Rhabdomyolysis, a complicated syndrome with serious potential complications, is associated with acquired or inherited causes [5]. In the present case, rhabdomyolysis was caused by chronic pressure ulcers in a paraplegic patient. Pressure ulcers, also termed pressure sores, bedsores, decubitus ulcers or pressure injuries, are injuries of the skin and its underlying appendages and soft tissues, from constant or prolonged pressure exerted on an unspecified part of the trunk, limb, or body region. These lesions mostly occur in people who suffer from certain conditions, such as coma, drug overdose, surgery, paralysis, and spinal cord injury [6, 7], which may lead to decreased mobility and difficulty in postural movement [8]. Therefore, as a serious complication of various chronic diseases, pressure ulcers may result in more severe problems. Common manifestations of rhabdomyolysis include muscle pain, tenderness, swelling, and weakness, combined with fever, general weakness, increased white blood cells and/or neutrophils, and abnormalities in urine appearance. Statistically, about 13–50% of patients may develop acute renal failure (ARF) [9], leading to oliguria, anuria, or azotemia. However, the accurate incidence rate of rhabdomyolysis is difficult for clinicians to determine, especially in the ED [10], because prospective studies assessing the morbidity of rhabdomyolysis are quite rare. Thus, a limited number of cases in the early stages of rhabdomyolysis are diagnosed in the clinic. Although numerous researchers study rhabdomyolysis, only a few cases regarding the treatment of patients suffering from rhabdomyolysis from pressure ulcers have been reported. It was previously reported that a case of rhabdomyolysis caused by acute pressure sores, in which the patient died in the end[11].
In the present research, before admission of the patient to our hospital, he was sent to the emergency department of a local hospital and had no certain diagnosis. However, this patient had sacrococcygeal pressure ulcers for over 10 years, and the wounds from some ulcers were ruptured for over 3 months. It should be noted that not only the family members of the patient, but also the clinicians of local hospitals had no awareness of the risks in the care of long-term bedridden patients. Importantly, with respect to prevention of the further complications, the vigilance of patients with paraplegia and their family members should be enhanced in regard to identification and treatment of pressure ulcers [12]. As a severe complication of pressure ulcers, rhabdomyolysis needs to be prevented or better identified during the early stages. Thus, education, awareness, and specific training are effective measures in the daily care of those patients.
However, the treatment of rhabdomyolysis is strictly based on accurate diagnosis. Aside from the fever, dark-colored urine, and metabolic disturbance of the patient, a sensitive indicator of rhabdomyolysis was the CK level, which was up to 10809 U/L. The higher the CK level, the more severe the muscle damage and the higher the risk of acute kidney injury. Due to the critical condition and multidisciplinary problems of this case of rhabdomyolysis with acute infection, we organized a multidisciplinary diagnosis and treatment (MDT) model, which was implemented by the Orthopedics Department with input from the Nephrology Department, Infection Department, and Intensive Care Unit (ICU). A number of physicians demonstrated that the patient had severe renal dysfunction and acute infections, and they suggested improving renal function and controlling the infection pre-operatively. However, other physicians believed the necrotic muscle tissues in the sacrococcygeal bedsores were the primary and exact cause of other manifestations, and debridement should be performed immediately in order to prevent fatal consequences, such as renal failure and sepsis. We eventually adopted the latter opinion and performed debridement immediately. It was disclosed that all symptoms and laboratory data were gradually relieved postoperatively. To our knowledge, anesthetics mainly cause damage to renal function. In the present case, the patient suffered from paraplegia, leading to the loss of skin sensation around the operative region. Thus, it was unnecessary to conduct an emergency operation with anesthesia, which could prevent further damage and reduce the risk of acute kidney injury.