, liver function protection, active treatment of complications, and early nutritional support were rescued without specific medications.In our country, the rate of spinal anesthesia was 70%, rare MH cases reported. As the proportion of general anesthesia increases, the incidence of MH is increasing gradually. We need to pay more attention to MH and establish MH treatment center with special treatment drugs and equipment. Make MH patients get timely treatment.
