eMedicine Specialties > Pediatrics: General Medicine > Rheumatology
Rhabdomyolysis: Treatment & Medication
Updated: Nov 16, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- The inciting cause of rhabdomyolysis must be identified and corrected.33 Expansion of extracellular volume is the cornerstone of treatment. Other supportive measures include correction of electrolyte imbalances.5,34 No randomized trials of fluid repletion regimens in any age-group have been done.6 Few studies on these treatments in children are available.7
- Aggressive and early hydration with isotonic sodium chloride solution is important for the prevention of pigment-associated renal failure. The composition of repletion fluid is controversial and may also include sodium bicarbonate. Initial fluid use in young children has been recommended at 20 mL/kg and 1-2 L/h in adolescents. Subsequent hydration 2-3 times maintenance may be sufficient.7,35
- Insert a Foley catheter for careful monitoring of urine output.
- Obtain an ECG to monitor effects of hyperkalemia and other electrolyte disturbances.
- Alkalinization of urine is believed to be helpful and is based on the observation that acidic urine is necessary to cause acute tubular necrosis (ATN). Some authorities believe that aggressive hydration sufficiently causes a solute diuresis that alkalinizes the urine. Mannitol is often used to induce diuresis in adult patients. Its efficacy has not been adequately compared with that of aggressive hydration regimens.10,36,6
- Sodium bicarbonate is used with care to prevent metabolic acidosis because it may potentiate hypocalcemia. Intravenous bicarbonate concentration is often adjusted to achieve a urine pH level of more than 6.5. This level of alkalinization inhibits precipitation of myoglobin and hemoglobin in the tubules.
- Ferrihemate and globin are the breakdown products of myoglobin when pH levels fall to less than 5.6. Ferrihemate is one of the agents responsible for ATN. It contains iron, a transition element, which is free to accept and donate electrons. This results in the generation of free radicals, which cause direct renal cell injury. Heme-proteins may also affect nitrous oxide (NO), endothelin receptors, and cytokines.10
- Frequently monitor serum electrolyte levels, urine pH levels, and acid-base status. Metabolic abnormalities should also be addressed.
- Treat hyperkalemia by administering insulin and glucose, a nebulized beta agonist, and a potassium exchange resin. These measures transiently shift potassium from extracellular to intracellular compartments.7,32
- Correct hypocalcemia only if the patient has cardiac dysrhythmias or seizures. Calcium may combine with phosphate, forming a metastatic calcification, often intramuscularly. Control hyperphosphatemia using alkaline diuresis. Hypercalcemia may develop during the recovery phase.
- If urine output is adequate, consider the use of diuretics such as mannitol (in adults) and furosemide. Mannitol, acting as an osmotic diuretic, is thought to increase urinary flow and reduce myoglobin cast obstruction in renal tubules.5
- Dialysis may be required in patients with oliguric renal failure, persistent hyperkalemia, other electrolyte abnormalities, pulmonary edema, congestive heart failure, and persistent metabolic acidosis.
- The role of free-radical scavengers and antioxidants in rhabdomyolysis (eg, pentoxifylline, vitamin E and vitamin C) has been studied in animal models of ischemia-reperfusion injuries. Controlled studies evaluating the efficacy of these agents have not been performed, and their clinical use remains unclear.10,6
Surgical Care
- Surgical care may be necessary, depending on the cause of rhabdomyolysis.5
- Measure compartment pressures and perform a fasciotomy if pressures are high (>30 mm Hg).
- Limb fractures may require surgical and orthopedic treatment.37
Consultations
- Consult a nephrologist for patients who have significant rhabdomyolysis, show evidence of renal failure, or require dialysis.
- Consult a neurologist for patients with status epilepticus or newly onset seizures.
- Consult an orthopedic surgeon for patients with a limb fracture or compartment syndrome.
- Notify the poison control center in cases of overdose or snake/insect envenomation.
- Consult a rheumatologist for patients with suspected inflammatory myopathies, systemic lupus erythematosus, or sarcoidosis.
- Consult a geneticist and metabolism specialist for patients with genetic or metabolic abnormalities. Diagnosis of inborn errors of metabolism and prompt metabolic interventions may be life saving.
