What is the treatment for Rhabdomyolysis?

Treatment of Rhabdomyolysis

Aggressive intravenous fluid resuscitation with isotonic saline is the cornerstone of treatment for rhabdomyolysis, targeting a urine output of 300 mL/hour to prevent acute kidney injury, which is the most life-threatening complication. 1, 2

Immediate Fluid Resuscitation

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

• Administer isotonic saline (0.9% NaCl) as the primary resuscitation fluid 2
• For severe rhabdomyolysis (CK >15,000 IU/L), infuse >6L per day 1, 2
• For moderate cases, use 3-6L per day 1, 2
• Target urine output of 300 mL/hour to facilitate myoglobin clearance and prevent renal tubular obstruction 2
• Monitor hourly urine output with bladder catheterization; inadequate output (<300 mL/hour) suggests worsening kidney function 2
• Monitor closely for fluid overload, particularly in patients with cardiac or renal compromise 2

Critical Electrolyte Management

Hyperkalemia from muscle breakdown can precipitate life-threatening cardiac arrhythmias and sudden cardiac death—monitor potassium levels closely and correct promptly. 1, 2

• Perform repeated bioassessment including plasma myoglobin, CK, and potassium measurements 1
• Check electrolyte panels every 6-12 hours in severe cases 2
• Correct significant hyperkalemia immediately to prevent cardiac arrest 1, 3
• Correct hypocalcemia and hyperphosphatemia, which commonly occur 2, 3
• Assess for metabolic acidosis through arterial blood gas analysis 1, 2

Discontinue Causative Agents

Immediately discontinue any medications or supplements that may contribute to rhabdomyolysis. 1

• Stop statins 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
• Avoid medications that increase rhabdomyolysis risk, particularly in combination therapy 1
• Cease the physical activity that triggered exertional rhabdomyolysis 2

Bicarbonate Therapy Considerations

The role of sodium bicarbonate remains controversial, with limited evidence for routine use. 4, 5

• Sodium bicarbonate is FDA-indicated for treatment of metabolic acidosis in severe conditions including cardiac arrest and circulatory insufficiency 6
• Maintain urine pH at approximately 6.5 if bicarbonate is used 2
• Bicarbonate solutions are hypertonic and may produce undesirable rises in plasma sodium concentration 6
• In less urgent forms of metabolic acidosis, sodium bicarbonate may be added to other IV fluids at 2-5 mEq/kg over 4-8 hours 6
• However, bicarbonate does not possess strong evidence for improved outcomes in rhabdomyolysis specifically 4

Compartment Syndrome Surveillance

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

• Early signs include pain, tension, paresthesia, and paresis 1
• Late signs include pulselessness and pallor, which indicate irreversible damage 1
• 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

Renal Replacement Therapy

If CK remains persistently elevated despite 4 days of adequate hydration, initiate RRT, as this indicates severe rhabdomyolysis with significant risk of irreversible kidney damage. 2, 3

• Early RRT initiation is associated with improved outcomes in severe cases 2, 3
• 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

Diuretic Use

• After ensuring adequate volume expansion, a diuretic challenge with furosemide may help assess kidney function in select cases 2
• Response to diuretics may predict successful recovery of kidney function 2
• Loop diuretics do not possess strong evidence for improved outcomes and should not replace aggressive fluid resuscitation 4

Supportive Care

• Provide supplemental oxygen to address potential hypoxemia 2, 3
• Support vital signs as needed 2
• Consider cooling measures if hyperthermia is present to protect against fulminating rhabdomyolysis 2, 3
• Ensure rapid transport to a medical facility for severe cases 2

Critical Pitfalls to Avoid

• Delaying fluid resuscitation is associated with higher risk of acute kidney injury and worse outcomes 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 1, 2
• Missing compartment syndrome, particularly in traumatic or severe exertional cases, can result in irreversible muscle and nerve damage 2
• Attempting full correction of acidosis within the first 24 hours may be accompanied by unrecognized alkalosis due to delayed ventilatory readjustment 6

Special Considerations for Statin-Induced Cases

• Consider nonstatin therapies such as ezetimibe, PCSK9 inhibitors, or bempedoic acid for patients requiring continued lipid management after statin discontinuation 1
• If lipid management is needed, use hydrophilic statins (fluvastatin, pravastatin) as they have fewer metabolic interactions 1
• Genetic factors such as SLCO1B1 gene mutations increase the risk of statin-induced rhabdomyolysis 1