The case, published in Clinical Case Reports, documents perioperative rhabdomyolysis, a condition in which skeletal muscle fibers break down and dump their intracellular contents into the bloodstream. The mechanism is deceptively simple and physiologically brutal. When muscle cells are compressed or deprived of blood flow for extended periods, their membranes fail, calcium floods into the cells, and ATP reserves are depleted. The result is irreversible necrosis of muscle fibers and the release of myoglobin, potassium, phosphate, and creatine kinase, an enzyme that serves as the biochemical fingerprint of muscle destruction. In the circulation, these liberated molecules can trigger dangerous electrolyte disturbances, including hyperkalemia and hyperphosphatemia, while the myoglobin filtered by the kidneys can obstruct renal tubules, poison them directly, and constrict renal vessels, all of which threaten acute kidney injury.

This patient carried nearly every established risk factor in the literature. He stood 188 centimeters tall and weighed 136 kilograms, giving him a body mass index of 38.5, well within Class II obesity. His medical history included Type 2 diabetes, hypertension, and a 36-pack-year smoking history, and his American Society of Anesthesiologists physical status was rated 3, indicating severe systemic disease. Obesity, male sex, prolonged operative times, and lateral decubitus positioning, lying on one’s side, have all been consistently identified as risk factors in reports of laparoscopic renal surgery. A large national cohort study estimated the incidence of rhabdomyolysis after major urologic surgery at roughly 0.1 percent, rare enough that many surgical teams will never encounter it, but common enough to demand vigilance in high-risk patients.

The operation lasted five hours and fifteen minutes, and that duration may have been decisive. The patient was placed in the right flank position, the standard posture for left-sided kidney surgery, with pressure-relieving padding at joints and pressure points that were reassessed every fifteen minutes. Even so, his dependent right gluteal muscles were compressed under his own body weight for the entire procedure. Prior research has identified a three-hour operative duration as a critical threshold for rhabdomyolysis risk in obese patients undergoing laparoscopic nephrectomy, with experts recommending early serum creatine kinase measurement on the day of surgery for such cases. This patient’s procedure far exceeded that threshold, and no intraoperative repositioning was performed.

The laboratory findings on the first postoperative day were striking. Serum creatine kinase measured 53,067 units per liter, roughly 180 times the upper limit of the normal reference range of 51 to 298 units per liter. Serum myoglobin was elevated at 1,625 nanograms per milliliter against a reference value below 91. For context, levels above 5,000 units per liter are associated with increased kidney injury risk, and values exceeding 15,000 units per liter are classified as severe rhabdomyolysis. The peak value here was comparable to a previously reported case of rhabdomyolysis after prolonged laparoscopic radical nephrectomy, in which the first postoperative day creatine kinase reached 51,050 units per liter. Notably, the patient’s creatinine remained essentially normal at 1.19 milligrams per deciliter, and a review of the anesthesia record found no episodes of prolonged or untreated hypotension, ruling out low blood pressure as a significant contributor.

Imaging added a layer of diagnostic complexity that illustrates how challenging these cases can be. A CT scan revealed an enlarged right gluteus medius muscle consistent with an intramuscular hematoma, with fluid and stranding tracking into the right posterior thigh. Yet an ultrasound performed immediately afterward showed no hematoma or fluid collection at all. Compartment pressure measured with a Stryker needle in the upper outer gluteal quadrant was only mildly elevated at 12 millimeters of mercury. The clinical team acknowledged that the CT abnormality and the biochemical evidence of rhabdomyolysis may not have represented the same pathological process, and that the exact timing and mechanism of the suspected hematoma could not be determined. Nevertheless, the overall picture, acute gluteal pain after prolonged surgery combined with dramatically elevated muscle enzymes, pointed firmly to perioperative rhabdomyolysis as the principal diagnosis.

Treatment began immediately. The patient received aggressive intravenous hydration with 100 milliequivalents of sodium bicarbonate in one liter of 0.45 percent sodium chloride, continued at 200 milliliters per hour through the second postoperative day, following an institutional practice aimed at urinary alkalinization. The physiology behind this approach is well understood: once muscle injury occurs, fluid shifts from the intravascular space into damaged tissue, creating a so-called third space that contributes to hypovolemia and renal ischemia. Hypovolemia further restricts renal blood flow through sympathetic activation, vasoconstrictor release, and nitric oxide degradation. Early volume resuscitation preserves renal perfusion and helps flush myoglobin through the kidneys before it can cause tubular obstruction and toxicity. Interestingly, the authors note that adjunctive therapies such as mannitol and sodium bicarbonate, long mainstays of rhabdomyolysis management, are now viewed with skepticism, as recent evidence does not support their routine use; current practice emphasizes early volume expansion and avoiding agents that reduce renal blood flow.

