What is the treatment for Rhabdomyolysis?

Treatment of Rhabdomyolysis

Immediate aggressive intravenous fluid resuscitation with isotonic saline is the cornerstone of rhabdomyolysis treatment, targeting urine output of at least 300 mL/hour to prevent acute kidney injury and reduce mortality. 1, 2

Immediate Fluid Resuscitation

Early fluid administration is the single most critical intervention and must be initiated immediately upon diagnosis, as delayed treatment directly correlates with higher rates of acute kidney injury and worse outcomes. 1, 2, 3

Fluid Volume Requirements

• 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
• Optimal regimen: Start with ≥12L daily of alkaline solution in extensive cases to stabilize circulation, mobilize sequestered edema fluids, correct hyperkalemia and acidosis, and protect against myoglobin nephrotoxicity 3
• Initial fluid: Use isotonic saline (0.9% NaCl) for volume expansion 4, 2

Monitoring During Resuscitation

• Place bladder catheter for hourly urine output monitoring 4, 2
• Target urine output: ≥300 mL/hour 2, 5
• Monitor for fluid overload, especially in patients with cardiac or renal compromise 4, 2
• Maintain urine pH at approximately 6.5 4, 2

Electrolyte Management

Hyperkalemia is the most immediately life-threatening complication requiring urgent attention and continuous monitoring. 2

• Perform repeated bioassessments every 6-12 hours including plasma myoglobin, CK, potassium, creatinine, and BUN 1, 4, 2
• Monitor and correct significant electrolyte abnormalities, particularly potassium, calcium, and phosphorus 1, 4
• Watch for hyperkalemia, hypocalcemia, and hyperphosphatemia which are common complications 4
• Failure to monitor potassium closely can lead to fatal cardiac arrhythmias 2

Medication Management

Immediately discontinue any offending agents upon diagnosis. 1, 2

• Stop statins immediately if drug-induced rhabdomyolysis is suspected 1
• Avoid succinylcholine 1
• Discontinue dietary supplements associated with rhabdomyolysis risk including red yeast rice, creatine monohydrate, wormwood oil, licorice, and Hydroxycut 1
• Avoid medications that increase rhabdomyolysis risk, particularly statins metabolized by CYP3A4 1

Role of Adjunctive Therapies

Bicarbonate and mannitol lack strong evidence for routine use and should not delay aggressive fluid resuscitation. 2, 5

Bicarbonate

• Sodium bicarbonate may be added to intravenous fluids for urine alkalinization 6
• Indicated in severe metabolic acidosis where rapid increase in plasma CO2 is crucial 6
• Dosing: 2-5 mEq/kg body weight over 4-8 hours depending on severity 6
• Caution: Bicarbonate solutions are hypertonic and may produce undesirable rise in plasma sodium 6

Mannitol

• May only benefit patients with CK >30,000 U/L, but even this benefit is undefined 2
• Contraindicated in oligoanuria 2

Diuretics

• Should only be considered after adequate volume expansion has been achieved 2, 5
• Use primarily for volume overload management rather than primary treatment 2
• Furosemide can be administered as intermittent dose or infusion to evaluate kidney function response 4
• Avoid diuresis as primary treatment, as it may increase risk of AKI unless adequate volume resuscitation is achieved first 2

Renal Replacement Therapy Indications

Consider RRT when conservative management fails or life-threatening complications develop. 4, 2

Specific Indications

• Persistent elevation of CK despite 4 days of adequate hydration 4, 2
• Acute kidney injury with inadequate urine output (<300 mL/hour) 4
• Severe hyperkalemia refractory to medical management 4, 2
• Metabolic acidosis refractory to medical management 4, 2
• Early initiation of RRT is associated with improved outcomes in severe rhabdomyolysis 4, 2

RRT Implementation

• Continuous RRT is preferred in hemodynamically unstable ICU patients 2
• Use effluent volume of 20-25 mL/kg/h 2
• Consider discontinuation when urine output recovers adequately (>100 mL/day) 4, 2
• Delaying RRT initiation when indicated can lead to irreversible kidney damage and increased mortality 4, 2

Compartment Syndrome Surveillance

Early recognition and intervention for compartment syndrome is critical as late signs indicate irreversible damage. 1, 2

• Early signs include pain, tension, paresthesia, and paresis 1
• Late signs include pulselessness and pallor, often indicating irreversible damage 1
• Consider fasciotomy when compartment pressure exceeds 30 mmHg 1
• Consider fasciotomy when differential pressure (diastolic BP – compartment pressure) is <30 mmHg 1
• Early fasciotomy is indicated for established compartment syndrome 1, 2

Critical Pitfalls to Avoid

• Delaying fluid resuscitation is the single most important modifiable risk factor for AKI 2, 3
• Using diuretics before adequate volume expansion may worsen kidney injury 2
• Failing to monitor potassium closely can lead to fatal cardiac arrhythmias 2
• Missing compartment syndrome requires urgent surgical decompression 2
• Inadequate fluid resuscitation before starting RRT may worsen outcomes 4

Disposition and Follow-up

• Most patients require hospitalization for close monitoring and aggressive treatment 1
• Continue serial measurements of CK, electrolytes, and renal function every 6-12 hours during acute phase 4, 2
• Consider investigating underlying causes (medications, genetic disorders, autoimmune conditions) for persistent cases 4
• For patients requiring continued lipid management after statin discontinuation, consider nonstatin therapies such as ezetimibe, PCSK9 inhibitors, or bempedoic acid 1