Immediate Treatment for Rhabdomyolysis in the ICU
Initiate aggressive intravenous fluid resuscitation immediately with isotonic saline (0.9% NaCl) targeting urine output of at least 300 mL/hour, as this is the cornerstone of preventing acute kidney injury and reducing mortality. 1, 2, 3
Initial Resuscitation and Fluid Management
Early fluid administration is critical - delayed initiation is directly associated with higher risk of acute kidney injury and worse outcomes. 1, 2
Fluid Volume Based on Severity:
- Severe rhabdomyolysis (CK >15,000 IU/L): Administer >6L of intravenous fluids per day 1, 2
- Moderate rhabdomyolysis: Administer 3-6L of intravenous fluids per day 1, 2
- Start with isotonic saline (0.9% NaCl) for initial volume expansion 2, 3
- Target urine output: Maintain at least 300 mL/hour 3, 4
Monitoring During Resuscitation:
- Place bladder catheter for hourly urine output monitoring 2
- Perform repeated bioassessments every 6-12 hours: plasma myoglobin, CK, potassium, creatinine, BUN 1, 2, 5
- Monitor urine pH - maintain approximately 6.5 2, 5
- Watch for fluid overload, especially in patients with cardiac or renal compromise 2, 5
Electrolyte Management
Hyperkalemia is the most immediately life-threatening complication and requires urgent attention. 1, 3
- Obtain ECG immediately to identify cardiac effects of hyperkalemia 6
- Monitor and correct significant electrolyte abnormalities, particularly potassium, calcium, and phosphorus 1, 5
- Serial electrolyte measurements every 6-12 hours during acute phase 5
Medication Review and Discontinuation
Immediately discontinue any offending agents, particularly:
- Statins if drug-induced rhabdomyolysis is suspected 1
- Succinylcholine - avoid in ICU setting 1
- Dietary supplements: red yeast rice, creatine monohydrate, wormwood oil, licorice, Hydroxycut 1
Role of Adjunctive Therapies
Bicarbonate and mannitol do NOT have strong evidence for improved outcomes and should not be considered first-line therapy. 3, 7
- Mannitol may only benefit patients with CK >30,000 U/L, but even this benefit is undefined and it is contraindicated in oligoanuria 2
- Diuretics should only be considered AFTER adequate volume expansion has been achieved, primarily for volume overload management rather than primary treatment 2
- Avoid diuresis as primary treatment - it may increase risk of AKI unless adequate volume resuscitation achieved first 2
Indications for Renal Replacement Therapy
Consider RRT when:
- Persistent elevation of CK despite 4 days of adequate hydration 5
- Acute kidney injury with inadequate urine output (<300 mL/hour despite fluid resuscitation) 5
- Severe hyperkalemia or metabolic acidosis refractory to medical management 8
- Early initiation of RRT is associated with improved outcomes in severe rhabdomyolysis 5
RRT Modality Selection:
- Continuous RRT is preferred in hemodynamically unstable ICU patients 8
- Effluent volume of 20-25 mL/kg/h should be delivered when using continuous RRT 8
- Consider discontinuation when urine output recovers adequately (>100 mL/day) 5
Compartment Syndrome Surveillance
Early signs (pain, tension, paresthesia, paresis) require immediate evaluation, as late signs (pulselessness, pallor) indicate irreversible damage. 1
- Consider fasciotomy when compartment pressure exceeds 30 mmHg or differential pressure (diastolic BP - compartment pressure) is <30 mmHg 1
- Early fasciotomy is indicated for established compartment syndrome 1
Duration of Treatment
Continue intravenous fluids until CK levels decrease below 1,000 U/L, maintaining adequate urine output throughout. 4
Critical Pitfalls to Avoid
- Delaying fluid resuscitation - this is the single most important modifiable risk factor for AKI 1, 2
- Using diuretics before adequate volume expansion - may worsen kidney injury 2
- Failing to monitor potassium closely - can lead to fatal cardiac arrhythmias 1, 5
- Missing compartment syndrome - requires urgent surgical decompression 1, 5
- Delaying RRT initiation when indicated - can lead to irreversible kidney damage and increased mortality 5