Recommended Fluid Administration Rate in Rhabdomyolysis
For patients with rhabdomyolysis, aggressive intravenous fluid resuscitation is recommended with volumes of >6L per day for severe cases (CPK >15,000 IU/L) and 3-6L per day for moderate cases to prevent acute kidney injury. 1
Fluid Administration Protocol Based on Severity
Severe Rhabdomyolysis (CPK >15,000 IU/L)
- Administer >6L of intravenous fluids per day to prevent acute kidney injury and need for renal replacement therapy 1
- Initial fluid resuscitation should be started as early as possible, as delayed initiation is associated with higher risk of acute kidney injury 1
- Aim for urine output >2 mL/kg/hour to facilitate myoglobin clearance 2
Moderate Rhabdomyolysis
- Administer 3-6L of intravenous fluids per day 1
- Monitor urine output to ensure adequate kidney perfusion 1
Fluid Type and Administration
- Begin with isotonic saline (0.9% NaCl) for initial volume expansion 3, 4
- After initial resuscitation, fluid choice depends on hydration status and serum electrolyte levels 3
- If corrected serum sodium is normal or elevated, switch to 0.45% NaCl at 4-14 mL/kg/hour 3
- If corrected serum sodium is low, continue with 0.9% NaCl at similar rates 3
- Once renal function is assured, add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO4) to the infusion 3
Monitoring Parameters
- Monitor hemodynamic parameters (blood pressure improvement) 3
- Track fluid input/output carefully 3
- Perform repeated bio-assessments of plasma myoglobin, CPK, and potassium levels 1
- Use bladder catheterization to monitor hourly urine output 1
- Monitor urine pH, which should be maintained at approximately 6.5 1
- Ensure induced change in serum osmolality does not exceed 3 mOsm/kg/hour 3
Special Considerations
- In patients with renal or cardiac compromise, perform frequent assessment of cardiac, renal, and mental status to avoid iatrogenic fluid overload 3
- Early aggressive fluid resuscitation has been shown to reduce mortality in crush syndrome from nearly 100% to <20% 5
- Automated fluid management systems may help achieve higher urine output more quickly compared to manual fluid management 2
Cautions and Pitfalls
- Delayed fluid resuscitation is associated with increased risk of acute kidney injury 1
- Excessive fluid administration in patients with cardiac or renal compromise can cause fluid overload 3
- Failure to monitor and replace potassium can lead to dangerous electrolyte imbalances 3
- While some clinicians use bicarbonate and mannitol, evidence suggests that aggressive fluid resuscitation alone may be sufficient to prevent acute kidney injury 4, 6