From the Guidelines
The management of rhabdomyolysis should focus on aggressive intravenous fluid resuscitation with normal saline at rates of 1-2 L/hour to maintain urine output of 200-300 mL/hour, as this approach has been shown to reduce the risk of acute kidney injury 1.
Key Components of Management
- Aggressive hydration to flush myoglobin from the kidneys, preventing acute kidney injury
- Monitoring and correction of electrolyte abnormalities, particularly hyperkalemia, hypocalcemia, and hyperphosphatemia
- Discontinuation of any causative medications or substances
- Monitoring for compartment syndrome, which may require fasciotomy if present
- Renal replacement therapy (dialysis) for severe cases with refractory hyperkalemia, acidosis, or fluid overload
Fluid Resuscitation
- Normal saline is the preferred initial fluid, with rates of 1-2 L/hour to maintain urine output of 200-300 mL/hour
- The volume to be administered remains debated, but a retrospective study suggested that volumes greater than 6L were required in patients with severe rhabdomyolysis to prevent acute kidney injury and the need for renal replacement therapy 1
Electrolyte Management
- Hyperkalemia may require calcium gluconate, insulin with glucose, sodium bicarbonate, or potassium binders like sodium polystyrene sulfonate
- Urine alkalinization with sodium bicarbonate may be considered in severe cases to reduce myoglobin precipitation in renal tubules
Prevention of Recurrence
- Addressing underlying causes such as medication adjustments, lifestyle modifications, or treatment of metabolic disorders
- Gradual physical rehabilitation should be initiated once the acute phase resolves
Additional Considerations
- The management of kidney injury built up after rhabdomyolysis has no specificity, and experts refer to the French recommendations for acute kidney injury in the perioperative period and intensive care units 1
- The use of diuretics, such as loop diuretics, is not recommended for the prevention or treatment of AKI, except for the treatment of volume overload 1
From the Research
Management of Rhabdomyolysis
The management of rhabdomyolysis involves several key strategies to prevent complications and improve patient outcomes.
- Aggressive intravenous fluid resuscitation (IVFR) is conditionally recommended to improve outcomes of acute renal failure (ARF) and lessen the need for dialysis 2.
- The use of bicarbonate or mannitol is not recommended, as it does not improve the incidence of acute renal failure and need for dialysis in patients with rhabdomyolysis 2.
- Early implementation of fluid therapy is crucial, and electrolyte disturbances should be detected and treated in the early stages 3.
- Renal replacement therapy, such as hemodialysis, may be necessary in severe cases with acute kidney injury (AKI) 4, 5.
Treatment Strategies
The following treatment strategies are used in the management of rhabdomyolysis:
- Aggressive fluid resuscitation to restore renal perfusion and increase urine flow 2, 6
- Discontinuation of further skeletal muscle damage 6
- Prevention of acute renal failure 6
- Rapid identification of potentially life-threatening complications, such as hyperkalemia and compartment syndrome 6
- Use of diuretics, such as loop diuretics, to manage fluid overload and electrolyte disturbances 5
Prevention of Complications
Prevention of complications is a critical aspect of the management of rhabdomyolysis.
- Early recognition and treatment of rhabdomyolysis can help prevent acute kidney injury and other complications 3.
- Maintenance of normal or high intravascular volume and administration of diuretics can help prevent severe clinical symptoms 5.
- Avoidance of hypovolemia, hyperthermia, and electrolyte disorders can also help prevent complications 5.