INDEX

    Rhabdomyolysis – Treatment

    Critical Care / Resuscitation, Environmental Injuries / Exposures, Metabolic / Endocrine, Urological

    Last Updated Dec 05, 2020
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    Context

    • Rhabdomyolysis can result from a variety of traumatic and non-traumatic mechanisms that cause muscle injury and release intracellular muscle constituents into the circulation.
    • Can result in life threatening acute renal failure, electrolyte and metabolic abnormalities, fluid shifts and disseminated intravascular coagulation (DIC).
    • Early recognition and appropriate resuscitation can therefore be lifesaving.
    • Many patients will likely need to be admitted for treatment and monitoring of potential complications. Depending on your setting, much of the initial management may occur in the ED.
    • See the Rhabdomyolysis diagnosis PECS for presentation details.

    Recommended Treatment

    Management Overview

    1. Finding and treating the underlying cause,
    2. Prevention of renal failure, and
    3. The management of life or limb-threatening complications (may require intubation; cardiac arrest from hyperkalemia, hypocalcemia and acidosis).
    4. Essentially if the kidney function is normal and the CK is less than 5K, give a couple of liters NS and forget about it.
    5. If the eGFR is 30 – 60, or CK 5K to 10K recheck after a few litres NS, and values are improving, can discharge home in 6 – 12 hours assuming no other problems.
    6. If the eGFR of CK doesn’t improve after recheck, admit.
    7. If eGFR is less than 30 or CK > 10K, may as well admit since that isn’t going to get better in 12 hours.
    8. Use bicarb for elevated K or acidosis and such patients should be admitted.

    More specifically

    Volume Administration

    • Volume expansion (bordering on hypervolemia) is critical to avoiding myoglobin-induced acute renal failure.
    • Initiate aggressive fluid resuscitation early in treatment:
      • Choice of crystalloid type is controversial.
      • One recommended approach is to start volume repletion with normal saline at an initial rate from 200 to 1500 ml per hour depending on severity of rhabdomyolysis.
      • Target fluid rate to achieve a urine output of approximately 3 ml/kg/hr
      • Regularly check a serum pH to monitor for an iatrogenically induced hyperchloremic metabolic acidosis if using a large volume of normal saline.
      • Consider switching to Ringers Lactate or Plasmalyte after 2-4 litres fon saline.
      • IV fluids should be continued until CK concentration decreases to less than 1000 U/L.

    Alkalization

    • Bicarbonate administration is considered because urine alkalization, in theory, prevents heme-protein precipitation with Tamm-Horsfall proteins. There is no clear clinical evidence however that an alkaline diuresis is more effective than a saline diuresis in preventing AKI.
    • Probably more benefit for hyperkalemia/acidosis.
    • Check urine pH. If less than 6.5, consider urine alkalization with the following:
      • Sodium bicarbonate (150 mL [3 amps] of 8.4 percent sodium bicarbonate mixed with 1 L of 5 percent dextrose) via an intravenous line separate from that used for the isotonic saline infusion. The initial rate of infusion is 200 mL/hour; the rate is adjusted to achieve a urine pH of >6.5.
      • Bicarbonate may be given only if hypocalcemia is not present, arterial pH is less than 7.5 and serum bicarbonate is less than 30 mmol/L.
    • If bicarbonate is given, the arterial pH and serum calcium should be monitored every two hours during the infusion.

    Additional Medications

    • Hyperkalemia: calcium gluconate/chloride, insulin-dextrose, B-2 agonists, NaHCO3.
    • Loop diuretics may be indicated if volume overload is present.
    • Administration of mannitol is not routinely recommended. If given, it should only be administered after volume replacement and avoided in patient with oliguria.
    • May need hemodialysis but plasma exchange has not been shown to be beneficial.

     Complications

    • Regularly monitor electrolytes for potentially life-threatening abnormalities.
    • Monitor for compartment syndrome in affected extremities.
    • Monitor for signs and symptoms of disseminated intravascular coagulation.

    Consider Renal Replacement Therapy

    • As with non-rhabdomyolysis related causes of renal failure, monitor for indications for emergent dialysis including
      • Uncorrectable metabolic acidosis
      • Life-threatening hyperkalemia and other electrolyte disturbances despite medical management
      • Manifestations of uremia, and anuria or oliguria
      • Fluid overload.

    Criteria For Hospital Admission

    Disposition

    • Most patients with rhabdomyolysis will likely require admission for parenteral fluid resuscitation, monitoring for complications as outlined above and treatment of coexisting injuries.

    Prognosis

    • Most patients with rhabdomyolysis will recover sufficient kidney function to be dialysis independent, and many recover to normal or near normal kidney function.
    • The McMahon score for Rhabdomyolysis can be used as a predictive tool for morality and AKI

    Criteria For Safe Discharge Home

    • The kidney function is normal and the CK is less than 5K, give a couple of litres NS and can discharge assuming underlying cause addressed.
    • If the eGFR is 30 – 60, or CK 5,000-10,000:
      • recheck after a few litres NS, and if values are improving, can discharge home in 6 – 12 hours assuming no other problems.

    Quality Of Evidence?

    Justification

    Intravenous fluid resuscitation.

    Moderate

    Choice of crystalloid, adjunct therapeutics (mannitol).

    Low

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