From the Guidelines
Rhabdomyolysis treatment requires immediate medical attention and focuses on preventing kidney damage through aggressive intravenous fluid administration, with the goal of administering volumes greater than 6L in patients with severe rhabdomyolysis to prevent acute kidney injury and the need for renal replacement therapy. The primary treatment is IV fluids, typically normal saline, to maintain urine output above 200-300 mL/hour, as supported by a retrospective study of 638 earthquake victims in 2011 1. This dilutes myoglobin in the bloodstream and promotes its excretion before it can damage the kidneys. Key considerations in treatment include:
- Aggressive fluid resuscitation to prevent acute kidney injury
- Monitoring for and managing electrolyte imbalances, particularly hyperkalemia
- Avoiding nephrotoxic medications
- Identifying and addressing the underlying cause of rhabdomyolysis
- Considering the use of sodium bicarbonate to alkalinize the urine and prevent myoglobin precipitation in kidney tubules. According to the guidelines for the acute care of severe limb trauma patients, 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. Severe cases may necessitate dialysis, especially with acute kidney injury, severe electrolyte abnormalities, or acidosis.
From the Research
Treatment Overview
- The mainstay of treatment for rhabdomyolysis is hospitalization with aggressive intravenous fluid (IVF) resuscitation and correction/prevention of electrolyte abnormalities 2, 3, 4, 5.
- Early and aggressive fluid resuscitation is agreed upon as the main intervention for preventing and treating acute kidney injury (AKI) 4, 5.
Adjunctive Therapies
- There are additional adjunctive therapies to IVF, such as alkalinisation of the urine with sodium bicarbonate, diuretic therapy, or combinations of both, but the lack of large randomized control studies makes it difficult to make strong recommendations for or against their use 2.
- The use of bicarbonate, mannitol, and loop diuretics is not supported by high-quality evidence, with some studies suggesting no benefit in preventing AKI or improving outcomes 3, 4, 5.
Automated Fluid Management
- Automated fluid management using devices such as RenalGuard has shown promise in optimizing urine output and preventing AKI in patients with rhabdomyolysis, but further research is needed to confirm its effectiveness 6.
Electrolyte Management
- Electrolyte imbalances must be treated with standard medical management, but there is no established benefit of using specific therapies such as mannitol or bicarbonate infusion 3, 5.
Prognosis
- The overall prognosis for rhabdomyolysis is favorable when treated with early and aggressive IVF resuscitation, and full recovery of renal function is common, but the mortality rate may still be as high as 8% 2.