REPERFUSION INJURY IN SKELETAL-MUSCLE - A PROSPECTIVE-STUDY IN PATIENTS WITH ACUTE LIMB ISCHEMIA AND CLAUDICANTS TREATED BY REVASCULARIZATION

A study was carried out to document the occurrence of rhabdomyolysis and renal complications in patients undergoing vascular reconstruction. Indices of muscle damage and renal function were monitored before, during and for up to 10 days after vascular reconstruction for a variety Of conditions ranging from intermittent claudication to acute ischaemia. Seven patients with acute limb ischaemia (group 1) and nine with intermittent claudication (group 2) were studied prospectively. In group 1, median creatine kinase (CK) and myoglobin levels were markedly raised 24-48 h after surgery (CK, 29370 units/l; myoglobin, 8-17 mg/l). Myoglobin reached its peak concentration and declined more quickly, than CK, but both indices gave similar in formation about the extent of muscle damage. In contrast, patients undergoing elective surgery for claudication showed no significant departure from reference values for myoglobin or CK. All patients in group 1 underwent fasciotomy to relieve raised compartmental pressures and five were treated with alkali and mannitol to produce diuresis. Despite these measures, two patients suffered renal failure (peak creatinine levels 611 and 590 mumol/l) after successful revascularization and subsequently required haemodialysis; these patients did not have diuresis. One of these patients died following a stroke 8 days after surgery; the other survived and was discharged with a normal limb and restored renal function. There was no evidence of muscle damage or renal complications in group 2. It is concluded that: (1) the risk of muscle damage and renal complications is minimal in patients undergoing elective surgery for intermittent claudication; (2) in patients who present acutely, revascularization after several hours of ischaemia leads to rhabdomyolysis and high levels of circulating CK and myoglobin (despite fasciotomy there was evidence of subsequent muscle damage); (3) it is not possible to predict which patients will go into renal failure; and (4) in all acutely ischaemic patients there is a risk of renal complications and it is suggested that prophylactic measures, such as an alkaline diuresis and mannitol infusion, be instituted during or before the operation as a matter of course.