Detailed review of unusual cases is a cornerstone of anesthesiology education. Each month, the AQI-AIRS Steering Committee will abstract a case and provide a detailed discussion based on a submission to the national Anesthesia Incident Reporting System. Feedback regarding this item can be sent by email tor.dutton@asahq.org. Report incidents towww.aqiairs.org.

A 37-year-old, 150 kg, ASA Physical Status 3 woman underwent a robot-assisted laparoscopic vaginal hysterectomy (RAVH) under general anesthesia in steep Trendelenberg position. A customized positioning device that fit over the shoulders was used to secure the patient to the bed. The anesthetic lasted for six hours and the procedure itself took more than 4.5 hours. The patient was awakened and extubated uneventfully. Postoperatively, dark-colored urine was noted in the PACU. Laboratory assay revealed serum creatinine of 1.5 mg/dl and creatine phosphokinase of 1,500 IU/liter. Rhabdomyolysis was diagnosed and the patient treated with increased intravenous hydration, sodium bicarbonate and diuretics. Laboratory values returned to normal over 24 hours postoperatively and the patient experienced no long-term sequelae.