Diet
- Dietary modification may help to reduce the symptoms associated with some of the metabolic disorders and inborn errors of metabolism.8
- Dietary supplementation with glucose or fructose may decrease the pain and fatigue associated with phosphorylase deficiency.
- The muscle pain and myoglobinuria due to carnitine palmityl transferase deficiency may be reduced with frequent meals and a low-fat, high-carbohydrate diet. Substitution of medium-chained triglycerides may also be helpful.
- Dietary modification does not seem to change the muscle symptoms of phosphofructokinase deficiency or phosphoglycerate mutase deficiency.
Activity
- Strenuous activities (eg, competitive sports) should be avoided if they cause recurrent myalgias, myopathy, or rhabdomyolysis.8 Children and adolescents with recurrent rhabdomyolysis related to exertion require further medical evaluation.
- High-school coaches and trainers must ensure proper hydration and maintain fluid balance during practice sessions and games. Signs and symptoms of heat exhaustion must be evaluated in a timely fashion during hot and humid conditions.14
- Alcohol abuse should be stopped.
- Use of narcotics and sedative hypnotics should be avoided, and inciting prescribed medications must be stopped.
Medication
Hydration with isotonic sodium chloride solution (0.9% NaCl) is the cornerstone of rhabdomyolysis therapy. Many clinicians recommend the use of sodium bicarbonate. Use furosemide or other diuretics (such as mannitol in adults) with sufficient hydration if urine output is inadequate. Hyperkalemia should also be addressed.
Diuretic agents
Diuretics promote the excretion of water and electrolytes by the kidneys.
Furosemide (Lasix)
Increases water excretion by interfering with chloride-binding cotransport system, which, in turn, inhibits sodium and chloride reabsorption in ascending loop of Henle and distal renal tubule.
Adult
20-80 mg/d PO in divided doses q6-12h
Pediatric
1-2 mg/kg/d PO in divided doses q6-12h; not to exceed 10 mg/kg/d
Metformin decreases concentrations; furosemide interferes with hypoglycemic effect of antidiabetic agents and antagonizes muscle-relaxing effect of tubocurarine; coadministration with aminoglycosides may increase auditory toxicity; varying degrees of hearing loss may occur; may enhance anticoagulant activity of warfarin; may increase plasma lithium levels and toxicity
Documented hypersensitivity; hepatic coma; anuria; severe electrolyte depletion
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Excessive diuresis may cause dehydration and blood volume reduction with circulatory collapse; increased blood glucose levels may be observed, and precipitation of diabetes mellitus has been reported (rarely); asymptomatic hyperuricemia can occur, and gout may be precipitated (rarely); patients with sulfonamide allergy may exhibit cross-allergenicity; exacerbation of systemic lupus erythematosus is possible
Intracellular potassium transporters
These are used to decrease serum potassium levels. Insulin and glucose cause a transcellular shift of potassium into muscle cells, thereby temporarily lowering serum levels of potassium.
Insulin (Humulin) and dextrose, intravenous
Stimulates cellular potassium uptake within 20-30 min. Administer with dextrose to prevent hypoglycemia. Monitor blood sugar levels frequently.
Adult
10 U IV with 50 mL dextrose 50% IV bolus or 500 mL dextrose 10% infused IV over 1 h
Pediatric
0.1 U/kg IV with 0.5 g/kg (2 mL/kg) dextrose 25% IV infused over 30 min
Medications that may decrease hypoglycemic effects include acetazolamide, AIDS antivirals, asparaginase, phenytoin, nicotine isoniazid, diltiazem, diuretics, corticosteroids, thiazide diuretics, thyroid estrogens, ethacrynic acid, calcitonin, oral contraceptives, diazoxide, dobutamine, phenothiazines, cyclophosphamide, dextrothyroxine, lithium carbonate, epinephrine, morphine sulfate, and niacin
Medications that may increase hypoglycemic effects include calcium, ACE inhibitors, alcohol, tetracyclines, beta blockers, lithium carbonate, anabolic steroids, pyridoxine, salicylates, MAOIs, mebendazole, sulfonamides, phenylbutazone, chloroquine, clofibrate, fenfluramine, guanethidine, octreotide, pentamidine, and sulfinpyrazone
Documented hypersensitivity; hypoglycemia
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hyperthyroidism may increase renal clearance of insulin and may require increased dose to treat hyperkalemia; hypothyroidism may delay turnover and may require decreased dose to treat hyperkalemia; monitor glucose carefully; dose adjustments of insulin may be necessary in renal and hepatic dysfunction
Beta2- adrenergic agonists
These agents are used adjunctively to temporarily decrease serum potassium levels. Albuterol and other beta-adrenergic agents induce the intracellular movement of potassium via stimulation of the Na/K-ATPase pump. Some studies in adults and children using nebulized albuterol indicate that this method of therapy is effective in lowering serum potassium levels, but peak response is unclear. Therefore, nebulized albuterol has not been established as a first-line therapy in severe hyperkalemia.
