Acute renal failure due to crush injury and prolonged positional compression on a muscle group

Introduction

Widespread muscle crush injury and prolonged positional compression on a muscle group are often associated with myoglobinuric acute renal failure (ARF). Treatment consists of early massive volume replacement and forced alkaline solute diuresis. With this regimen it is possible to increase survival of life and limbs, and prevent myoglobinuric ARF.

Methods

The present study was carried out to describe clinical pattern of ARF caused by crush injury and prolonged positional compression on a muscle group. Clinical and laboratory data of 61 crush or positional compression injury patients transferred to ICU were analyzed. All patients were evaluated by physical examination, determinations of serum levels of electrolytes, urea, creatinine, acid-base balance. Also we recorded the following data: a) the period from the onset of injury to the commencement of treatment; b) the form of ARF; c) need of hemodialysis; d) complications; e) the mortality rate. The only indications for fasciotomy were lack of a distal pulse or open lesions.

Results

Sixty-one patients were admited to our ICU with ARF caused by crush injury (25 patients) or prolonged positional compression on a muscle group (36 patients). These patients consisted of 55 men and 6 women with a mean age of 40.9 ± 13.4 years, ranging from 19 to 85. All the patients demonstrated kidney failure with increased concentrations of serum urea (13.22–79.40 mmol/l) and creatinine (172–1398 μmol/l). ARF was highly associated with massive muscle damage and insufficient initial fluid resuscitation. The period from the onset of symptoms and signs of the injury to the commencement of treatment with hemodialysis varied from 4 hours to 9 days. Fifty-nine (97%) patients were oliguric. Fifty-eight (95%) of these patients were treated with hemodialysis from 1 to 21 days. Hyperkalemia (5.6–8.1 mmol/l) was present in 38 (62%) patients. More than in half cases hyperkalemia was diagnosed before azotemia. Six (9.8%) patients underwent fasciotomies and 6 (9.8%) patients underwent amputations. The outcome was favorable in 43 (70%) patients, 18 (29.5%) patients died. The half causes of death were infection and sepsis.

Conclusions

1. Hyperkalemia, and metabolic acidosis appear before azotemia and within hours of the rescue of casualties with traumatic rhabdomyolysis. 2. Very early, aggressive volume replacement followed by forced solute-alkaline diuresis therapy may protect the kidney against acute renal failure.