What is the treatment for rhabdomyolysis?

Treatment of Rhabdomyolysis

Aggressive intravenous fluid resuscitation is the cornerstone of rhabdomyolysis treatment, with early initiation being critical to prevent acute kidney injury and reduce mortality. 1, 2

Immediate Management: Fluid Resuscitation

Fluid Volume Based on Severity

• 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: Aim for 300 mL/hour to ensure adequate kidney perfusion and myoglobin clearance 3, 4

Timing and Fluid Type

• Start fluid resuscitation immediately upon diagnosis, as delayed treatment significantly increases the risk of acute kidney injury 1, 2
• Begin with isotonic saline (0.9% NaCl) for initial volume expansion 2
• After initial resuscitation, adjust fluid choice based on hydration status and serum electrolyte levels 2

Evidence Supporting Aggressive Fluids

The Eastern Association for the Surgery of Trauma meta-analysis demonstrated that aggressive intravenous fluid resuscitation decreased both the incidence of acute renal failure and the need for dialysis in rhabdomyolysis patients 5. Early vigorous fluid resuscitation with ≥12L daily has reduced mortality in crush syndrome from nearly 100% to <20% over the past 70 years 6.

What NOT to Use: Bicarbonate and Mannitol

Do not routinely administer bicarbonate or mannitol for rhabdomyolysis treatment. 5

• The Eastern Association for the Surgery of Trauma conditionally recommends against bicarbonate use, as it does not improve acute renal failure incidence or reduce dialysis need 5
• Mannitol may only benefit patients with markedly elevated CK levels (>30,000 U/L), but even this benefit remains undefined and is contraindicated in patients with oligoanuria 2
• Diuretics should only be considered after adequate volume expansion for management of volume overload, not as primary treatment 2

Identify and Remove the Causative Agent

Medication-Induced Rhabdomyolysis

• Immediately discontinue statins if drug-induced rhabdomyolysis is suspected 1
• Stop dietary supplements associated with rhabdomyolysis risk, including red yeast rice, creatine monohydrate, wormwood oil, licorice, and Hydroxycut 1
• Avoid succinylcholine in susceptible patients 1

Drug Interactions to Avoid

• Do not combine statins metabolized by CYP3A4 with antipsychotics or other interacting medications 1
• If lipid management is needed after statin-induced rhabdomyolysis, consider hydrophilic statins (fluvastatin, pravastatin) or nonstatin therapies (ezetimibe, PCSK9 inhibitors, bempedoic acid) 1

Critical Monitoring Parameters

Laboratory Monitoring

• Repeated measurements of plasma myoglobin, creatine kinase (CK), and potassium levels 1, 2
• Monitor potassium closely, as hyperkalemia can cause life-threatening cardiac arrhythmias requiring urgent treatment 1, 3
• Complete electrolyte panel including calcium, phosphorus, and magnesium 1
• Renal function monitoring to assess for acute kidney injury 3

Urine Monitoring

• Use bladder catheterization to monitor hourly urine output 2
• Maintain urine pH at approximately 6.5 2
• Look for brown-colored urine positive for blood without RBCs (myoglobinuria) 1

Compartment Syndrome Recognition and Management

Early Warning Signs

• Pain, tension, paresthesia, and paresis are early signs requiring immediate evaluation 1, 3
• Late signs include pulselessness and pallor, which often indicate irreversible damage 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, 3

Disposition and Admission Criteria

Hospitalize patients with rhabdomyolysis who have immunocompromised state, severe pain requiring management, mental confusion, pulmonary infiltrates, abnormal spinal fluid findings, or specific organ failure 1. Most patients require admission for aggressive fluid resuscitation and monitoring, though select mild cases may be appropriate for discharge after initial stabilization 4.

Common Pitfalls to Avoid

• Delayed fluid resuscitation is the most critical error, as it dramatically increases acute kidney injury risk 1, 2, 6
• Excessive fluid administration in patients with cardiac or renal compromise can cause fluid overload—monitor carefully 2
• Failure to monitor and correct hyperkalemia can lead to fatal cardiac arrhythmias 1, 2
• Missing compartment syndrome in its early stages when intervention is still effective 1, 3