What is the treatment for rhabdomyolysis?

Treatment for Rhabdomyolysis

Aggressive intravenous fluid resuscitation is the cornerstone of treatment for rhabdomyolysis, with a goal urine output of 300 mL/hour to prevent acute kidney injury. 1, 2

Diagnosis and Assessment

• Rhabdomyolysis is diagnosed when creatine kinase (CK) levels are at least 5-10 times the upper limit of normal, often accompanied by myoglobinuria 3
• Laboratory assessment should include:
  • Plasma myoglobin and CK levels 2
  • Complete electrolyte panel (potassium, calcium, phosphorus, magnesium) 2
  • Renal function tests to monitor for acute kidney injury 2
• Clinical presentation may include muscle pain, weakness, dark-colored urine, or non-specific symptoms 3

Treatment Algorithm

First-Line Management

• Aggressive IV fluid resuscitation:
  • For severe rhabdomyolysis (CK >15,000 IU/L): >6L of fluid per day 2
  • For moderate cases: 3-6L per day 2
  • Target urine output: 300 mL/hour 1, 4
  • Normal saline is the preferred fluid 5
  • Early initiation is critical to prevent acute kidney injury 2

Electrolyte Management

• Monitor and correct electrolyte abnormalities, particularly: 1, 2
  • Hyperkalemia (requires urgent treatment to prevent cardiac arrhythmias)
  • Hypocalcemia (early) and hypercalcemia (late)
  • Hyperphosphatemia
  • Metabolic acidosis

Additional Interventions

• Sodium bicarbonate may be used for patients with acidosis, though evidence for improved outcomes is limited 3, 5
• Mannitol lacks strong evidence for routine use but may be considered if urine output goals are not met despite adequate fluid resuscitation 3, 5
• Loop diuretics have insufficient evidence to support routine use 3

Monitoring and Complications Management

• Monitor for compartment syndrome: 1, 2
  • Early signs: pain, tension, paresthesia, paresis
  • Late signs: pulselessness, pallor (indicate irreversible damage)
  • Consider fasciotomy when compartment pressure exceeds 30 mmHg 2
• Assess for disseminated intravascular coagulation with coagulation studies 2, 6
• Continue IV fluids until CK levels decrease to <1,000 U/L 4
• Consider renal replacement therapy for: 3, 6
  • Severe, refractory hyperkalemia
  • Persistent metabolic acidosis
  • Fluid overload unresponsive to diuretics
  • Progressive uremia

Cause-Specific Management

• Identify and address underlying causes: 1, 2
  • Discontinue causative medications (e.g., statins)
  • Treat infections if present
  • For immune checkpoint inhibitor-induced myositis, high-dose corticosteroids are recommended 1
  • For exertional rhabdomyolysis, proper calibration of training and conditioning is important 2

Disposition

• Most patients require admission for continued IV hydration and monitoring 3
• Patients with mild rhabdomyolysis (minimal CK elevation, normal renal function, no electrolyte abnormalities) may be appropriate for discharge with close follow-up 3
• Those with physiological exertional rhabdomyolysis without underlying disease can return to normal activities in a graded fashion 7