What is the treatment protocol for rhabdomyolysis using bicarbonate (sodium bicarbonate) drip?

Treatment Protocol for Rhabdomyolysis

For patients with rhabdomyolysis, aggressive intravenous fluid resuscitation should be the primary treatment, while sodium bicarbonate therapy is not routinely recommended. 1

Initial Assessment and Diagnosis

• Diagnosis is confirmed when serum creatine kinase (CK) level is >1000 U/L or at least 5 times the upper limit of normal 2
• Obtain serum myoglobin, urinalysis (to check for myoglobinuria), and a complete metabolic panel including serum creatinine and electrolytes 2
• Calculate McMahon score on admission - a score of 6 or greater predicts acute kidney injury (AKI) requiring renal replacement therapy 2

Primary Treatment: Fluid Resuscitation

• Early and aggressive fluid replacement using crystalloid solution is the cornerstone for preventing and treating AKI due to rhabdomyolysis 2
• Aim for urine output of approximately 80-100 mL/m²/h (or 4-6 mL/kg/h in smaller patients) 3
• Monitor for signs of volume overload, especially in patients with pre-existing cardiac or renal dysfunction 4

Bicarbonate Therapy: Not Routinely Recommended

• Current evidence does not support routine use of sodium bicarbonate for prevention of AKI in rhabdomyolysis 1
• A recent propensity score-matched cohort study showed that bicarbonate therapy was associated with higher incidence of AKI, higher rate of dialysis dependency, higher 30-day mortality, and longer hospital stays compared to non-bicarbonate therapy 4
• Bicarbonate administration has been associated with sodium and fluid overload, increased lactate and PaCO₂, and decreased serum ionized calcium 3

Mannitol: Not Recommended

• Evidence does not support the use of mannitol in patients with rhabdomyolysis 1
• Conditional recommendation against treatment with mannitol based on very low quality evidence 1

Special Considerations

• Treat underlying electrolyte imbalances according to standard medical management 2
• Monitor serum potassium levels closely and obtain electrocardiograms to identify life-threatening complications of hyperkalemia 5
• In cases of severe acidosis (pH <7.15) associated with tricyclic antidepressant overdose or sodium channel blocker toxicity, sodium bicarbonate may be considered at 1-2 mEq/kg IV boluses until arterial pH >7.45 3

Monitoring During Treatment

• Regularly monitor serum CK levels, renal function, electrolytes, and fluid balance 2
• Watch for signs of compartment syndrome, which may require surgical intervention 1
• Assess for volume overload, which was significantly higher in patients receiving bicarbonate therapy 4

Treatment Algorithm

1. Confirm diagnosis with CK >1000 U/L
2. Initiate aggressive IV fluid resuscitation with crystalloids
3. Target urine output of 80-100 mL/m²/h
4. Monitor and correct electrolyte abnormalities
5. Avoid routine use of sodium bicarbonate unless specific indications exist (severe acidosis pH <7.15)
6. Avoid mannitol administration
7. Consider renal replacement therapy if severe AKI develops despite fluid resuscitation

Pitfalls and Caveats

• Excessive fluid administration can lead to volume overload; high-volume fluid therapy (≥3 mL/kg/hr) was associated with worse renal outcomes and higher mortality compared to lower-volume fluid therapy 4
• Bicarbonate therapy may cause metabolic alkalosis and decrease ionized calcium levels 3
• Do not delay treatment while waiting for laboratory confirmation, as early intervention is critical for preventing complications 2