From the Guidelines
A fluid rate of 30 mg/kg is not appropriate for patients with rhabdomyolysis who also meet sepsis criteria, as the recommended initial fluid resuscitation is typically 20-30 mL/kg of crystalloid fluid administered within the first 3 hours. For a patient with both conditions, aggressive fluid resuscitation is crucial, with isotonic crystalloids like normal saline or lactated Ringer's solution being the preferred options, as suggested by the Surviving Sepsis Campaign guidelines 1. The initial bolus should be followed by continued fluid administration guided by clinical parameters including:
- Urine output (targeting >200-300 mL/hour)
- Hemodynamic stability
- Laboratory values such as creatine kinase levels and renal function tests
Fluid management must be carefully balanced to address both the need to flush out myoglobin from damaged muscles while also supporting hemodynamics in sepsis. The aggressive hydration helps prevent acute kidney injury by diluting nephrotoxic substances released during muscle breakdown and maintaining renal perfusion, as recommended by the guidelines 1. However, fluid administration should be adjusted based on the patient's cardiac and renal status, with close monitoring for signs of fluid overload, especially in patients with heart or kidney dysfunction. The guidelines suggest using a fluid challenge technique, where fluid administration is continued as long as hemodynamic factors continue to improve 1.
From the Research
Fluid Resuscitation in Rhabdomyolysis and Sepsis
- The management of rhabdomyolysis and sepsis involves fluid resuscitation, with the goal of restoring circulating fluid volume and optimizing stroke volume 2.
- For patients with rhabdomyolysis, aggressive intravenous fluid resuscitation (IVFR) is conditionally recommended to improve outcomes of acute renal failure (ARF) and lessen the need for dialysis 3.
- In sepsis, current guidelines recommend the administration of at least 30mL/kg of isotonic crystalloid fluid as part of the initial resuscitation 2.
- However, the optimal fluid resuscitation strategy for patients with both rhabdomyolysis and sepsis is not clearly defined.
Fluid Resuscitation Dosing
- The dosing of 30 mg/kg of fluid may be appropriate for patients with sepsis, as it is consistent with current guidelines 2.
- However, it is unclear if this dosing is sufficient for patients with rhabdomyolysis, as the condition may require more aggressive fluid resuscitation 3.
- Further research is needed to determine the optimal fluid resuscitation strategy for patients with both rhabdomyolysis and sepsis.
Choice of Resuscitation Fluid
- Crystalloids are the preferred solution for the resuscitation of patients with severe sepsis and septic shock 4.
- Balanced crystalloids may improve patient-centered outcomes and should be considered as an alternative to normal saline, if available 4, 5.
- The use of colloids, such as albumin, may also be considered, although the evidence is less clear 6.