What is the treatment for rhabdomyolysis?

Treatment of Rhabdomyolysis

Aggressive intravenous fluid resuscitation with isotonic saline is the cornerstone of rhabdomyolysis treatment to prevent acute kidney injury, with a goal of achieving diuresis greater than 300 mL/hour. 1

Initial Management

Fluid Resuscitation

• Begin with isotonic saline as the initial fluid of choice 1
• Target urine output >300 mL/hour 1
• Avoid potassium-containing fluids 1
• Early and vigorous fluid resuscitation (≥12 L daily) is crucial for preventing myoglobinuric acute kidney injury 2

Electrolyte Management

• Monitor and urgently correct hyperkalemia if present 1
• Address hypocalcemia only if symptomatic 1
• Monitor serum electrolytes, urea nitrogen, and creatinine during treatment 1
• Obtain electrocardiogram to assess for cardiac complications and effects of electrolyte abnormalities 1

What NOT to Use

• Bicarbonate administration is not recommended as it does not improve outcomes in rhabdomyolysis 3, 4
• Mannitol is not recommended as it does not reduce the incidence of acute renal failure or need for dialysis 3, 4
• Loop diuretics lack strong evidence for improved outcomes 4
• The National Kidney Foundation notes that mannitol may only be of benefit in patients with markedly elevated creatine kinase levels (>30,000 U/L), but even in these cases, the true benefit remains undefined 5

Specialized Care

Nephrology Consultation

• Consult nephrology for all cases with acute kidney injury 1
• Consider renal replacement therapy for:
  • Severe hyperkalemia
  • Acidosis
  • Volume overload
  • Uremic symptoms 1

Surgical Intervention

• Fasciotomy is indicated for compartment syndrome with:
  • Hypotensive patients with intracompartment pressures ≥20 mmHg
  • Uncooperative/unconscious patients with pressures ≥30 mmHg
  • Normotensive patients with positive clinical findings and pressures ≥30 mmHg 1
• Benefits of fasciotomy decrease significantly if delayed beyond 8 hours 1
• Remove tight dressings and avoid limb elevation if compartment syndrome is suspected 1

Monitoring and Follow-up

• Track serum creatine kinase (CK) levels, which typically peak 24-72 hours after muscle injury 1
• Monitor for signs of compartment syndrome: pain, tension, paresthesia, and paresis 1
• Continue fluid therapy until CK levels decrease significantly (approaching normal values) 6

Common Pitfalls and Caveats

1. Delayed recognition: The classic triad of myalgia, muscle weakness, and pigmenturia is present in less than 10% of cases 1, 6
2. Inadequate fluid resuscitation: Mortality has been reduced from nearly 100% to <20% through early vigorous fluid therapy 2
3. Overemphasis on urine alkalinization: Despite theoretical benefits, evidence does not support bicarbonate administration 3, 4
4. Missing compartment syndrome: Failure to recognize and treat compartment syndrome can lead to permanent muscle damage and disability 1
5. Nephrotoxic medications: Avoid all nephrotoxic medications, including NSAIDs, ACE inhibitors/ARBs, and certain antibiotics 1

Special Considerations

• For recurrent rhabdomyolysis, consider genetic testing for underlying conditions such as glycogen storage diseases, fatty acid oxidation disorders, and mitochondrial disorders 1
• Mortality rate is approximately 10% but significantly higher in patients who develop acute renal failure 6
• Most patients experience only one episode of rhabdomyolysis, commonly due to substance abuse, medication effects, trauma, or seizures 6