What is the management of rhabdomyolysis?

From the Guidelines

Aggressive intravenous fluid resuscitation with isotonic saline is crucial in managing rhabdomyolysis to prevent acute kidney injury, with volumes greater than 6L often required in severe cases 1. Management of rhabdomyolysis involves prompt recognition and treatment to prevent complications. Key aspects of management include:

• Discontinuing any causative medications or substances immediately
• Monitoring serum creatine kinase (CK) levels, electrolytes, renal function, and acid-base status every 6-12 hours initially
• Treating hyperkalemia if present using appropriate measures such as insulin with glucose, calcium gluconate, sodium bicarbonate, or potassium-binding resins
• Considering urinary alkalinization with sodium bicarbonate in severe cases with myoglobinuria
• Providing pain management with appropriate analgesics
• Identifying and addressing the underlying cause of rhabdomyolysis The goal of fluid resuscitation is to achieve a urine output of 200-300 mL/hour until myoglobinuria clears, with the total fluid requirement often ranging from 6-12 L in the first 24 hours, adjusted based on clinical response 1. In severe cases, renal replacement therapy may be necessary, particularly with persistent hyperkalemia, acidosis, or uremia. Early aggressive fluid therapy is critical because myoglobin is directly nephrotoxic, causing renal tubular obstruction, vasoconstriction, and direct cytotoxicity, especially in acidic environments 1.

From the Research

Management of Rhabdomyolysis

• The treatment of rhabdomyolysis involves aggressive intravenous fluid resuscitation (IVFR) to improve outcomes and reduce the need for dialysis 2.
• IVFR should be initiated as soon as possible, preferably within the first 6 hours after muscle injury, at a rate that maintains a urine output in adults of 300 mL/h or more for at least the first 24 hours 3.
• The use of bicarbonate and mannitol is not recommended unless necessary to correct systemic acidosis or maintain urine output 2, 3.
• Early vigorous fluid resuscitation with ≥12 l daily intravenous infusion of alkaline solution can help stabilize the circulation, mobilize edema fluids, correct hyperkalemia and acidosis, and protect against the nephrotoxic effects of myoglobinemia and hyperuricosuria 4.

Treatment Methods

• Aggressive IV fluid resuscitation is the most commonly utilized treatment method for decreasing creatine kinase (CK) levels and resolving myoglobinuria 5.
• The addition of compounds within the IV fluid, such as sodium bicarbonate, sodium chloride, or potassium chloride, may be used to achieve reduction of CK levels and myoglobinuria 5.
• Normal saline is the most commonly reported treatment for decreasing CK levels and myoglobinuria following exertional rhabdomyolysis 5.
• Hospitalization time and return to activity vary depending on the severity of the condition 5.

Prevention of Kidney Injury

• Intravenous fluids should be initiated as soon as possible to prevent kidney injury following rhabdomyolysis 3.
• Delayed fluid administration increases the risk of acute renal failure (ARF) 3.
• No evidence supports a preferred fluid type or that sodium bicarbonate with or without mannitol is superior to fluid therapy alone in preventing ARF 3.