Case of the Month #27 - rhabdomyolysis

Published 02/03/2022

Controversies with fluid management

There has been a longstanding interest in urinary alkalization and use of diuretics. Alkalization of urine theoretically reduces Tamm-Horsfall/myoglobin precipitation in DCT of the nephron. Targeting urinary pH >6.5-7 with sodium bicarbonate has been postulated but not been shown to be effective.Its benefit versus crystalloid in preventing acidosis may also be less relevant in the age of balanced crystalloid rather than traditional 0.9% Saline regimes.4 Mannitol has also been used in its role as a diuretic.  It is thought to reduce myoglobin deposition in nephron and is known to be a free radical scavenger. There is however no high quality evidence to support either of these therapies and systemic review of the evidence does not support their superiority vs crystalloid alone.3