What is the treatment for rhabdomyolysis?

Treatment of Rhabdomyolysis

Aggressive fluid resuscitation with isotonic saline is the cornerstone of rhabdomyolysis treatment, targeting a urine output of 200-300 mL/hour (approximately 6L daily) to prevent acute kidney injury.

Initial Management

Fluid Resuscitation

• Begin with isotonic saline at 15-20 mL/kg/hour for the first hour (approximately 1-1.5 liters in an average adult) 1
• Continue aggressive fluid resuscitation at 4-14 mL/kg/hour 1
• Target urine output of 200-300 mL/hour (at least 6L daily) 1, 2
• Adjust fluid type based on serum electrolyte levels:
  • Use 0.9% NaCl for patients with low corrected serum sodium
  • Use 0.45% NaCl for patients with normal or elevated corrected serum sodium 1

Monitoring

• Frequent assessment of:
  • Urine output (target >200-300 mL/hour)
  • Serum electrolytes, particularly potassium and calcium
  • Creatine kinase (CK) levels
  • Renal function (BUN, creatinine)
  • Acid-base status
  • Compartment pressures if clinically indicated 3, 1

Electrolyte Management

Hyperkalemia

• Monitor for hyperkalemia, which can develop as potassium is released from damaged muscle 1
• Treat hyperkalemia according to severity:
  • Calcium gluconate for cardiac membrane stabilization if ECG changes present
  • Insulin with glucose to shift potassium intracellularly
  • Sodium polystyrene sulfonate or patiromer to enhance potassium elimination
  • Consider dialysis for refractory hyperkalemia

Hypocalcemia

• Monitor for hypocalcemia, which may develop as calcium binds to phosphate released from damaged muscle 1
• Correct symptomatic hypocalcemia with calcium supplementation

Additional Interventions

Medication Management

• Discontinue any medications that may have caused or contributed to rhabdomyolysis 1
• Consider sodium bicarbonate for severe metabolic acidosis 4
  • Note: Evidence for routine use of bicarbonate is limited, and it is not recommended as standard therapy 2, 5

Compartment Syndrome Assessment

• Perform frequent neurovascular checks of all extremities (pain, paresthesia, pallor, pulselessness, and paralysis) 1
• Consider compartment pressure measurement if clinical suspicion exists
  • Threshold of >30 mmHg or differential pressure (diastolic BP - compartment pressure) <30 mmHg indicates compartment syndrome requiring surgical consultation 1

Indications for Renal Replacement Therapy

Consider dialysis for:

• Refractory hyperkalemia
• Severe metabolic acidosis
• Volume overload unresponsive to diuretics
• Uremic symptoms 1

Common Pitfalls to Avoid

1. Inadequate fluid resuscitation: Insufficient fluid administration is a common error; aggressive hydration is essential 2, 5

2. Overreliance on adjunctive therapies: Current evidence does not support routine use of mannitol or bicarbonate 2, 5

3. Delayed recognition of compartment syndrome: This requires immediate surgical intervention 1, 6

4. Failure to identify and address the underlying cause: Treating the primary cause (medications, trauma, excessive exercise, etc.) is essential 7, 5

5. Inadequate monitoring: Close monitoring of fluid status, electrolytes, and renal function is crucial to prevent complications 1

The evidence strongly supports that early and aggressive fluid resuscitation is the most effective intervention for preventing acute kidney injury in rhabdomyolysis 2, 5. While bicarbonate and mannitol are sometimes used, the evidence for their routine use is limited, and they should not delay the initiation of aggressive fluid therapy 2.