The recovery was reassuringly rapid. Serial monitoring showed creatine kinase falling from 53,067 to 17,712 units per liter later on the first postoperative day, then to 11,011 by day two. Creatinine rose transiently to 1.38 milligrams per deciliter before settling back to 1.18. Calcium dipped to 8.0 milligrams per deciliter on day two, a predictable consequence of injured myocytes sequestering calcium, with the caveat that clinicians avoid calcium replacement unless hyperkalemia with electrocardiographic changes is present, because rebound hypercalcemia can occur during recovery as calcium is released back into circulation. The patient was discharged on postoperative day three without ever requiring renal replacement therapy, a fortunate outcome given that other reported cases have progressed to hemodialysis despite aggressive hydration. At one-month follow-up, his creatine kinase had normalized to 72 units per liter, creatinine was 1.27, and calcium had rebounded to 10.9 milligrams per deciliter.

The broader lesson extends well beyond a single case. As minimally invasive robotic and laparoscopic techniques enable ever longer and more complex operations, surgeons and anesthesiologists are increasingly confronting complications rooted not in the surgery itself but in the stillness it demands. Preventive strategies include optimizing pressure distribution with careful padding, minimizing flank flexion, and periodically repositioning the patient during lengthy procedures, alongside postoperative monitoring of creatine kinase and renal function to catch muscle injury early. For patients who combine obesity with anticipated operative times beyond three hours in the lateral decubitus position, the authors suggest that early enzyme measurement on the day of surgery may allow timely recognition before kidney damage occurs. This case is a vivid reminder that in modern surgery, the most dangerous forces are sometimes not the scalpel or the robot, but gravity and time acting silently on a body held motionless under anesthesia.

Subject of Research: Perioperative rhabdomyolysis following prolonged laparoscopic radical nephrectomy in the lateral decubitus position

Article Title: Perioperative Rhabdomyolysis Following Prolonged Laparoscopic Radical Nephrectomy in the Lateral Decubitus Position

Article References: Dow, M., Srinivasan, A., & Ayad, S. (2026). Perioperative Rhabdomyolysis Following Prolonged Laparoscopic Radical Nephrectomy in the Lateral Decubitus Position. Clinical Case Reports, 14(10), Article e73640. https://doi.org/10.1002/ccr3.73640

Image Credits: AI Generated

DOI: 10.1002/ccr3.73640

Keywords: rhabdomyolysis, laparoscopic nephrectomy, lateral decubitus position, creatine kinase, myoglobin, acute kidney injury, obesity, patient positioning, perioperative complications, robotic surgery, gluteal muscle injury, case report

The study, conducted by Karin Falk-Brynhildsen, Carina Bååth, Dimitri Beeckman, Christine Leo Swenne, Charlotte Raepsaet and Camilla Wistrand, set out to describe Swedish operating room nurses’ self-estimated knowledge and attitudes regarding the prevention of intraoperative pressure ulcers. Using a cross-sectional design reported according to the STROBE guidelines for observational studies, the team distributed an online questionnaire by email to operating room nurses across all 21 of Sweden’s healthcare regions. Of the 2247 addresses contacted, 343 proved non-functional, leaving 1904 eligible recipients. After two reminders, 284 nurses completed the survey, a response rate of 15 percent. Data collection took place in August and September 2020 as part of a larger project developing two validated instruments tailored to the operating room: the Pressure Ulcer Knowledge Assessment Tool for the operating room, known as PUKAT 2.0 OR, and the Attitudes toward Pressure Ulcer Prevention instrument adapted for the same setting, the APuP-OR.

The scale of the clinical problem provides the context for why this matters. According to the European Pressure Ulcer Advisory Panel guidelines, surgery-related pressure ulcers occur in approximately 4 to 45 percent of surgical procedures. Recent studies have documented intraoperative incidence rates ranging from 6.2 to 16.2 percent, and one study of patients aged 65 and older reported an incidence of 18.8 percent, with operative times of 180 minutes or longer strongly associated with increased risk. Medical devices compound the danger: blood pressure cuffs, adhesive tapes, endotracheal tubes and spectral index monitors can all damage skin and mucosal surfaces, and device-related pressure ulcers have been estimated at a prevalence of around 11.8 percent, while positioning-related ulcers may reach 23.5 percent. The operating room is therefore recognised as a high-risk environment where every member of the surgical team shares responsibility for tissue protection.

The 284 respondents were an experienced and highly educated group. Their mean age was 42.8 years, 93 percent were women, and 37 percent held a master’s degree while another 33.8 percent held a professional operating room nursing degree. More than 63 percent had over 11 years of experience in healthcare, and 37.7 percent had more than 20 years. When asked to rate their own expertise using Benner’s classic proficiency levels, half identified as proficient and 38 percent as competent, with 11.3 percent claiming expert status and only two nurses describing themselves as novices. Crucially, 87 percent said that further education in pressure ulcer prevention would be beneficial, an appetite for learning that the study’s findings suggest is well founded.

