Would alkalinizing urine help with rhabdomyolysis (rhabdo)?

From the Guidelines

Alkalizing urine may be beneficial in the management of rhabdomyolysis, as recommended by the most recent guideline from the Association of Anaesthetists in 2021 1.

Key Considerations

• The primary goal in treating rhabdomyolysis is to maintain urine output and flush myoglobin from the kidneys through aggressive intravenous fluid administration.
• Urine alkalinization with sodium bicarbonate can help prevent myoglobin from precipitating in kidney tubules and causing further damage.
• However, this should only be done under medical supervision as part of comprehensive treatment, as self-administering alkalizing agents without medical supervision could lead to electrolyte imbalances and worsen the condition.

Treatment Approach

• The standard approach includes IV fluids at rates of 200-300 mL/hour initially, with the goal of producing urine output of 200-300 mL/hour.
• Sodium bicarbonate can be used to alkalize urine, but its use should be determined by a healthcare provider in a hospital setting.
• It is essential to seek immediate medical attention for rhabdomyolysis, as it is a serious medical emergency that requires prompt hospital treatment to prevent kidney failure and other complications.

Evidence Summary

• A study published in the journal Anaesthesia in 2021 1 recommends the use of sodium bicarbonate to alkalize urine in the prevention of acute kidney injury from myoglobinuria.
• However, other studies, such as one published in Kidney International in 2014 1, suggest that current evidence does not support the benefit of active alkalinization over active fluid resuscitation.
• Another study published in the Journal of Clinical Oncology in 2008 1 discusses the use of sodium bicarbonate in the management of tumor lysis syndrome, but its findings are not directly applicable to rhabdomyolysis.

From the Research

Rhabdomyolysis Treatment

• The treatment of rhabdomyolysis remains controversial, with debate surrounding the benefits of aggressive intravenous fluid resuscitation, urine alkalization with bicarbonate, and the use of mannitol 2.
• Studies have shown that aggressive intravenous fluid resuscitation can decrease the incidence of acute renal failure and the need for dialysis in patients with rhabdomyolysis 2, 3, 4, 5.
• However, the use of bicarbonate and mannitol in the treatment of rhabdomyolysis is not supported by high-quality evidence, with most studies suggesting that these interventions do not improve outcomes 2, 4, 5.

Urine Alkalization

• Urine alkalization with sodium bicarbonate has been proposed as a potential treatment for rhabdomyolysis, but the evidence for its effectiveness is limited 3, 5.
• A comprehensive review of the literature found that the use of sodium bicarbonate and mannitol in rhabdomyolysis is not entirely justified, and that aggressive early volume resuscitation with normal saline should remain the principal focus of therapy 5.

Treatment Recommendations

• The Eastern Association for the Surgery of Trauma recommends against the use of bicarbonate and mannitol in patients with rhabdomyolysis, and conditionally recommends aggressive intravenous fluid resuscitation to improve outcomes 2.
• Other studies emphasize the importance of early and aggressive fluid resuscitation, as well as the need for further research on the optimal management of rhabdomyolysis 3, 4, 5, 6.