From the Research
For pain management in a patient with rhabdomyolysis following prolonged floor time with hypothermia, I recommend acetaminophen as the first-line agent at 650-1000 mg orally every 6 hours, not exceeding 4000 mg daily, as it does not stress the kidneys, which are already at risk from myoglobin release 1. This approach is supported by the most recent evidence, which emphasizes the importance of avoiding further kidney injury in patients with rhabdomyolysis 2.
Key Considerations
- If additional pain control is needed, consider low-dose opioids such as hydrocodone/acetaminophen 5/325 mg every 6 hours as needed, with careful monitoring for respiratory depression and constipation.
- Avoid NSAIDs like ibuprofen or naproxen completely as they can worsen kidney injury 3.
- The patient requires aggressive IV fluid resuscitation with normal saline to maintain urine output above 200 mL/hour, which will help flush myoglobin from the kidneys and may itself reduce muscle pain 2.
- Monitor creatine kinase levels, renal function, and electrolytes (especially potassium and calcium) frequently, as hyperkalemia and hypocalcemia can develop 4.
- Physical therapy consultation should be initiated early for gentle mobilization once medically stable.
- Pain management should be reassessed daily and tapered as the patient improves 5.
Rationale
The management of rhabdomyolysis involves addressing the underlying cause, preventing further muscle damage, and supporting the patient's overall health. Given the patient's condition, with a temperature of 87.4°F and rhabdomyolysis following a prolonged period on the floor, it is crucial to prioritize kidney protection and pain management. The use of acetaminophen as a first-line agent for pain management is recommended due to its safety profile regarding kidney function, especially when compared to NSAIDs, which are contraindicated in this scenario 3, 2.
Monitoring and Adjustment
Regular monitoring of the patient's condition, including renal function, electrolyte levels, and pain management, is essential. Adjustments to the treatment plan should be made as necessary to ensure the patient's comfort and to prevent complications. The goal is to improve the patient's quality of life while minimizing morbidity and mortality risks associated with rhabdomyolysis and its treatment 1.