How to manage rhabdomyolysis in an involuntarily committed patient who is refusing intravenous (IV) fluids and has not responded to Zyprexa (olanzapine)?

Management of Rhabdomyolysis in an Involuntarily Committed Patient Refusing IV Fluids

In a patient with rhabdomyolysis who is involuntarily committed and refusing IV fluids, aggressive IV fluid resuscitation should be administered despite patient refusal when there is risk of acute kidney injury, as this constitutes a medical emergency that overrides patient autonomy in this specific circumstance.

Assessment of Medical Emergency Status

1. Evaluate severity of rhabdomyolysis:

   • Check creatine kinase (CK) levels - extremely high levels (>10,000 U/L) indicate severe rhabdomyolysis with high risk of acute kidney injury 1
   • Assess for signs of acute kidney injury (elevated creatinine, decreased urine output)
   • Monitor for electrolyte abnormalities, particularly hyperkalemia
   • Check for metabolic acidosis

2. Determine if immediate intervention is necessary:

   • If CK levels are extremely elevated (cases have been reported with levels as high as 345,125 U/L) 2
   • If there are signs of developing acute kidney injury
   • If there are dangerous electrolyte imbalances

Legal and Ethical Framework for Intervention

1. Involuntary commitment status considerations:

   • Involuntary commitment already establishes that the patient lacks capacity to make certain decisions
   • When a medical emergency exists, treatment can be provided despite refusal 3
   • The presence of rhabdomyolysis with risk of acute kidney injury constitutes a medical emergency

2. Decision-making process:

   • Consult with institutional ethics committee if time permits 3
   • Document clinical reasoning for overriding patient refusal
   • Ensure consensus among treating clinicians about the necessity of intervention

Treatment Protocol

1. IV fluid administration:

   • Administer isotonic fluids (normal saline) at 10-20 mL/kg initial bolus (maximum 1,000 mL) 4
   • Continue with infusion at 5-10 mL/kg/hour 4
   • Target urine output of >0.5 mL/kg/hour 4
   • Consider systemic alkalinization to prevent myoglobin precipitation in renal tubules 1

2. Monitoring during treatment:

   • Frequent vital sign checks
   • Monitor for signs of fluid overload (increased jugular venous pressure, crackles/rales, decreasing oxygen saturation) 4
   • Regular laboratory monitoring of CK levels, renal function, and electrolytes
   • Adjust fluid rate based on clinical response

3. Physical restraint considerations:

   • Use minimal restraint necessary to administer life-saving treatment
   • Document necessity of restraints if used
   • Discontinue restraints as soon as possible

Psychiatric Management

1. Alternative antipsychotic options:

   • Consider switching from olanzapine (Zyprexa) to a different antipsychotic with lower risk of rhabdomyolysis 5
   • Aripiprazole has been associated with rhabdomyolysis but may be considered at low doses with careful monitoring 6
   • Any antipsychotic switch should be done cautiously as multiple antipsychotics have been associated with rhabdomyolysis 7

2. Addressing refusal behavior:

   • Continue attempts at verbal de-escalation
   • Consider consulting psychiatry for medication adjustments to address agitation
   • Provide clear, simple explanations about the medical necessity of treatment

Conflict Resolution

1. If conflict persists:

   • Involve institutional ethics committee 3
   • Consider second opinions from other specialists
   • Document all attempts at conflict resolution
   • If time permits and patient condition allows, consider court involvement for treatment authorization

2. Time-pressured decisions:

   • In urgent situations where full conflict resolution isn't possible, clinicians should:
     • Verify facts and prognosis
     • Ensure consensus among treating clinicians
     • Explain reasons for treatment to patient and/or surrogate 3

Common Pitfalls and Caveats

1. Avoid excessive fluid administration which can lead to pulmonary edema, especially in patients with cardiac or renal dysfunction

2. Don't delay treatment while waiting for full conflict resolution if the patient is at imminent risk of acute kidney injury

3. Don't assume all antipsychotics are equally likely to cause rhabdomyolysis - careful selection of alternative agents is important 7

4. Monitor for recurrence of rhabdomyolysis even after resolution of the initial episode, especially if antipsychotic therapy is continued

5. Be alert for early warning signs of rhabdomyolysis such as muscle pain, weakness, and dark urine, which often precede the full syndrome 7

The management of rhabdomyolysis in an involuntarily committed patient refusing treatment represents a complex intersection of medical necessity and patient autonomy. While patient autonomy is important, the risk of acute kidney injury from untreated severe rhabdomyolysis constitutes a medical emergency that justifies intervention despite patient refusal in this specific circumstance.