From the Guidelines
The treatment of rhabdomyolysis should focus on aggressive intravenous fluid resuscitation, with volumes greater than 6L required in patients with severe rhabdomyolysis (CPK >15,000 IU/L) to prevent acute kidney injury and the need for renal replacement therapy, as suggested by a retrospective study in 2011 1. The goal of fluid resuscitation is to maintain urine output at 200-300 mL/hour to prevent acute kidney injury by diluting nephrotoxic myoglobin and flushing it from the kidneys.
- Key considerations in the management of rhabdomyolysis include:
- Aggressive fluid resuscitation with normal saline
- Correction of electrolyte abnormalities, particularly hyperkalemia
- Urinary alkalinization with sodium bicarbonate to maintain urine pH above 6.5, although this remains controversial
- Early identification and addressing of the underlying cause of rhabdomyolysis
- Consideration of fasciotomy for patients with compartment syndrome
- The management of kidney injury resulting from rhabdomyolysis follows the same principles as for other causes of acute kidney injury, with referral to guidelines for acute kidney injury in the perioperative period and intensive care units 1.
- Renal replacement therapy (dialysis) is indicated for patients with severe acute kidney injury, persistent hyperkalemia, or volume overload unresponsive to conservative management, and early nephrology consultation is recommended for patients with significant kidney injury.
- It is essential to continue fluid therapy until serum creatine kinase (CK) levels decrease to below 5,000 U/L, as indicated by the clinical response and laboratory findings 1.
From the Research
Treatment Overview
- The mainstay of treatment for rhabdomyolysis is hospitalization with aggressive intravenous fluid (IVF) resuscitation and correction/prevention of electrolyte abnormalities 2.
- Early and aggressive fluid resuscitation is agreed upon as the main intervention for preventing and treating acute kidney injury (AKI) 3, 4.
- Automated fluid management has the potential to optimize urine output while avoiding fluid accumulation in rhabdomyolysis patients 5.
Fluid Resuscitation
- Aggressive intravenous fluid resuscitation (IVFR) has been shown to decrease the incidence of acute renal failure (ARF) and need for dialysis in patients with rhabdomyolysis 6.
- Early vigorous fluid resuscitation with ≥12 l daily intravenous infusion of alkaline solution started at the scene of injury can stabilize the circulation, mobilize edema fluids, correct hyperkalemia and acidosis, and protect against the nephrotoxic effects of myoglobinemia and hyperuricosuria 4.
Adjunctive Therapies
- The use of bicarbonate, mannitol, and loop diuretics is not supported by high-quality evidence, and their routine use is not recommended 6, 3.
- Urine alkalization with bicarbonate and diuretic therapy may be considered as adjunctive therapies, but their benefits are not well established 2.
Complications and Monitoring
- Hyperkalemia and compartment syndrome are additional complications of rhabdomyolysis that must be treated effectively 3.
- Close monitoring of patients with rhabdomyolysis is necessary to identify and manage potential complications, including acute renal failure, electrolyte abnormalities, and cardiac dysrhythmias 2.