What is the treatment for rhabdomyolysis?

Treatment of Rhabdomyolysis

Immediately initiate aggressive intravenous fluid resuscitation with isotonic saline (0.9% NaCl) targeting urine output of at least 300 mL/hour, as this is the single most critical intervention to prevent acute kidney injury and reduce mortality. 1, 2, 3

Immediate Management: Fluid Resuscitation

Initial Fluid Strategy

• Begin isotonic saline (0.9% NaCl) for initial volume expansion as soon as rhabdomyolysis is suspected. 2
• Start fluid resuscitation as early as possible—delayed initiation is directly associated with higher risk of acute kidney injury. 1, 2
• For severe rhabdomyolysis (CK >15,000 IU/L), administer >6L of intravenous fluids per day. 1, 2
• For moderate rhabdomyolysis, administer 3-6L of intravenous fluids per day. 1, 2
• Target urine output of at least 300 mL/hour to maintain adequate kidney perfusion. 4, 5

Monitoring During Fluid Resuscitation

• Use bladder catheterization to monitor hourly urine output. 2, 6
• Perform repeated bioassessments of plasma myoglobin, creatine kinase (CK), and potassium levels every 6-12 hours. 1, 2, 6
• Monitor urine pH, maintaining it at approximately 6.5. 2, 6
• Continue intravenous fluids until CK levels fall below 1,000 U/L. 4

Critical Pitfall: Excessive fluid administration in patients with cardiac or renal compromise can cause fluid overload—monitor carefully for signs of volume overload. 2, 6

Electrolyte Management

Hyperkalemia Monitoring and Treatment

• Monitor potassium levels closely and frequently, as hyperkalemia can lead to life-threatening cardiac arrhythmias. 1, 6
• Obtain complete electrolyte panel including potassium, calcium, phosphorus, and magnesium. 1
• Perform ECG to assess for cardiac effects of hyperkalemia. 1
• Correct significant electrolyte abnormalities promptly to avoid cardiac arrest. 1, 6

Medications to AVOID

Diuretics and Alkalinization

• Do NOT routinely use bicarbonate—it does not improve outcomes in rhabdomyolysis. 3
• Do NOT routinely use mannitol—it does not improve acute renal failure rates or need for dialysis. 3
• Mannitol may only benefit patients with markedly elevated CK levels (>30,000 U/L), though even this benefit remains undefined, and is contraindicated in patients with oligoanuria. 2
• Diuretics should only be considered after adequate volume expansion has been achieved, and primarily for management of volume overload rather than as primary treatment. 2

Important Note: Despite widespread historical use, the 2022 Eastern Association for the Surgery of Trauma practice management guideline conditionally recommends AGAINST bicarbonate and mannitol based on lack of evidence for improved outcomes. 3

Identify and Remove Causative Agents

Medication Review

• Immediately discontinue any offending medications, particularly statins, which are a common cause of rhabdomyolysis. 1
• Review for other causative medications including succinylcholine (avoid in susceptible patients). 1
• Discontinue dietary supplements associated with myositis or rhabdomyolysis risk, including red yeast rice, creatine monohydrate, wormwood oil, licorice, and Hydroxycut. 7, 1

Assess for Underlying Causes

• Evaluate for trauma, especially crush injuries and severe limb trauma. 1
• Assess for exertional causes, particularly novel overexertion or unaccustomed exercise. 1
• Consider genetic factors such as SLCO1B1 gene mutations that increase statin-induced rhabdomyolysis risk. 1

Compartment Syndrome Surveillance and Management

Early Recognition

• Monitor for early signs: pain, tension, paresthesia, and paresis. 1
• Late signs include pulselessness and pallor, which often indicate irreversible damage. 1
• Compartment syndrome can develop as both an early or late complication. 6, 4

Surgical Intervention

• Perform early fasciotomy for established compartment syndrome. 1
• Consider fasciotomy when compartment pressure exceeds 30 mmHg or when differential pressure (diastolic blood pressure minus compartment pressure) is <30 mmHg. 1

Renal Replacement Therapy Indications

When to Initiate Dialysis

• Initiate renal replacement therapy (RRT) if CK remains persistently elevated despite 4 days of adequate hydration (>6L/day). 6
• Early initiation of RRT is associated with improved outcomes in severe rhabdomyolysis. 6
• Other indications include: severe hyperkalemia unresponsive to medical management, severe metabolic acidosis, volume overload despite diuretics, or uremic complications. 6

RRT Discontinuation

• Consider discontinuation of RRT when urine output recovers adequately (>100 mL/day). 6
• Successful weaning from RRT is more likely with recovery of urine output. 6

Critical Pitfall: Delaying RRT initiation can lead to irreversible kidney damage and increased mortality. 6

Additional Laboratory Monitoring

Comprehensive Assessment

• Obtain liver function tests to assess for hepatic involvement. 1
• Perform coagulation studies to evaluate for disseminated intravascular coagulation. 1
• Obtain arterial blood gas analysis to assess for metabolic acidosis. 1
• Check cardiac troponin and ECG to rule out cardiac involvement in severe cases. 1
• Perform urinalysis looking for brown color, cloudiness, and positive blood without RBCs (indicating myoglobinuria). 1

Etiology-Specific Testing

• Consider viral studies if viral myositis is suspected. 1
• Evaluate autoimmune markers (ANA, ASMA, ANCA) if autoimmune myositis is suspected. 1

Special Populations

Perioperative Patients

• Discontinue dietary supplements associated with theoretical or known higher risk for myositis or rhabdomyolysis before elective surgery. 7, 1
• Maintain adequate hydration throughout the perioperative period. 1

Exertional Rhabdomyolysis

• Properly calibrate training and conditioning sessions, especially during transition periods (e.g., returning after injury). 1

Key Evidence Strength: The strongest evidence supports aggressive intravenous fluid resuscitation, with a 2022 systematic review and meta-analysis demonstrating decreased incidence of acute renal failure and need for dialysis. 3 The same analysis found no benefit for bicarbonate or mannitol, representing a significant shift from historical practice patterns. 3