Treatment of Rhabdomyolysis
Aggressive fluid resuscitation with isotonic saline should be the cornerstone of rhabdomyolysis management, with a target urine output of 200-300 mL/hour to prevent acute kidney injury. 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, targeting at least 6L daily for severe cases 1
- Target urine output of 200-300 mL/hour 1, 2
- Early fluid resuscitation is critical - delays increase risk of acute kidney injury 1, 3
Medication Management
- Immediately discontinue any medications that may have caused or contributed to rhabdomyolysis 1
- For statin-induced rhabdomyolysis, promptly discontinue the statin and evaluate creatine kinase, renal function, and perform urinalysis for myoglobinuria 4, 1
Ongoing Management
Fluid Adjustment
- Adjust fluid type and rate based on:
- Serum electrolyte levels
- Hydration status
- Urine output
- Consider switching to 0.45% NaCl at 4-14 mL/kg/hour for patients with normal or elevated corrected serum sodium 1
- Continue 0.9% NaCl at 4-14 mL/kg/hour for patients with low corrected serum sodium 1
Electrolyte Management
- Monitor for hyperkalemia and hypocalcemia 1
- Add potassium to IV fluids (20-30 mEq/L, 2/3 KCl and 1/3 KPO₄) once renal function is assured 1
- Perform frequent electrolyte monitoring and correction as needed
Bicarbonate and Mannitol
- Current evidence does not strongly support routine use of bicarbonate for alkalinization over aggressive fluid resuscitation alone 1, 2, 5
- Bicarbonate may be considered in specific circumstances for severe rhabdomyolysis, though evidence is primarily from animal studies 1
- Mannitol is not recommended based on current evidence 2
Monitoring and Complications
Kidney Function
- Monitor for signs of acute kidney injury with serial measurements of BUN and creatinine 1
- Consider early nephrology consultation for significantly elevated CK levels 1
- Prepare for potential renal replacement therapy if the patient develops:
- Refractory hyperkalemia
- Severe metabolic acidosis
- Volume overload
- Uremic symptoms 1
Compartment Syndrome
- Perform frequent neurovascular checks of all extremities (pain, paresthesia, pallor, pulselessness, and paralysis) 1
- Consider compartment pressure measurement if clinical suspicion exists
- Threshold: >30 mmHg or differential pressure (diastolic BP - compartment pressure) <30 mmHg indicates compartment syndrome requiring surgical consultation 1
- Prompt surgical fasciotomy is required for confirmed compartment syndrome 4, 6
Special Considerations
High-Risk Patients
- More careful fluid titration and monitoring in:
- Patients with cardiac or renal compromise
- Elderly patients
- Patients with lower muscle mass 1
- Monitor for signs of fluid overload, such as pulmonary edema and peripheral edema 1
Drug Interactions
- Be aware of pharmacokinetic drug interactions that can increase rhabdomyolysis risk
- Combination of certain macrolide antibiotics with statins can increase risk of rhabdomyolysis 4
Automated Fluid Management
- Emerging evidence suggests automated fluid management systems may help achieve target urine output more consistently than manual fluid adjustment 7
- These systems resulted in higher urine output more quickly in rhabdomyolysis treatment 7
Remember that early and aggressive fluid resuscitation is the most important intervention with the strongest evidence base for preventing acute kidney injury in rhabdomyolysis 1, 2, 3, 5, 6.