The knowledge assessment told a story of two halves. In the domain of aetiology, the nurses performed impressively. More than 95 percent correctly identified the causes of pressure ulcers and understood the biomechanical consequences of a patient sliding in a semi-upright position, and 90.1 percent recognised that body weight contributes to risk. These results align with previous research emphasising the role of knowledge in delivering evidence-based care. But when the questions turned to prevention, classification and observation, performance dropped sharply. Only 38 percent correctly identified where deep tissue injuries develop during surgery, and just 41.2 percent correctly classified blisters observed on both heels after a three-hour procedure. Nearly 60 percent answered incorrectly when asked about heel protection measures for a patient already lying on a pressure-redistributing mattress, and questions about patient positioning yielded correct response rates of only around 51 to 52 percent.

The researchers applied a demanding benchmark to these results, using a 90 percent threshold for correct answers, and only 3 of the 14 knowledge items met it. Even when the cut-off was lowered to 70 percent, the number of adequate responses remained limited. The authors deliberately retained the stricter threshold, reflecting on whether adjusting the standard of what counts as sufficient knowledge in pressure ulcer prevention is appropriate at all. The finding that positioning competencies are limited is consistent with earlier work by Sørensen and colleagues, who reported similar gaps among surgical teams, and it points to a specific, teachable weakness at the heart of intraoperative care: knowing how to position a patient safely is not the same as knowing why pressure damages tissue.

Attitudes, by contrast, were overwhelmingly positive. A remarkable 94.7 percent of respondents reported feeling confident in their ability to prevent pressure ulcers, and 98.6 percent agreed that prevention should be a priority and a personally important responsibility. Fully 94 percent acknowledged the financial burden that pressure ulcers place on society. The nurses firmly rejected dismissive statements: 93.7 percent disagreed that the impact of pressure ulcers on patients is exaggerated, 96.5 percent rejected the notion that too much attention is paid to prevention, and 96.1 percent refused the idea that they bear no responsibility if an ulcer develops in their patient. Attitude scores were higher than those reported in a previous study by Khong and colleagues, suggesting Swedish operating room nurses occupy an unusually favourable motivational position.

Experience shaped confidence in measurable ways. Pairwise comparisons revealed statistically significant differences across years of operating room experience in perceived training: nurses with more than 20 years of experience felt significantly better trained than those with 5 to 10 years, with a p-value of 0.049. A similar pattern emerged for perceived confidence, with significant differences between the most experienced nurses and those with 5 to 10 years of experience, and between the 11-to-20-year group and their less experienced colleagues. Yet the study’s central paradox remains: despite this confidence and experience, overall knowledge was insufficient, and positive attitudes did not translate into consistently correct answers about prevention strategies such as surgical linen use, positioning angles and heel offloading.

The authors are candid about the limitations of their work. Self-reported data are vulnerable to recall bias and social desirability bias, and some question wording may have confused participants. The 15 percent response rate restricts generalisability, and it is possible that respondents were more interested in pressure ulcer prevention than non-respondents, which could have inflated the apparent knowledge and attitude scores. The measurement instruments themselves, while validated, showed modest internal consistency on some subscales, and the authors note that PUKAT 2.0 OR requires further refinement to capture the complexity of pre-positioning across different surgical procedures while preserving operative exposure for the surgeon.

The implications reach beyond Sweden. Because most pressure ulcers are preventable, the authors argue, raising awareness and promoting evidence-based prevention strategies across the entire operating room team is imperative, including surgeons, anaesthesiologists and nurse anaesthetists, not nurses alone. They call for systematic, evidence-based educational interventions, structured training programmes, simulation-based learning and regular competency assessments integrated into continuing professional development, alongside mixed-methods research to clarify why positive attitudes fail to produce adequate knowledge or consistent preventive action. Structured risk assessment tools, which guidelines consider the gold standard, should complement rather than replace clinical judgement. For a complication that can begin forming the moment a patient is positioned on the table, the message of this survey is clear: the will to prevent pressure ulcers is present in the operating room, but the knowledge to do so reliably still needs to be built, one training programme at a time.

Subject of Research: Operating room nurses' knowledge and attitudes regarding intraoperative pressure ulcer prevention

Article Title: Preventing Pressure Ulcers in the Operating Room: A National Survey of Operating Room Nurses' Knowledge and Attitudes

Article References: Falk‐Brynhildsen, K., Bååth, C., Beeckman, D., Leo Swenne, C., Raepsaet, C., & Wistrand, C. (2026). Preventing Pressure Ulcers in the Operating Room: A National Survey of Operating Room Nurses' Knowledge and Attitudes. Nursing Open, 13(9), Article e70808. https://doi.org/10.1002/nop2.70808

Image Credits: AI Generated

DOI: 10.1002/nop2.70808

Keywords: pressure ulcers, operating room nurses, patient safety, intraoperative care, nursing knowledge, survey research, Sweden, patient positioning, surgical complications, nursing education, pressure injury prevention, cross-sectional study