What is the treatment for Rhabdomyolysis?

Treatment of Rhabdomyolysis

The cornerstone of rhabdomyolysis treatment is aggressive fluid resuscitation with isotonic saline at 200-300 mL/hour until creatine kinase (CK) levels decrease to <1,000 U/L, with close monitoring of electrolytes, renal function, and urine output every 12-24 hours. 1

Initial Management

Fluid Resuscitation

• Begin immediate IV fluid therapy with isotonic saline (0.9% NaCl)
  • Target rate: 200-300 mL/hour
  • Goal: Achieve urine output of 300 mL/hour 2
  • Continue until CK levels decrease to <1,000 U/L 1

Monitoring Parameters

• Check electrolytes, renal function, and urine output every 12-24 hours 1
• Monitor for:
  • Hyperkalemia (>6.0 mEq/L)
  • Metabolic acidosis
  • Volume overload
  • Compartment syndrome
  • Disseminated intravascular coagulation 2

Management of Complications

Hyperkalemia Management

• Discontinue potassium-containing fluids
• Stop nephrotoxic medications 1
• For severe hyperkalemia (>6.0 mEq/L):
  • Consider calcium gluconate, insulin with glucose, sodium bicarbonate, or potassium-binding resins
  • Monitor ECG for cardiac effects of hyperkalemia

Acute Kidney Injury

• Early recognition and aggressive fluid therapy are essential
• Avoid nephrotoxic agents including NSAIDs and aminoglycosides
• Consider nephrology consultation for:
  • Significantly elevated CK levels
  • Signs of developing acute kidney injury
  • Potential need for renal replacement therapy 1

Special Considerations

Renal Replacement Therapy

• Consider on a case-by-case basis for:
  • Persistent hyperkalemia (>6.0 mEq/L)
  • Severe metabolic acidosis (pH <7.1)
  • Volume overload unresponsive to diuretics
  • Uremic symptoms
  • Rapidly rising BUN/creatinine levels 1, 2

Medications with Limited Evidence

• Bicarbonate and mannitol do not have strong evidence for improved outcomes 2
• Loop diuretics may be considered for volume overload but not as primary therapy 2

Addressing Underlying Causes

• Identify and treat the underlying etiology:
  • Discontinue causative medications or toxins
  • Treat infections
  • Correct metabolic and endocrine disorders
  • Address trauma-related issues 3, 4

Disposition

• Most patients require hospital admission for monitoring and continued treatment
• Discharge may be appropriate for select patients with:
  • Mild elevation of CK
  • No evidence of renal dysfunction
  • No electrolyte abnormalities
  • Ability to maintain adequate oral hydration 2

Pitfalls and Caveats

• Delayed recognition can lead to preventable complications
• The classic triad of myalgias, weakness, and pigmenturia is present in less than 10% of cases 4
• Mortality is significantly higher in patients who develop acute renal failure
• Risk of acute renal failure increases when CK levels exceed 16,000 IU/L 4
• Avoid potassium-containing balanced salt fluids which may worsen hyperkalemia 1
• Watch for complications of aggressive fluid therapy, including volume overload and electrolyte imbalances