What is the treatment for rhabdomyolysis (Rhabdo)?

Treatment of Rhabdomyolysis

Aggressive intravenous fluid resuscitation is the cornerstone of rhabdomyolysis treatment, with a target urine output of 300 mL/hour to prevent acute kidney injury. 1, 2, 3

Immediate Management

Fluid Resuscitation

• Initiate aggressive IV saline immediately upon diagnosis – early treatment is critical as delayed resuscitation significantly increases acute kidney injury risk 1, 2
• For severe rhabdomyolysis (CK >15,000 IU/L): administer >6L of fluid per day 1
• For moderate rhabdomyolysis: administer 3-6L of fluid per day 1
• Maintain urine output at 300 mL/hour until CK levels fall below 1,000 U/L 2, 3

Discontinue Causative Agents

• Immediately stop any offending medications, particularly statins, if drug-induced rhabdomyolysis is suspected 1
• Discontinue dietary supplements associated with myositis risk, including red yeast rice, creatine monohydrate, wormwood oil, licorice, and Hydroxycut 1

Critical Monitoring and Laboratory Assessment

Electrolyte Management

• Monitor potassium levels closely and aggressively – hyperkalemia can cause life-threatening cardiac arrhythmias 1, 2, 3
• Perform repeated bioassessments including plasma myoglobin, CK, and potassium 1
• Correct significant electrolyte abnormalities promptly, particularly hyperkalemia, to prevent cardiac arrest 1, 3

Renal Function Monitoring

• Assess for myoglobinuria – urinalysis showing brown color, cloudiness, and positive for blood without RBCs indicates myoglobinuria 1
• Monitor serum creatinine to detect acute kidney injury early 2, 3

Compartment Syndrome Surveillance

Early Recognition

• Watch for early signs: pain, tension, paresthesia, and paresis 1
• Late signs indicate irreversible damage: pulselessness and pallor 1

Surgical Intervention

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

Adjunctive Therapies

Bicarbonate and Mannitol

While these agents have been historically used, bicarbonate and mannitol do not possess strong evidence for improved outcomes 2. Bicarbonate can be considered for acidotic patients, and mannitol for those not achieving goal urine output 3, but aggressive saline remains the primary therapy.

Renal Replacement Therapy

• Determine need for dialysis on a case-by-case basis for severe cases with refractory acute kidney injury 2
• Early initiation of renal replacement therapy may improve outcomes in severe cases 4

Common Pitfalls to Avoid

• Do not rely on fluid therapy alone – while aggressive hydration is essential, other complications (electrolyte abnormalities, compartment syndrome) require specific management 4
• Avoid medications that exacerbate rhabdomyolysis, particularly succinylcholine in susceptible patients 1
• Do not delay treatment – early initiation of fluid resuscitation is associated with better outcomes and lower acute kidney injury risk 1

Disposition

Most patients require hospital admission for monitoring and continued aggressive fluid resuscitation 2. Continue IV fluids until CK levels decrease below 1,000 U/L 3.