Albuterol nebulized (Proventil, Ventolin)
Adrenergic agonist that increases plasma insulin concentrations. Increase in insulin may shift potassium into intracellular space. Onset of decreased potassium is 30 min. Duration is dose dependent and typically lasts 2-5 h.
Adult
2.5 mg in 3 mL 0.9% NaCl inhaled via nebulizer; higher adult doses have also been used (ie, 10-20 mg) in various clinical trials
Pediatric
Note: Albuterol for nebulization is diluted in 0.9% NaCl before inhalation
Infants: 0.05-0.15 mg/kg/d
1-5 years: 1.25-2.5 mg/d
5-12 years: 2.5 mg/d
>12 years: 2.5-5 mg/d
Beta-adrenergic blockers antagonize effects; inhaled ipratropium may increase duration of bronchodilatation; cardiovascular effects may increase with MAOIs, inhaled anesthetics, tricyclic antidepressants, and sympathomimetic agents
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiovascular disease, convulsive disorders, and unusual unresponsiveness to sympathomimetic amine
High doses may inhibit uterine contraction (unlikely with the nebulized dosage); resistance to lower potassium in ESRD is common
Potassium exchange resin
Potassium exchange resins decrease serum potassium levels. Sodium polystyrene sulfonate is an exchange resin that can be used to treat mild-to-moderate hyperkalemia. Each mEq of potassium is exchanged for 1 mEq of sodium.
Sodium polystyrene sulfonate (Kayexalate)
Exchanges sodium for potassium and binds it in the gut, primarily large intestine. Decreases total-body potassium levels. Onset of action after PO administration ranges from 2-12 h and is longer when administered rectally.
Do not use as first-line therapy for severe life-threatening hyperkalemia. May use in the second stage of therapy to reduce total-body potassium levels. Resin typically mixed in 25% sorbitol before administration.
Adult
1 g/kg/dose, up to 15 g PO or 30-50 g as a retention enema
Pediatric
Exchange ratio is 1 mEq K per 1 g resin
Calculate dosage according to desired exchange
Usual dose: 1 g/kg/dose PO/PR
Coadministration with nonabsorbable cation-donating antacids and laxatives may reduce resin potassium exchange capability and increases serum carbon dioxide levels, leading to metabolic alkalosis; intestinal obstruction reported when coadministered with aluminium hydroxide; toxic effects of digitalis exaggerated with hypokalemia
Documented hypersensitivity; hyperkalemia and hypernatremia; PO administration in bowel obstruction; rectal manipulation in patients with bleeding tendency (eg, neutropenia, thrombocytopenia)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients who cannot tolerate even a small increase in sodium load; administer with sorbitol to prevent constipation
More on Rhabdomyolysis |
| Overview: Rhabdomyolysis |
| Differential Diagnoses & Workup: Rhabdomyolysis |
 Treatment & Medication: Rhabdomyolysis |
| Follow-up: Rhabdomyolysis |
| Multimedia: Rhabdomyolysis |
| References |
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Further Reading
Keywords
rhabdomyolysis, muscle weakness, myalgia, dark urine, myoglobinuria, sarcolemma, acute renal failure, myoglobin-induced acute renal failure, nephrotoxicity, malignant hyperthermia, crush injury, disseminated intravascular coagulation, treatment, diagnosis
