What is the best IV fluid for treating rhabdomyolysis?

From the Guidelines

Normal saline (0.9% sodium chloride) is the best IV fluid for treating rhabdomyolysis. It should be administered at high rates, typically 200-1000 mL/hour initially, with the goal of producing urine output of 200-300 mL/hour. Total fluid requirements often range from 6-10 liters per day, adjusted based on clinical response, as suggested by a retrospective study of 638 earthquake victims that concluded volumes greater than 6L were required in patients with severe rhabdomyolysis to prevent acute kidney injury and the need for renal replacement therapy 1. The aggressive hydration helps flush myoglobin from the kidneys, preventing acute kidney injury. Normal saline is preferred over lactated Ringer's because the latter contains potassium, which could worsen the hyperkalemia often present in rhabdomyolysis. Key considerations in the management of rhabdomyolysis include:

• Early initiation of volume resuscitation to prevent acute kidney injury, as 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
• Monitoring of clinical signs and compartment pressure in patients with severe limb trauma, as these patients are at increased risk of developing compartment syndrome 1
• Measurement of compartment pressure and differential pressure to aid in the diagnosis of compartment syndrome, with a measurement of compartment pressure 30 mmHg and/or differential pressure (diastolic blood pressure – compartment pressure <30 mmHg) being useful tests for diagnosis 1
• The potential need for fasciotomy in patients with established compartment syndrome, involving a wide incision of the skin, subcutaneous tissue, and fascia 1.

From the Research

IV Fluids for Rhabdomyolysis Treatment

• The best IV fluid for treating rhabdomyolysis is a topic of ongoing debate, with various studies suggesting different approaches 2, 3, 4, 5, 6.

Key Findings

• Aggressive intravenous fluid resuscitation (IVFR) has been shown to decrease the incidence of acute renal failure (ARF) and the need for dialysis in patients with rhabdomyolysis 2.
• Automated fluid management using devices such as RenalGuard has been found to optimize urine output and prevent fluid accumulation in rhabdomyolysis patients 3.
• Early fluid resuscitation with alkaline solutions has been recommended to stabilize circulation, correct hyperkalemia and acidosis, and protect against the nephrotoxic effects of myoglobinemia and hyperuricosuria 5.

Recommended IV Fluids

• Normal saline is commonly used for fluid resuscitation in rhabdomyolysis patients, although the optimal fluid composition is still a topic of debate 4, 6.
• Alkaline solutions, such as those containing bicarbonate, may be beneficial in certain cases, but their use is not universally recommended 2, 5.

Important Considerations

• The goal of IV fluid therapy in rhabdomyolysis is to maintain adequate urine output, prevent acute kidney injury, and correct electrolyte imbalances 2, 3, 4, 5, 6.
• Individualized treatment approaches may be necessary, taking into account the underlying cause of rhabdomyolysis, the severity of symptoms, and the patient's overall clinical condition 6.