What is the treatment for Rhabdomyolysis (muscle breakdown disease)?

Treatment of Rhabdomyolysis

Aggressive intravenous fluid resuscitation initiated immediately is the cornerstone of rhabdomyolysis treatment, with a target urine output of 300 mL/hour to prevent acute kidney injury and other life-threatening complications. 1, 2

Immediate Fluid Resuscitation

Early and aggressive IV fluid administration is critical—delayed treatment significantly increases the risk of acute kidney injury and mortality. 1, 2

• Administer isotonic saline (0.9% NaCl) for volume expansion immediately upon diagnosis 2
• For severe rhabdomyolysis (CK >15,000 IU/L): infuse >6L of fluid per day 1, 2
• For moderate rhabdomyolysis: administer 3-6L per day 1, 2
• Target urine output of 300 mL/hour to facilitate myoglobin clearance and prevent renal tubular obstruction 2, 3, 4
• Monitor hourly urine output with bladder catheterization—inadequate output (<300 mL/hour) indicates worsening kidney function 2

The Anaesthesia guideline society emphasizes that early initiation is associated with lower rates of acute kidney injury, while delayed resuscitation carries substantially higher risk 1, 2. Historical data from crush syndrome patients demonstrates mortality reduction from nearly 100% to <20% through early vigorous fluid resuscitation 5.

Electrolyte Monitoring and Correction

Hyperkalemia represents the most immediately life-threatening complication and requires urgent correction to prevent cardiac arrhythmias and arrest. 1, 2

• Check electrolyte panels every 6-12 hours in severe cases, with particular attention to potassium levels 2
• Perform repeated bioassessment including plasma myoglobin, CK, and potassium measurements 1
• Correct significant electrolyte abnormalities promptly, including hypocalcemia and hyperphosphatemia 1, 2
• Assess for metabolic acidosis, which commonly occurs in severe rhabdomyolysis 2
• Maintain urine pH at approximately 6.5 if possible 2

The American College of Cardiology notes that hyperkalemia can precipitate pulseless electrical activity where external defibrillation may be ineffective, making early recognition and treatment essential 2.

Medication Management

Immediately discontinue all causative agents, particularly statins, and avoid medications that exacerbate rhabdomyolysis. 1

• Stop statins and other prescription medications immediately if drug-induced rhabdomyolysis is suspected 1
• Discontinue dietary supplements including red yeast rice (containing lovastatin), creatine monohydrate, wormwood oil, licorice, and Hydroxycut 1, 2
• Avoid succinylcholine in all myopathic patients due to risk of worsening rhabdomyolysis and hyperkalemia 6, 1
• After ensuring adequate volume expansion, consider a diuretic challenge with furosemide to assess kidney function in select cases 2

The Genetics in Medicine guideline society specifically warns against succinylcholine use in patients with underlying muscle disease, as it can precipitate severe rhabdomyolysis 6.

Monitoring for Compartment Syndrome

Maintain high suspicion for compartment syndrome, which can both cause and complicate rhabdomyolysis, requiring urgent surgical intervention. 1, 2

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

The Anaesthesia guideline society emphasizes that late signs represent irreversible damage, making early recognition critical 1.

Renal Replacement Therapy

Initiate RRT if CK remains persistently elevated despite 4 days of adequate hydration, as this indicates severe rhabdomyolysis with significant risk of irreversible kidney damage. 2

• Early initiation of RRT is associated with improved outcomes in severe cases 2
• Consider RRT for refractory hyperkalemia, severe metabolic acidosis, or progressive acute kidney injury 2
• Consider discontinuation of RRT when urine output recovers adequately (>100 mL/day) 2

Supportive Care

• Provide supplemental oxygen to address potential hypoxemia 2
• Support vital signs as needed 2
• Consider cooling measures if hyperthermia is present to protect against fulminating rhabdomyolysis 2
• Continue IV fluids until CK levels decrease to <1,000 U/L 4

Critical Pitfalls to Avoid

Delaying fluid resuscitation is the most common and dangerous error, associated with significantly higher rates of acute kidney injury and mortality. 1, 2

• Inadequate fluid volume (using <6L/day in severe cases) may fail to prevent renal complications 2
• Failure to monitor and correct hyperkalemia can lead to pulseless electrical activity and cardiac arrest 2
• Missing compartment syndrome, particularly in traumatic or severe exertional cases, results in irreversible muscle and nerve damage 2
• Bicarbonate, mannitol, and loop diuretics lack strong evidence for improved outcomes and should not delay aggressive saline resuscitation 3