From the Guidelines
Rhabdomyolysis treatment should primarily focus on aggressive intravenous fluid administration, with the goal of maintaining urine output at 200-300 mL/hour until myoglobin is cleared from the kidneys, as supported by the most recent guidelines 1. The treatment approach involves administering normal saline at rates of 200-400 mL/hour initially to restore fluid volume and flush out muscle breakdown products.
- Key considerations include:
- Correcting electrolyte imbalances, particularly hyperkalemia, which may require calcium gluconate, insulin with glucose, sodium bicarbonate, or potassium binders like sodium polystyrene sulfonate (Kayexalate) in severe cases.
- Administering sodium bicarbonate to alkalinize the urine (target pH >6.5) to prevent myoglobin precipitation in the kidneys, typically given as 1-2 ampules in 1L of IV fluid.
- Identifying and addressing the underlying cause of rhabdomyolysis, whether it's medication-related, trauma, or exertion.
- For severe cases with acute kidney injury, renal replacement therapy (dialysis) may be necessary, as indicated by the guidelines for acute kidney injury management 1.
- Patients should avoid nephrotoxic medications, maintain adequate hydration after discharge, and gradually return to physical activity under medical supervision to prevent recurrence, highlighting the importance of careful management and follow-up in the treatment of rhabdomyolysis.
From the Research
Treatment Overview
The treatment of rhabdomyolysis involves several key components, including:
- Aggressive intravenous fluid resuscitation (IVFR) to improve outcomes of acute renal failure (ARF) and lessen the need for dialysis 2
- Correction and prevention of electrolyte abnormalities
- Management of associated complications such as compartment syndrome, cardiac dysrhythmias, and disseminated intravascular coagulopathy
Aggressive Intravenous Fluid Resuscitation
Aggressive IVFR is conditionally recommended to improve outcomes of ARF and lessen the need for dialysis in patients with rhabdomyolysis 2, 3, 4, 5, 6. The goal of IVFR is to maintain a urine output of at least 300 mL/hour 4.
Use of Bicarbonate and Mannitol
The use of bicarbonate and mannitol in the treatment of rhabdomyolysis is not universally recommended. Some studies suggest that bicarbonate can be used for patients who are acidotic 4, while others found no benefit in using bicarbonate or mannitol in improving outcomes 2, 5.
Management of Complications
Significant electrolyte abnormalities may be present and must be managed to avoid cardiac arrhythmias and arrest 4. Compartment syndrome can develop as an early or late finding and requires decompressive fasciotomy for definitive management 4. Hyperkalemia and compartment syndrome are additional complications of rhabdomyolysis that must be treated effectively 5.
Additional Considerations
Intravenous fluids typically are continued until creatine kinase (CK) levels are lower than 1,000 U/L 4. The overall prognosis for rhabdomyolysis is favourable when treated with early and aggressive IVF resuscitation, and full recovery of renal function is common 3.