What is the management of rhabdomyolysis?

Management of Rhabdomyolysis

Early and aggressive fluid resuscitation is the cornerstone of rhabdomyolysis management to prevent acute kidney injury and should be initiated immediately upon diagnosis. 1

Diagnosis and Initial Assessment

• Laboratory evaluation:

  • Measure creatine kinase (CK) levels to confirm diagnosis
  • Monitor plasma myoglobin, CPK, and potassium levels repeatedly 1
  • Check renal function (creatinine, BUN)
  • Assess electrolytes, particularly potassium (risk of hyperkalemia)
  • Monitor urine output and pH

• Clinical assessment:

  • Evaluate for signs of compartment syndrome (pain, pain with passive stretch, paresthesia, paresis) 1
  • Measure compartment pressure if suspected (>30 mmHg or differential pressure <30 mmHg is diagnostic) 1
  • Identify and address the underlying cause of rhabdomyolysis

Treatment Algorithm

1. Fluid Resuscitation

• Volume: Administer aggressive intravenous fluid resuscitation 2
  • For severe rhabdomyolysis (CPK >15,000 IU/L): >6L per day
  • For moderate rhabdomyolysis: 3-6L per day 1
• Type: Isotonic crystalloid solutions (normal saline)
• Goal: Maintain urine output >2 mL/kg/hour 3
• Monitoring: Closely monitor fluid balance to avoid volume overload, especially in patients with cardiac or renal compromise

2. Management of Compartment Syndrome

• Perform early fasciotomy for established compartment syndrome 1
• Wide incision of skin, subcutaneous tissue, and fascia
• Monitor compartment pressures in high-risk patients

3. Urine Alkalization

• Target urine pH of 6.5 1
• Consider bladder catheterization to monitor hourly urine output and pH 1
• Note: Evidence for routine use of bicarbonate is limited 2

4. Electrolyte Management

• Aggressively treat hyperkalemia if present
• Monitor and correct other electrolyte abnormalities (calcium, phosphorus)
• Be vigilant for early hypocalcemia and late hypercalcemia 4

5. Renal Replacement Therapy

• Initiate when indicated for:
  • Life-threatening hyperkalemia unresponsive to medical management
  • Severe metabolic acidosis
  • Volume overload unresponsive to diuretics
  • Progressive uremia

Special Considerations

Medications

• Discontinue any medications that may contribute to rhabdomyolysis:
  • Statins (associated with muscle injury) 1
  • Red yeast rice supplements (contain lovastatin-like compounds) 1
  • Other supplements: wormwood oil, licorice, creatine monohydrate 1

Surgical Patients

• For patients requiring surgery with history of rhabdomyolysis:
  • Optimize positioning to avoid prolonged torsion and limb flexion 1
  • Maintain adequate hydration perioperatively
  • Consider thromboprophylaxis as immobility increases VTE risk 1

Monitoring and Follow-up

• Serial CK measurements to track resolution
• Monitor renal function and electrolytes
• Continue fluid therapy until CK levels show significant downward trend
• Assess for complications: acute kidney injury, compartment syndrome, cardiac arrhythmias

Pitfalls to Avoid

1. Delayed fluid resuscitation - Early initiation of fluid therapy is critical; delayed treatment significantly increases risk of acute kidney injury 1, 5

2. Inadequate volume - Underdosing fluids in severe rhabdomyolysis can lead to preventable kidney injury 1

3. Overreliance on mannitol - Evidence does not support routine use of mannitol 2

4. Missing compartment syndrome - Don't rely on absence of late signs (pulselessness, pallor); these indicate irreversible damage 1

5. Failure to identify and address the underlying cause - Treating symptoms without eliminating the trigger can lead to continued muscle breakdown

By implementing this management approach promptly, the complications of rhabdomyolysis can be significantly reduced, improving patient outcomes and preventing progression to acute kidney injury.