What is the treatment for post-viral (post-viral) rhabdomyolysis?

Treatment of Post-Viral Rhabdomyolysis

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

Immediate Fluid Resuscitation Protocol

Initiate early and aggressive IV fluid administration immediately upon diagnosis, as delayed treatment significantly increases the risk of acute kidney injury. 1, 2

• Administer isotonic saline (0.9% NaCl) for initial volume expansion 1, 2
• For severe rhabdomyolysis (CK >30,000 U/L or clinical severity): administer >6L of fluid per day 1, 3, 2
• For moderate rhabdomyolysis: administer 3-6L of fluid per day 1, 3, 2
• Target urine output of ≥300 mL/hour (approximately 3-5 mL/kg/hour for a 70 kg patient) 1, 3, 2
• Insert a bladder catheter to monitor hourly urine output 3, 2

Avoid potassium-containing fluids such as Lactated Ringer's solution, Hartmann's solution, and Plasmalyte A, as potassium levels may increase markedly even with intact renal function. 3

Avoid starch-based fluids due to their association with increased rates of acute kidney injury. 3

Electrolyte Monitoring and Management

Monitor potassium levels closely, as hyperkalemia can precipitate life-threatening cardiac arrhythmias and pulseless electrical activity. 1, 2

• Check electrolyte panels every 6-12 hours in severe cases 1, 2
• Perform repeated bioassessment including plasma myoglobin, CK, and potassium measurements 1, 3, 2
• Correct significant hyperkalemia immediately using standard protocols (insulin/glucose, calcium gluconate, albuterol) 2
• Monitor and correct hypocalcemia and hyperphosphatemia 1, 2
• Assess for metabolic acidosis via arterial blood gas, which commonly occurs in severe cases 2

Medications to Discontinue

Immediately discontinue all causative agents, including any prescription medications, supplements, or over-the-counter products that may contribute to rhabdomyolysis. 2

• Stop statins if the patient is taking them 2
• Discontinue dietary supplements such as red yeast rice, creatine monohydrate, wormwood oil, licorice, and Hydroxycut 2
• Avoid NSAIDs due to nephrotoxic effects 2

What NOT to Use

Do not routinely use bicarbonate for urinary alkalization, as current evidence does not demonstrate benefit over aggressive fluid resuscitation with crystalloids alone. 3, 4

• Bicarbonate should only be used for treatment of severe metabolic acidosis (pH <7.1) or life-threatening hyperkalemia, not for routine urinary alkalization 3
• Large doses of bicarbonate can worsen hypocalcemia by decreasing free calcium levels 3

Do not routinely use mannitol, as studies suggest little additional benefit compared to crystalloid resuscitation alone, and it is potentially nephrotoxic. 3, 4

• Mannitol may only benefit patients with markedly elevated CK (>30,000 U/L), though this benefit remains undefined 3
• Mannitol is contraindicated in patients with oligoanuria 3

Do not use diuretics as a primary treatment strategy unless adequate volume resuscitation has first been achieved. 3

• After ensuring adequate volume expansion, a diuretic challenge with furosemide may help assess kidney function in select cases 1
• Diuretics should only be considered for management of volume overload, not as primary treatment 3

Monitoring for Complications

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

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

Monitor renal function through serial creatinine and BUN measurements. 1

• Check CK, creatinine, potassium, calcium, and phosphorus every 6-12 hours in severe cases 3, 2
• Monitor for fluid overload, particularly in patients with cardiac or renal compromise 1, 2

Renal Replacement Therapy Indications

Initiate RRT if CK remains persistently elevated despite 4 days of adequate hydration, as this indicates severe rhabdomyolysis with significant risk of irreversible kidney damage. 1, 2

Consider RRT for:

• Refractory hyperkalemia 1, 2
• Severe metabolic acidosis unresponsive to medical management 1, 2
• Progressive acute kidney injury despite adequate fluid resuscitation 1, 2
• Fluid overload despite conservative management 3

Intermittent hemodialysis is the preferred modality, as it provides rapid clearance of potassium. 3

Consider discontinuation of RRT when urine output recovers adequately (>100 mL/day). 1, 2

Critical Pitfalls to Avoid

Delaying fluid resuscitation is the most common and dangerous error, as it is strongly associated with higher risk of acute kidney injury and worse outcomes. 1, 2, 4

Inadequate fluid volume (using <6L/day in severe cases) may fail to prevent renal complications. 1, 2

Failure to monitor and correct hyperkalemia can lead to pulseless electrical activity and cardiac arrest. 1, 2

Missing compartment syndrome, particularly in cases with prolonged immobility or severe muscle injury, can result in irreversible muscle and nerve damage. 1, 2

Special Considerations for Viral Etiology

Post-viral rhabdomyolysis (including COVID-19-associated cases) follows the same treatment principles as other causes of rhabdomyolysis. 5, 6

• Viral infection can lead directly to kidney tubular injury, making aggressive fluid resuscitation even more critical 5
• COVID-19 patients may have additional challenges including concurrent pneumonia that limits aggressive fluid administration 6
• In cases where pulmonary status limits fluid administration, early consideration of RRT may be necessary 6
• CK levels can reach extremely high values (>100,000 U/L) in viral-induced cases, requiring prolonged intensive monitoring 6