From the Guidelines
The recommended fluid rate for rhabdomyolysis management is typically greater than 6L per day 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 are deemed sufficient in moderate rhabdomyolysis. This is based on a retrospective study of 638 earthquake victims 1. The goal of fluid therapy is to maintain urine output of 200-300 mL/hour, which can be achieved with aggressive initial hydration. Isotonic crystalloids like normal saline (0.9% NaCl) are preferred initially, though some clinicians may switch to half-normal saline with sodium bicarbonate to alkalinize the urine.
- Key considerations in fluid management include:
- Monitoring urine output to ensure it remains above 200-300 mL/hour
- Adjusting fluid therapy based on the patient's cardiovascular status
- Regular monitoring of electrolytes, kidney function, and fluid status
- Using isotonic crystalloids as the initial fluid of choice
- 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.
- It is essential to note that the volume to be administered remains debated, but most retrospective studies report that patients who eventually developed acute kidney injury had a longer time to initiate volume resuscitation compared to those who did not 1.
From the Research
Rhabdomyolysis Fluid Rate
- The recommended fluid rate for rhabdomyolysis management is a topic of ongoing research and debate 2, 3, 4, 5, 6.
- Studies suggest that aggressive intravenous fluid resuscitation (IVFR) can decrease the incidence of acute renal failure (ARF) and need for dialysis in patients with rhabdomyolysis 2, 3.
- A daily intravenous infusion of ≥12 L of alkaline solution has been recommended to stabilize circulation, mobilize edema fluids, correct hyperkalemia and acidosis, and protect against the nephrotoxic effects of myoglobinemia and hyperuricosuria 3.
- The goal of fluid resuscitation is to maintain a urine output of 300 mL/h or more for at least the first 24 hours 6.
- Fluid type, therapy duration, and monitoring parameters may vary, but immediate and aggressive intravenous volume expansion is indicated to prevent myoglobinuric renal failure 4, 6.
- Sodium bicarbonate and mannitol administration are not recommended unless necessary to correct systemic acidosis or maintain urine output, respectively 2, 6.