What is the treatment for rhabdomyolysis (rhabdo)

Treatment of Rhabdomyolysis

The cornerstone of rhabdomyolysis treatment is aggressive fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour for the first hour, followed by continued fluid administration at 4-14 mL/kg/hour, targeting a urine output of at least 200-300 mL/hour. 1

Initial Management

Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour for the first hour (approximately 1-1.5 liters in an average adult)
• Continue aggressive fluid resuscitation at 4-14 mL/kg/hour, with a target of at least 6L daily for severe cases
• Target urine output of 200-300 mL/hour
• Adjust fluid type based on serum electrolyte levels:
  • Continue 0.9% NaCl for patients with low corrected serum sodium
  • Switch to 0.45% NaCl for patients with normal or elevated corrected serum sodium

Laboratory Monitoring

• Obtain baseline and serial measurements of:
  • Creatine kinase (CK) - primary diagnostic marker
  • Electrolytes (particularly potassium and calcium)
  • Renal function (BUN, creatinine)
  • Urinalysis for myoglobinuria
  • Complete blood count
  • Liver function tests

Electrolyte Management

• Monitor and correct hyperkalemia, which can be life-threatening
• Monitor for hypocalcemia, which may develop as calcium binds to phosphate released from damaged muscle
• Add potassium to IV fluids (20-30 mEq/L) only once renal function is assured

Complications Management

Acute Kidney Injury Prevention and Management

• Early and aggressive fluid resuscitation is the main intervention for preventing AKI 1, 2
• Consider early nephrology consultation for significantly elevated CK levels
• Prepare for potential need for renal replacement therapy if the patient develops:
  • Refractory hyperkalemia
  • Severe metabolic acidosis
  • Volume overload
  • Uremic symptoms

Compartment Syndrome Monitoring

• Perform frequent neurovascular checks of all extremities, assessing for the 5 P's:
  • Pain
  • Paresthesia
  • Pallor
  • Pulselessness
  • Paralysis
• Consider compartment pressure measurement if clinical suspicion exists
• Surgical consultation for fasciotomy if compartment pressure >30 mmHg or differential pressure (diastolic BP - compartment pressure) <30 mmHg 1

Special Considerations

Bicarbonate Use

• Current evidence does not strongly support routine use of bicarbonate for alkalinization over aggressive fluid resuscitation alone 1
• May be considered in specific circumstances to alkalinize urine and reduce myoglobin precipitation in renal tubules, although evidence is primarily from animal studies and retrospective observations

High-Risk Patients

• More careful fluid titration and monitoring in:
  • Patients with cardiac or renal compromise
  • Elderly patients
  • Patients with lower muscle mass (higher risk of fluid overload)

Medication Review

• Discontinue any medications that may have caused or contributed to rhabdomyolysis
• If statin-induced, promptly discontinue the statin and evaluate CK, creatinine, and perform urinalysis for myoglobinuria 3

Common Pitfalls to Avoid

• Delaying fluid resuscitation while waiting for complete diagnostic workup
• Missing concomitant conditions that may complicate management (cardiac dysfunction, malignant hyperthermia)
• Assuming pre-renal azotemia based solely on BUN:Creatinine ratio
• Overlooking compartment syndrome, which requires urgent surgical intervention
• Failing to recognize that rhabdomyolysis can occur from various causes including exertional overexertion, medications, alcohol, illicit drugs, and trauma 2, 4

Early recognition and aggressive treatment of rhabdomyolysis is crucial to prevent life-threatening complications such as acute kidney injury, severe electrolyte abnormalities, and compartment syndrome.