From the Guidelines
The immediate treatment for rhabdomyolysis is aggressive intravenous fluid resuscitation with isotonic crystalloids, typically normal saline at an initial rate of 1-2 L/hour, adjusted based on clinical response, as recommended by recent guidelines 1. The goal of this treatment is to maintain urine output at 200-300 mL/hour to prevent acute kidney injury by diluting nephrotoxic myoglobin and promoting its excretion.
- Fluid therapy should continue until creatine kinase (CK) levels show a clear downward trend and myoglobinuria resolves.
- Electrolyte imbalances, particularly hyperkalemia, hypocalcemia, and hyperphosphatemia, should be monitored and corrected as needed, with plasma potassium tests and measurements of kidney function by means of plasma creatinine tests being useful complementary assessments 1.
- While some clinicians consider urinary alkalinization with sodium bicarbonate (to maintain urine pH > 6.5), this remains controversial.
- Diuretics like mannitol may be considered in specific cases but aren't routinely recommended.
- The underlying cause of rhabdomyolysis must be identified and addressed simultaneously. Aggressive hydration is critical because myoglobin released from damaged muscle cells can precipitate in kidney tubules, causing obstruction and direct tubular toxicity, while adequate fluid volume helps maintain renal perfusion and glomerular filtration, as supported by studies on patients with severe limb trauma and rhabdomyolysis 1. Key considerations include:
- The volume to be administered remains debated, but a retrospective study suggested that 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 1.
- 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
Immediate Treatment for Rhabdomyolysis
The immediate treatment for a patient diagnosed with rhabdomyolysis involves several key components:
- Aggressive intravenous fluid resuscitation to maintain a urine output of at least 300 mL/hour, as recommended by 2 and 3
- Discontinuation of further skeletal muscle damage
- Prevention of acute renal failure
- Rapid identification of potentially life-threatening complications, such as hyperkalemia and compartment syndrome
Management of Electrolyte Abnormalities
Significant electrolyte abnormalities may be present and must be managed to avoid cardiac arrhythmias and arrest, as noted in 2 and 4
- Treatment of electrolyte imbalances with standard medical management
- Monitoring of serum creatinine and electrolytes
Use of Bicarbonate and Mannitol
There is little evidence to support the routine use of bicarbonate-containing fluids or mannitol in the treatment of rhabdomyolysis, as stated in 5, 6, and 4
- Bicarbonate may be used for patients who are acidotic, but its use is not universally recommended
- Mannitol may be used for patients whose urine output is not at goal, but its effectiveness is not well established
Goal of Treatment
The goal of treatment is to prevent acute kidney injury and improve outcomes, as emphasized in 5 and 4
- Early and aggressive fluid replacement is the cornerstone of treatment
- Prompt recognition and management of rhabdomyolysis is crucial to preserving renal function