What is the management of rhabdomyolysis?

Management of Rhabdomyolysis

Aggressive intravenous fluid resuscitation with isotonic saline is the cornerstone of rhabdomyolysis management, targeting urine output of 300 mL/hour, while bicarbonate and mannitol should not be routinely used. 1, 2, 3

Immediate Fluid Resuscitation

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

• Initiate isotonic saline (0.9% NaCl) immediately upon diagnosis 2
• For severe rhabdomyolysis (CK >15,000 IU/L): administer >6L per day 1, 2
• For moderate cases: administer 3-6L per day 1, 2
• Target urine output: 300 mL/hour to facilitate myoglobin clearance and prevent renal tubular obstruction 2, 4, 5
• Continue IV fluids until CK levels drop below 1,000 U/L 5
• Monitor closely for fluid overload, particularly in patients with cardiac or renal compromise 2

The Eastern Association for the Surgery of Trauma meta-analysis demonstrated that aggressive IVFR decreased both acute renal failure incidence and need for dialysis, though the quality of evidence was very low. 3 This remains the only intervention with demonstrated benefit in preventing renal complications. 3, 6

Electrolyte Monitoring and Management

Hyperkalemia represents the most life-threatening complication and requires continuous monitoring. 1, 2

• Check electrolyte panels every 6-12 hours in severe cases 2
• Perform repeated bioassessment including plasma myoglobin, CK, and potassium measurements 1
• Correct significant hyperkalemia immediately—it can precipitate cardiac arrhythmias and arrest 1, 2
• Monitor and correct hypocalcemia and hyperphosphatemia 2
• Assess for metabolic acidosis via arterial blood gas, which commonly occurs in severe cases 1, 2

Medications to Avoid and Discontinue

Immediately discontinue all causative agents. 1, 2

• Stop statins and all prescription medications that may contribute 1
• Discontinue dietary supplements: red yeast rice (containing lovastatin), creatine monohydrate, wormwood oil, licorice, and Hydroxycut 1, 2
• Avoid NSAIDs (ibuprofen, ketoprofen, diclofenac, naproxen, mefenamic acid) due to nephrotoxic effects 1
• In anesthesia settings: succinylcholine and inhaled anesthetics (halothane, isoflurane, sevoflurane) are contraindicated in patients with muscular dystrophy or at-risk populations 7, 1

Bicarbonate and Mannitol: Not Recommended

The Eastern Association for the Surgery of Trauma conditionally recommends against routine use of bicarbonate or mannitol—neither improved acute renal failure incidence or dialysis need. 3

• Bicarbonate may be considered only for patients with documented metabolic acidosis, not for routine urine alkalinization 3, 6
• Mannitol lacks strong evidence and should not be used routinely 3, 4, 6
• After ensuring adequate volume expansion, furosemide may help assess kidney function in select cases, but is not routinely recommended 2

Compartment Syndrome Surveillance

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

• Early signs: pain, tension, paresthesia, and paresis 1
• Late signs: pulselessness and pallor (indicating irreversible damage) 1
• Perform early fasciotomy when compartment pressure exceeds 30 mmHg or when differential pressure (diastolic BP – compartment pressure) is <30 mmHg 1, 2

Renal Replacement Therapy Indications

Consider RRT for specific complications, not as routine therapy. 2

• Initiate RRT if CK remains persistently elevated despite 4 days of adequate hydration 2
• Use RRT for refractory hyperkalemia, severe metabolic acidosis, or progressive acute kidney injury 2
• Early initiation of RRT is associated with improved outcomes in severe cases 2
• Consider discontinuation when urine output recovers adequately (>100 mL/day) 2

Pain Management

Use acetaminophen as first-line analgesic, avoiding nephrotoxic NSAIDs. 1

• Acetaminophen 500-1000 mg (onset 15-30 minutes, maximum 4-6 grams daily) 1
• Reserve opioids for severe muscle pain unresponsive to acetaminophen 1
• Oral morphine 20-40 mg for opioid-naive patients with moderate to severe pain 1
• In patients with acute kidney injury (eGFR <30 ml/min): use fentanyl or buprenorphine as safest opioid choices 1

Critical Pitfalls to Avoid

• Delaying fluid resuscitation is associated with higher risk of acute kidney injury and worse outcomes 1, 2
• Inadequate fluid volume (<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
• Using bicarbonate or mannitol routinely wastes resources without improving outcomes 3

Special Populations

Athletes with sickle cell trait experiencing collapse require immediate cessation of activity, supplemental oxygen, IV hydration, and possible cooling—this is a medical emergency where metabolic insult with lactic acidosis and hyperkalemia can lead to pulseless electrical activity where external defibrillation may be ineffective. 2