What is the recommended protocol for alkaline diuresis in a patient with high‑voltage electrical burns causing rhabdomyolysis to prevent acute kidney injury?

Alkaline Diuresis in Electrical Burns with Rhabdomyolysis

Primary Recommendation

Alkaline diuresis with bicarbonate is NOT recommended for preventing acute kidney injury in electrical burn patients with rhabdomyolysis—aggressive fluid resuscitation with isotonic saline is the cornerstone of treatment instead. 1, 2

Fluid Resuscitation Protocol

Initial Management

• Initiate aggressive IV fluid resuscitation immediately with 0.9% normal saline at 1000 mL/hour during the initial phase 1, 2
• High-voltage electrical injuries require substantially more fluid than standard burn formulas predict because deep tissue damage is not reflected in surface area calculations 3, 4
• Target urine output of ≥300 mL/hour (approximately 3-5 mL/kg/hour for a 70 kg patient) to facilitate myoglobin clearance and prevent tubular obstruction 5, 2
• This target is 6-10 times higher than the standard oliguria threshold used in general acute kidney injury 2

Fluid Volume Requirements

• Administer >6L of IV fluids per day for severe rhabdomyolysis 5, 2
• High-voltage electrical injury patients typically require 46.6 mL/kg in the first 24 hours compared to 22.5 mL/kg for low-voltage injuries 6
• Reduce infusion rate by at least 50% if initial resuscitation exceeds 2 hours to avoid volume overload 1, 2

Fluid Type Selection

• Use isotonic saline (0.9% NaCl) for initial volume expansion 5, 2
• Avoid potassium-containing solutions (Lactated Ringer's, Hartmann's solution, Plasmalyte A) because potassium levels can increase markedly after reperfusion, even with intact renal function 1, 2
• Avoid starch-based fluids due to association with increased acute kidney injury and bleeding 1, 2

Why Bicarbonate is NOT Recommended

Evidence Against Alkalinization

• Current evidence does not demonstrate benefit from active alkalinization over aggressive fluid resuscitation alone for preventing pigment nephropathy 1, 2
• The theoretical rationale that alkalinization prevents myoglobin cast precipitation in renal tubules has not been supported by clinical studies 1

Risks of Bicarbonate Administration

• Large doses of bicarbonate can decrease free calcium and worsen the hypocalcemia already associated with crush injury and rhabdomyolysis 1, 2
• Bicarbonate adds extra volume without proven benefit 2
• The Eastern Association for the Surgery of Trauma found that bicarbonate did not improve the incidence of acute kidney injury or need for dialysis 2

Limited Indications for Bicarbonate

• Bicarbonate should be reserved only for life-threatening hyperkalemia or severe metabolic acidosis as a general critical care principle, not as a primary treatment for rhabdomyolysis 2
• Standard bicarbonate dosing applies in these emergency scenarios to aid potassium reuptake into cells 2

Monitoring Parameters

Essential Monitoring

• Insert bladder catheter to monitor hourly urine output unless urethral injury is suspected 1, 5, 2
• Monitor urine pH (target approximately 6.5) 5, 2
• Check for myoglobinuria, which indicates need for continued aggressive hydration 4, 6
• Measure creatine kinase (CK), creatinine, potassium, calcium, and phosphorus every 6-12 hours in severe cases 5, 2

Secondary Resuscitation Endpoints

• Monitor lactate, base deficit, hemoglobin, and mean arterial pressure as secondary endpoints since urine output may be unreliable in electrical injuries 3
• Use point-of-care devices (e.g., iStat) if standard laboratory infrastructure is unavailable, noting they require 16-30°C operational temperature 1

Adjunctive Therapies: What NOT to Use Routinely

Mannitol

• Mannitol is NOT recommended for routine use as studies show little additional benefit compared to crystalloid resuscitation alone, and it is potentially nephrotoxic 1, 2, 4
• Mannitol may only benefit patients with markedly elevated CK (>30,000 U/L), though this benefit remains undefined 2
• Mannitol requires close monitoring that is often impossible in disaster or resource-limited settings 1
• If used, mannitol is contraindicated in patients with oligoanuria 2

Diuretics

• Diuretics are generally not recommended as primary treatment and may increase acute kidney injury risk unless adequate volume resuscitation has been achieved first 2
• After ensuring adequate volume expansion, a furosemide challenge may help assess kidney function in select cases 5, 7
• Response to diuretics may predict successful recovery of kidney function 5, 7

Complications to Monitor

Compartment Syndrome

• Maintain high suspicion for compartment syndrome, which can both cause and complicate rhabdomyolysis in electrical injuries 5, 4, 8
• Early signs include pain, tension, paresthesia, and paresis; late signs include pulselessness and pallor (indicating irreversible damage) 5
• Perform early fasciotomy when compartment pressure exceeds 30 mmHg or when differential pressure (diastolic BP – compartment pressure) is <30 mmHg 5
• Escharotomy should be performed within 48 hours if circulatory impairment develops 1

Electrolyte Abnormalities

• Monitor potassium levels closely as hyperkalemia can precipitate life-threatening cardiac arrhythmias 5, 2
• Correct hypocalcemia and hyperphosphatemia promptly 5
• Assess for metabolic acidosis, which commonly occurs in severe rhabdomyolysis 5

Cardiac Complications

• Cardiac dysrhythmias are among the most common complications of electrical injury 4
• High-voltage injuries can cause severe cardiogenic shock requiring advanced support 9

Advanced Interventions

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 5, 7
• Early initiation of RRT is associated with improved outcomes in severe cases 5, 7
• Consider RRT for refractory hyperkalemia, severe metabolic acidosis, or progressive acute kidney injury 5
• Continuous venovenous hemofiltration is well-supported for clearing myoglobin load that hemodialysis cannot remove 3, 8
• Consider discontinuation of RRT when urine output recovers adequately (>100 mL/day) 5, 7

Critical Pitfalls to Avoid

Timing and Volume Errors

• Delaying fluid resuscitation is associated with higher risk of acute kidney injury and worse outcomes 5, 2
• Inadequate fluid volume (using <6L/day in severe cases) may fail to prevent renal complications 5, 2
• Standard burn resuscitation formulas based on body surface area will underestimate fluid needs in electrical injuries 3, 4

Electrolyte Management Failures

• Failure to monitor and correct hyperkalemia can lead to pulseless electrical activity and cardiac arrest 5, 2
• Missing the need to avoid potassium-containing fluids can worsen hyperkalemia 1, 2

Surgical Complications

• Missing compartment syndrome, particularly in traumatic or severe exertional cases, can result in irreversible muscle and nerve damage 5, 8
• Approximately 15% of electrical burn victims sustain traumatic injuries from falls or being thrown, requiring full trauma evaluation 4

Inappropriate Alkalinization

• Using bicarbonate as primary treatment adds volume and risk without proven benefit for preventing acute kidney injury 1, 2
• Bicarbonate can worsen hypocalcemia, which is already a complication of rhabdomyolysis 1, 2