eMedicine Specialties > Pediatrics: General Medicine > Nephrology
Myoglobinuria: Treatment & Medication
Updated: Jul 27, 2009
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Treatment
Medical Care
All patients with suspected myoglobinuria or rhabdomyolysis should be admitted for intravenous (IV) hydration and management of complications. Initial treatment focuses on preventing myoglobin precipitation in the urine by inducing and maintaining a brisk diuresis. Immediately administer saline to patients with suspected myoglobinuria or rhabdomyolysis because early hydration is the key to ameliorate acute renal failure. Achievement of a minimum urine output goal of 2 mL/kg/h is recommended.
Follow-up with mannitol to induce diuresis, supported by adequate IV fluids, has been advocated. Mannitol causes diuresis, which minimizes intratubular myoglobin deposition, acts as a free radical scavenger and reduces tubule cell damage, and may act as a direct renal vasodilator. However, the clinical benefit of this therapy remains unproven. In retrospective studies, volume expansion with saline alone prevented acute renal failure, and mannitol had no additional benefit.7
Raising the pH of the urine to 6.5 or more can be facilitated by adding sodium bicarbonate to the fluids. Alkalinization of the urine has been postulated to minimize the breakdown of myoglobin into its nephrotoxic metabolites and to reduce crystallization of uric acid, thereby decreasing damage to tubule cells. However, this modality of therapy remains somewhat controversial because large volumes of crystalloid alone may be sufficient to alkalinize the urine and because bicarbonate therapy can aggravate the hypocalcemia. No large randomized trials have demonstrated that alkalinization of urine is superior to early aggressive hydration with crystalloid in the management of rhabdomyolysis.
- Hyperkalemia and hypocalcemia may require emergent treatment.
- Patients with crush injuries and trauma require treatment for the soft tissue and bony injuries.
- Patients with compartment compression due to muscle edema may require fasciotomy.
- Creatine kinase (CK) levels generally peak on day 3 and then rapidly decrease by half every 24-48 hours.
Surgical Care
Surgical debridement may be needed if muscle damage or necrosis is extensive. Fasciotomy may be required to manage compartment compression syndrome.
Consultations
Nephrologists may facilitate the safe initiation of diuresis to avoid dialysis. If dialysis is needed, consultation with a nephrologist is necessary.
Activity
Activity is restricted by the extent of muscle damage. Persons who have had exertional myoglobinuria must limit their future activity and maintain adequate hydration.
Medication
In patients with myoglobinuria, administer a sodium chloride solution for volume depletion as 0.9% NaCl solution, lactated Ringers solution, or a solution of 0.45% NaCl and sodium bicarbonate 50 mEq/L. Mannitol may be administered to facilitate osmotic diuresis. Diuretics such as furosemide are less desirable because they may accentuate intravascular volume depletion.
Osmotic diuretics
These agents raise the osmolality of plasma and renal tubular fluid, which creates an osmotic inhibition of water transport in the proximal tubule. This effect subsequently decreases the gradient for passive sodium absorption in the ascending limb of the loop of Henle. The increased urinary flow is achieved by means of nonelectrolyte solute diuresis. Increased glomerular filtration rate may also be observed.
Mannitol (Osmitrol)
Osmotic diuretic. Inhibits tubular reabsorption of electrolytes by increasing osmotic pressure of glomerular filtrate. Increases urinary output.
Adult
0.25-0.5 g/kg/dose IV; limit to bid for no more than 2 d to avoid resistance
Pediatric
Administer as in adults
May decrease serum lithium levels
Documented hypersensitivity; anuria; severe pulmonary congestion; progressive renal damage; severe dehydration; active intracranial bleeding; progressive heart failure
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
Carefully evaluate cardiovascular status before rapid administration because a sudden increase in extracellular fluid may lead to fulminating CHF; avoid pseudoagglutination, when blood is administered simultaneously, add at least 20 mEq NaCl to each liter of mannitol solution; do not administer electrolyte-free mannitol solutions with blood
Alkalinizing agents
Sodium bicarbonate is used as a gastric, systemic, and urinary alkalinizer. Sodium bicarbonate is administered IV to alkalinize the urine in patients with rhabdomyolysis because it may prevent the toxicity that can result from the presence of myoglobin in acidic urine and prevent the crystallization of uric acid.
Sodium bicarbonate
Useful in alkalizing urine to prevent acute myoglobinuric renal failure. Titrate dose to increase pH >7, usually available as 1 mEq/mL. Add to 0.45% NaCl to deliver 1-2 mEq/kg/d.
Adult
1-2 mEq/kg/d IV; adjust dose according to serum and urinary pH
Pediatric
Administer as in adults
Urinary alkalinization induced by increased sodium bicarbonate concentrations may cause decreased levels of lithium, tetracyclines, chlorpropamide, methotrexate, and salicylates; increases levels of amphetamines, pseudoephedrine, flecainide, anorexiants, mecamylamine, ephedrine, quinidine, or quinine
Alkalosis; hypernatremia; hypocalcemia; severe pulmonary edema; unknown abdominal pain
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
May cause alkalosis, decreased plasma potassium, hypocalcemia, or hypernatremia; caution in electrolyte imbalances (eg, CHF, cirrhosis, edema, corticosteroid use, renal failure); use extravasation precautions to avoid tissue necrosis
More on Myoglobinuria |
| Overview: Myoglobinuria |
| Differential Diagnoses & Workup: Myoglobinuria |
 Treatment & Medication: Myoglobinuria |
| Follow-up: Myoglobinuria |
| Multimedia: Myoglobinuria |
| References |
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References
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Further Reading
Keywords
rhabdomyolysis, acute renal failure, ARF, hyperkalemia, hypocalcemia, myoglobinuria, tubular obstruction, acute renal insufficiency, crush injury, muscle necrosis, viral myositis, connective tissue disease, hyperkalemia, hypocalcemia, multiorgan failure, potassium deficiency, sepsis, acute tumor lysis syndrome, autoimmune vesiculitis, dermatomyositis, ischemic pressure necrosis, external myolysis, gas gangrene, tetanus, Legionnaire disease, shigellosis, coxsackie viral infections, diabetic ketoacidosis, myxedema, nonketotic hyperosmolar comas, McArdle syndrome, muscular dystrophy, polymyositis, myophosphorylase, phosphofructokinase, phosphohexoisomerase deficiency, Reye syndrome
