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

Treatment of Rhabdomyolysis

Aggressive intravenous fluid resuscitation with isotonic saline is the cornerstone of rhabdomyolysis treatment, targeting urine output of 300 mL/hour, and must be initiated immediately to prevent acute kidney injury. 1, 2, 3

Immediate Fluid Management

Start isotonic saline (0.9% NaCl) resuscitation immediately upon diagnosis—delayed treatment significantly increases the risk of acute kidney injury and mortality. 1, 2, 3, 4

Volume Requirements

• Severe rhabdomyolysis (CK >15,000 IU/L): Administer >6L of fluid per day, with some sources recommending up to 12L daily in carefully monitored young patients 1, 2, 4
• Moderate rhabdomyolysis: Use 3-6L per day 1, 2
• Target urine output: 300 mL/hour to facilitate myoglobin clearance and prevent renal tubular obstruction 2, 3, 5, 6

Monitoring During Resuscitation

• Monitor closely for fluid overload, particularly in patients with cardiac or renal compromise 3
• Place bladder catheter for hourly urine output monitoring—inadequate output suggests worsening kidney function 2
• Continue IV fluids until CK levels decline below 1,000 U/L 6

Electrolyte Management

Monitor potassium levels every 6-12 hours in severe cases and correct hyperkalemia emergently—it can precipitate life-threatening cardiac arrhythmias and arrest. 1, 2, 3

Essential Monitoring

• Perform repeated bioassessment including plasma myoglobin, CK, and potassium measurements 1, 3
• Check complete electrolyte panels every 6-12 hours in severe cases 3
• Assess for metabolic acidosis via arterial blood gas, which commonly occurs in severe rhabdomyolysis 1, 3
• Correct hypocalcemia and hyperphosphatemia as needed 3

Medication Management

Immediately discontinue all causative agents, particularly statins, NSAIDs, and high-risk supplements. 1, 3

Medications to Stop

• Statins and other prescription medications contributing to rhabdomyolysis 1, 3
• Dietary supplements: red yeast rice (containing lovastatin), creatine monohydrate, wormwood oil, licorice, and Hydroxycut 1, 3
• Avoid NSAIDs entirely due to nephrotoxic effects in patients already at high risk for acute kidney injury 1, 3
• In anesthesia settings, succinylcholine and inhaled anesthetics are contraindicated in at-risk populations 7, 3

Pain Management

• First-line: Acetaminophen 500-1000 mg (maximum 4-6 grams daily) to avoid nephrotoxic effects 1
• For severe pain unresponsive to acetaminophen: Oral morphine 20-40 mg for opioid-naive patients 1
• If acute kidney injury present (eGFR <30 mL/min): Use fentanyl or buprenorphine as safest opioid choices 1, 3

Bicarbonate and Mannitol: Not Recommended

Do not routinely use sodium bicarbonate or mannitol—they do not improve outcomes in rhabdomyolysis. 8

• The Eastern Association for the Surgery of Trauma conditionally recommends against bicarbonate or mannitol, as neither improved acute renal failure incidence or need for dialysis 8
• Bicarbonate may be considered only for patients who are significantly acidotic 6
• After adequate volume expansion, a diuretic challenge with furosemide may help assess kidney function in select cases, but does not have strong evidence for routine use 2, 5

Compartment Syndrome Surveillance

Maintain high suspicion for compartment syndrome, which can both cause and complicate rhabdomyolysis. 1, 2, 3

Clinical Signs

• Early signs: Pain, tension, paresthesia, and paresis 1, 2, 3
• Late signs: Pulselessness and pallor, indicating irreversible damage 1, 2

Intervention Thresholds

• Perform early fasciotomy when compartment pressure exceeds 30 mmHg 1, 2, 3
• Consider fasciotomy when differential pressure (diastolic BP minus compartment pressure) is <30 mmHg 1, 2, 3

Renal Replacement Therapy

Initiate RRT for specific indications, not based on arbitrary creatinine thresholds. 2, 3

Indications for RRT

• Refractory hyperkalemia despite medical management 2, 3
• Severe metabolic acidosis 2, 3
• Progressive acute kidney injury 2, 3
• CK persistently elevated despite 4 days of adequate hydration, indicating severe rhabdomyolysis with significant risk of irreversible kidney damage 2, 3

Discontinuation

• Consider stopping RRT when urine output recovers adequately (>100 mL/day) 2, 3

Critical Pitfalls to Avoid

• Delaying fluid resuscitation is associated with higher risk of acute kidney injury and worse outcomes 2, 3, 4
• Inadequate fluid volume (using <6L/day in severe cases) may fail to prevent renal complications 3
• Failure to monitor and correct hyperkalemia can lead to pulseless electrical activity and cardiac arrest 2, 3
• Missing compartment syndrome, particularly in traumatic or severe exertional cases, can result in irreversible muscle and nerve damage 3
• Do not use the 1.5 mg/dL creatinine threshold as a trigger for intervention—this is specific to cirrhotic patients and not applicable to rhabdomyolysis 2

Special Considerations

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