Management of Rhabdomyolysis

Immediate Fluid Resuscitation

The American College of Physicians recommends aggressive intravenous fluid resuscitation with isotonic saline, targeting urine output of 300 mL/hour, to facilitate myoglobin clearance and prevent renal tubular obstruction 1, 2
Early and aggressive IV fluid administration is critical, as delayed treatment significantly increases acute kidney injury risk, and the American Heart Association suggests initiating isotonic saline immediately upon diagnosis 1, 2
For severe rhabdomyolysis, the European Society of Intensive Care Medicine recommends administering more than 6L of fluid per day, and for moderate cases, 3-6L per day 1, 2
The National Kidney Foundation suggests monitoring closely for fluid overload, particularly in patients with cardiac or renal compromise 2

The American Association of Clinical Endocrinologists recommends checking electrolyte panels every 6-12 hours in severe cases, and performing repeated bioassessment including plasma myoglobin, CK, and potassium measurements 1, 2
The Endocrine Society suggests correcting significant hyperkalemia immediately, as it can precipitate cardiac arrhythmias and arrest 1, 2
The American College of Physicians recommends monitoring and correcting hypocalcemia and hyperphosphatemia 2
The National Institute of Diabetes and Digestive and Kidney Diseases suggests assessing for metabolic acidosis via arterial blood gas, which commonly occurs in severe cases 1, 2

The American College of Cardiology recommends immediately discontinuing all causative agents, including statins and prescription medications that may contribute to rhabdomyolysis 1
The American Heart Association suggests discontinuing dietary supplements, such as red yeast rice, creatine monohydrate, wormwood oil, licorice, and Hydroxycut 1, 2
The European Society of Cardiology recommends avoiding NSAIDs due to nephrotoxic effects 1
The American Society of Anesthesiologists suggests that in anesthesia settings, succinylcholine and inhaled anesthetics are contraindicated in patients with muscular dystrophy or at-risk populations 1, 3

The Orthopaedic Trauma Association recommends maintaining high suspicion for compartment syndrome, which can both cause and complicate rhabdomyolysis, and performing early fasciotomy when compartment pressure exceeds 30 mmHg or when differential pressure is <30 mmHg 1, 2
The American Academy of Orthopaedic Surgeons suggests monitoring for early signs of compartment syndrome, including pain, tension, paresthesia, and paresis 1
The National Institute of Arthritis and Musculoskeletal and Skin Diseases recommends monitoring for late signs, including pulselessness and pallor, indicating irreversible damage 1

The National Kidney Foundation recommends considering renal replacement therapy for specific complications, such as refractory hyperkalemia, severe metabolic acidosis, or progressive acute kidney injury 2
The American Society of Nephrology suggests initiating RRT if CK remains persistently elevated despite 4 days of adequate hydration, and using RRT for severe cases 2
The European Renal Association recommends considering discontinuation of RRT when urine output recovers adequately (>100 mL/day) 2

The American Pain Society recommends using acetaminophen as first-line analgesic, avoiding nephrotoxic NSAIDs, and reserving opioids for severe muscle pain unresponsive to acetaminophen 1
The American Academy of Pain Medicine suggests using oral morphine for opioid-naive patients with moderate to severe pain, and using fentanyl or buprenorphine as safest opioid choices in patients with acute kidney injury 1

The American College of Emergency Physicians recommends avoiding delay in fluid resuscitation, as it is associated with higher risk of acute kidney injury and worse outcomes 1, 2
The National Institute of Diabetes and Digestive and Kidney Diseases suggests avoiding inadequate fluid volume, which may fail to prevent renal complications 2
The American Heart Association recommends monitoring and correcting hyperkalemia to prevent pulseless electrical activity and cardiac arrest 2
The Orthopaedic Trauma Association suggests avoiding missing compartment syndrome, particularly in traumatic or severe exertional cases, to prevent irreversible muscle and nerve damage 2

Viral infection can lead directly to kidney tubular injury, making aggressive fluid resuscitation even more critical, according to the British Medical Journal 4
The treatment principles for post-viral rhabdomyolysis, including COVID-19-associated cases, are the same as those for other causes of rhabdomyolysis, as stated by the British Medical Journal 4