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Cap 33 Rabdomiólise
Cap 33 Rabdomiólise
RABDOMILISE
Elsa Alidia Petry Gonalves
Fernando Goldoni
INTRODUO
A rabdomilise uma sndrome caracterizada por necrose muscular e liberao
de constituintes intracelulares do msculo para a circulao. A gravidade da doena
varia de elevaes assintomticas das enzimas musculares sricas a casos de extrema
elevao das enzimas, desequilbrio eletroltico e insuficincia renal aguda.
A primeira descrio moderna de rabdomilise atribuda a Bywaters e Beall,
que, em 1941, relataram quatro vtimas de esmagamento durante um bombardeio de
Londres. Nesse primeiro relato, todos desenvolveram insuficincia renal aguda e
morreram dentro de uma semana.
A causa de rabdomilise geralmente evidente a partir da histria ou das
circunstncias imediatas que precedem o transtorno, como o trauma, um estado de coma
ou ps-ictal, ou esforo fsico extraordinrio. Em alguns casos, porm, o fator
precipitante no bvio. Nessas situaes, possveis causas incluem deficincias
hereditrias de enzimas musculares, distrbios eletrolticos, infeces, drogas, toxinas e
endocrinopatia.
MANIFESTAES CLNICAS E DIAGNSTICO
A apresentao clssica de rabdomilise inclui mialgias, urina de colorao
vermelha a marrom devido mioglobinria e elevao de enzimas musculares sricas,
(incluindo creatina quinase). O grau de dor varia muito entre os pacientes com
rabdomilise; alm disso, fraqueza muscular pode ocorrer em pessoas com leso
muscular grave.
Enzimas musculares - Os nveis sricos de creatina quinase (CK) podem ser
maciamente elevados acima de 100.000 UI/L. A CK total ou quase totalmente a
frao muscular esqueltica (MM), embora pequena quantidade da frao miocrdica
(MB) possa estar presente. A presena da MB reflete a pequena quantidade desta frao
encontrada no msculo esqueltico e no a presena de doena do miocrdio. Elevaes
nas transaminases sricas so comuns e podem causar confuso se atribuda doena
heptica.
Cor da urina - mioglobina, uma protena que contm heme-respiratria liberada
do msculo danificado em paralelo com CK. A mioglobina um monmero que no
est ligado s protenas e, por isso, rapidamente excretada na urina, o que muitas vezes
resulta na produo de urina avermelhada ou marrom. Por causa da rpida excreo, a
mioglobina no produz uma mudana na cor do plasma. Esta pigmentria pode no ser
identificada na rabdomilise se a carga filtrada de mioglobina for insuficiente ou, em
grande parte, resolvida antes de o paciente procurar atendimento mdico. A mioglobina
eliminada do plasma mais rapidamente do que a CK. Assim, no incomum que os
nveis de CK permaneam elevados na ausncia de mioglobinria.
Insuficincia renal aguda (IRA) - uma complicao comum da rabdomilise.
Depleo de volume resultando em isquemia renal, obstruo tubular devido ao
pigmento heme, e leso tubular pelo ferro quelato livre contribuem para o
desenvolvimento de disfuno renal.
COMPLICAES DA RABDOMILISE
Coagulao intravascular disseminada
Hipocalcemia
Hiperfosfatemia (hipofosfatemia pode ocorrer tardiamente)
Hipercalemia
Hiperuricemia
Neuropatia perifrica
Sndrome compartimental
Tabela 33.2: Complicaes da rabdomilise
Rabdomilise:
Dosagem de sdio, potssio, uria, creatinina,
gasometria arterial, clcio, fsforo, albumina, cido
rico, dosagens seriadas de CPK, Urina tipo 1
Tratamento da Rabdomilise
Manitol
- Manitol a 10%: 15 a 45 ml/hora (cerca de 5 g/hora).
Dilise
- Procurar e tratar a causa da rabdomilise
- Controlar periodicamente os eletrlitos e a
funo renal
- Tratar a hipercalemia.
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Rotinas Clinicas em Urgncia e Emergncia no HRMS
Organizadores: Fernando Goldoni e Mrcio Estevo Midon
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