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Three Part Question

In [patient's with rhabdomyolysis and a CKMB >10,000] does the use of [iv sodium bicarbonate] [decrease morbidity]?

Clinical Scenario

A 36-year-old man presents to the emergency department following ingesting one bottle of OTC diphenhydramine. A friend found the patient down with the empty bottle next to him. The patient was last seen in his normal state of health over 24 hours before his discovery. In the ED, the patient is awake, has a GCS of 14, but is extremely agitated. He also exhibits anti-cholinergic signs and symptoms, such as tachycardia to 118, mydriasis, flushing, absence of perspiration, dry mouth, and decreased bowel sounds The patient was given benzodiazepines for his agitation and started on IV normal saline. The patient had a BMP completed, as well as a CKMB. The patient had a Creatinine of 2.6, elevated from previous data from 0.9 and a CKMB of 38,000. During his treatment, his CKMB continued to elevate to 43, 000 and his renal function continued to decline, reaching a Creatinine of 3.1. An EKG showed tachycardia and NSR. You have heard of sodium bicarbonate use and mannitol use in the treatment of rhabdomyolysis, but you wonder if there is any data supporting their use and if they have been found to decrease morbidity, such as acute renal failure.

Search Strategy

Medline 1950 ‑ Nov week 3 2009 using the Ovid interface.
[(rhabdomyolysis.mp. or exp Rhabdomyolysis) AND (sodium bicarbonate.mp. or exp Sodium Bicarbonate or alkalin$.mp. or diuresis.mp. or exp Diuresis or mannitol.mp. or exp Mannitol)].

Search Outcome

Altogether, 256 papers were found. Three were relevant to the question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Brown et al, 2004. USA	All trauma patients in a surgical ICU over 5 years reviewed, patient’s were divided into groups, CK <5,000, CK>5,000. The CK group >5,000 had 382 people, 154 received bicarbonate and mannitol (BIC/MAN group), 228 received NS (NS group). Group division was determined at the surgeon’s discretion	Retrospective review	Rate of renal failure	22% BIC/MAN vs 18% NS p=0.27	Retrospective review Division of patient’s into the BIC/MAN group v. NS group was not randomized. No strict guidelines for when to initiate and maintain BIC/MAN therapy, all up to surgeon’s discretion BIC/MAN had higher CK’s on average (23,492 +/- 38,336 v. 9,819 +/- 7,586) Small sample size of patient’s with high CK levels, may have contributed to lack of statistical significant improvements in the >30,000 CK BIC/MAN group
			Rate of dialysis	7% BIC/MAN vs 6% NS p=0.57
			Rate of mortality (all in patients with CK >5000)	15% BIC/MAN vs 18% p=0.37
Homsi E et al, 1997, Brazil	24 patients with rhabdomyolysis (CK >500 Ui/L) were treated prophylactically to prevent acute renal failure. There was a treatment group of 9 who got only NS (S), and a group of 15 who got NS, mannitol and bicarbonate (S+M+B).	Retrospective analysis	Fall in serum creatinine	Rate was the same in both groups	Small number Retrospective analysis Patients with renal failure were excluded, as were delayed ITU admissions Maximum CK values were measured earlier in the S+M+B group
			In hospital mortality	4/15 in S+M+B group. 2/9 in NS group
Peltonen et al, 2007, Finland	12 patients with rhabdomyolysis randomised to receive either sodium bicarbonate 1.4% with 1000 ml NS per h, or to receive haemodiafiltration and alkaline diuresis for 4 h. The groups then swapped over	Prospective controlled crossover study	Absolute decrease in plasma myoglobin over time	Greater decrease in plasma myoglobin levels when groups were treated with both alkaline diuresis and haemodiafiltration. Difference not statistically significant	Study underpowered Crossover study Alkaline diuresis was used in this case as the control

Comment(s)

There are minimal data addressing the use of bicarbonate and/or mannitol as a treatment in rhabdomyolysis.

Editor Comment

BIC/MAN, bicarbonate and mannitol; CK, creatine kinase; NS, normal saline; ITU, intensive therapy unit; S+M+B, normal saline, mannitol and bicarbonate.

Clinical Bottom Line

There is no quality published evidence that alkaline diuresis is a superior treatment to normal saline alone.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Brown, Carlos, Rhee, Peter, Chan, Linda, et al. Preventing Renal Failure in Patients with Rhabdomyolysis: Do Bicarbonate and Mannitol Make a Difference? Journal of Trauma 2004; 56(6): 1191-1196.
2. Homsi E, Fernanda M, Barreiro L, et al. Prophylaxis of acute renal failure in patients with rhabdomyolysis Ren Fail 1997; 19:283-288.
3. Peltonen S, Ahlstrom A, Kylavainio V, et al. The effect of combining intermittent hemodiafiltration with forced alkaline diuresis on plasma myoglobin in rhabdomyolysis. Acta Anaesthesiol Scand 2007;51:553–8.