Can Ringer's Lactate (RL) be given in cases of rhabdomyolysis?

Ringer's Lactate Should NOT Be Used in Rhabdomyolysis

Potassium-containing balanced salt fluids such as Lactated Ringer's solution must be avoided in patients with suspected or proven rhabdomyolysis, as potassium levels may increase markedly following reperfusion, even with intact renal function. 1

Why Ringer's Lactate is Contraindicated

• Potassium content is the critical concern: Lactated Ringer's contains 4 mmol/L of potassium, and rhabdomyolysis patients already face severe hyperkalemia risk from massive muscle breakdown releasing intracellular potassium into circulation 1, 2

• Reperfusion injury amplifies the risk: When crushed or ischemic muscle tissue is reperfused (such as after extrication from rubble or release of compartment syndrome), potassium floods from damaged muscle cells into the bloodstream, creating life-threatening hyperkalemia that can occur rapidly even with normal kidney function 1

• The hyperkalemia can be sudden and severe: This is not a gradual process—potassium levels can spike dramatically within minutes to hours of reperfusion, making any additional potassium load from IV fluids potentially fatal 1

The Preferred Fluid Choice

• Use 0.9% normal saline instead: This is the recommended crystalloid for rhabdomyolysis because it contains no potassium and provides aggressive volume expansion needed to prevent acute kidney injury from myoglobin precipitation 1

• Aggressive fluid resuscitation is the cornerstone: Initial rates of 1000 mL/hour are recommended if started early (such as before extrication), then tapered by at least 50% after 2 hours based on clinical response 1

• Target urine output of 200-300 mL/hour: This high urine flow helps flush myoglobin through the kidneys before it precipitates and causes tubular damage 1

Common Pitfalls to Avoid

• Do not use bicarbonate-containing fluids routinely: While alkalinization was historically advocated to prevent myoglobin cast formation, current evidence shows no benefit over aggressive fluid resuscitation with normal saline alone, and large bicarbonate doses can worsen the hypocalcemia that already accompanies crush injury 1

• Avoid mannitol unless absolutely necessary: Despite theoretical benefits (diuresis, antioxidant effects, reduced compartment pressure), studies show little extra kidney protection compared to crystalloids alone, and mannitol is potentially nephrotoxic and requires close monitoring often impossible in disaster settings 1

• Do not use starch-based colloids: These are associated with increased rates of acute kidney injury and bleeding complications 1

Monitoring Requirements

• Check potassium levels immediately and frequently: Use point-of-care devices like iStat if standard laboratory infrastructure is unavailable—these provide accurate potassium and creatinine results within minutes in field conditions 1

• Monitor creatine kinase, electrolytes, acid-base status, and renal function: Serial measurements guide the intensity and duration of fluid therapy 1

• Watch for signs of fluid overload: Older patients, children, those with low body mass, or mild trauma are more prone to volume overload and pulmonary edema, requiring more conservative fluid administration 1

The One Exception Where Balanced Solutions Were Studied

• A small study in doxylamine-induced rhabdomyolysis showed Lactated Ringer's required less supplemental bicarbonate than normal saline and maintained better acid-base balance 3. However, this was a specific toxicologic cause with only 28 patients, and the guideline recommendation against potassium-containing fluids in crush syndrome and rhabdomyolysis remains the standard of care 1

Clinical Algorithm

1. Suspect rhabdomyolysis? (crush injury, prolonged immobilization, compartment syndrome, severe exertion, drug toxicity)
2. Start 0.9% normal saline immediately at 1000 mL/hour if early presentation 1
3. Avoid all potassium-containing fluids including Lactated Ringer's, Hartmann's solution, and Plasmalyte A 1
4. Check potassium level stat and monitor continuously 1
5. Adjust fluid rate based on urine output (target 200-300 mL/hour), volume status, and time since injury 1
6. Prepare for dialysis if hyperkalemia develops despite fluid resuscitation or if acute kidney injury with anuria occurs 1