From the Guidelines
Rhabdomyolysis treatment should prioritize aggressive intravenous fluid resuscitation with isotonic saline at rates of 1-2 L/hour initially, adjusted based on the patient's cardiovascular status, to prevent kidney damage. The goal of this high-volume fluid therapy is to maintain urine output above 200-300 mL/hour, which helps flush myoglobin from the kidneys, preventing tubular obstruction and acute kidney injury 1.
Key Considerations
- Monitoring of electrolytes, particularly potassium, is crucial as hyperkalemia can develop and may require treatment with calcium gluconate, insulin with glucose, or sodium bicarbonate in severe cases.
- Urinary alkalinization with sodium bicarbonate may be considered to prevent myoglobin precipitation in the kidneys, though its benefit remains controversial.
- Dialysis may be necessary for patients who develop severe acute kidney injury, persistent hyperkalemia, or metabolic acidosis.
- The underlying cause of rhabdomyolysis must also be identified and addressed, and patients should avoid nephrotoxic medications.
- Creatine kinase levels should be monitored until they normalize, which indicates resolution of muscle breakdown.
Volume Resuscitation
According to a retrospective study of 638 earthquake victims, volumes greater than 6L were required in patients with severe rhabdomyolysis (CPK >15,000 IU/L) to prevent acute kidney injury and the need for renal replacement therapy, whereas 3–6L per day were deemed sufficient in moderate rhabdomyolysis 1.
Management of Kidney Injury
The management of kidney injury built up after rhabdomyolysis has no specificity, and experts refer to the French recommendations for acute kidney injury in the perioperative period and intensive care units 1.
From the Research
Rhabdomyolysis Treatment Overview
- Rhabdomyolysis is a clinical syndrome of muscle injury associated with myoglobinuria, electrolyte abnormalities, and often acute kidney injury (AKI) 2.
- The treatment of rhabdomyolysis remains controversial, with debate persisting regarding the benefit of further therapy including aggressive intravenous fluid resuscitation (IVFR), urine alkalization with bicarbonate, and the use of mannitol 3.
Aggressive Intravenous Fluid Resuscitation (IVFR)
- IVFR is conditionally recommended to improve outcomes of acute renal failure (ARF) and lessen the need for dialysis in patients with rhabdomyolysis 3.
- Early and aggressive fluid resuscitation to restore renal perfusion and increase urine flow is agreed on as the main intervention for preventing and treating AKI 2.
- Intravenous fluids 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 4.
Urine Alkalization with Bicarbonate and Mannitol
- Neither bicarbonate nor mannitol administration improved the incidence of acute renal failure and need for dialysis in patients with rhabdomyolysis 3.
- There is little evidence to support the routine use of bicarbonate-containing fluids, mannitol, and loop diuretics 2.
- Sodium bicarbonate should be administered only if necessary to correct systemic acidosis and mannitol only to maintain urine output of 300 mL/h or more despite adequate fluid administration 4.
Other Considerations
- Hyperkalemia and compartment syndrome are additional complications of rhabdomyolysis that must be treated effectively 2.
- 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 5.