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BET 1

https://doi.org/10.1136/emj.2009.090530a

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    Rhabdomyolysis and the use of sodium bicarbonate and/or mannitol

    Report by: Rachel Thomas, Medical Student

    Search checked by: Jessi Cox, Medical Student

    Institution: Oregon Health and Science University, Oregon, USA

    Three-part question

    In [patients with rhabdomyolysis and a CKMB >10 000] does the use of [intravenous sodium bicarbonate and/or mannitol] [decrease morbidity]?

    Clinical scenario

    A 36-year-old man presents to the Emergency Department (ED) following ingestion of one bottle of over-the-counter diphenhydramine. A friend found the patient lying down with the empty bottle next to him. The patient was last seen in his normal state of health over 24 h before. In the ED, the patient is awake, has a Glasgow Coma Scale of 14, but is extremely agitated. He also exhibits anticholinergic signs and symptoms, such as tachycardia to 118, mydriasis, flushing, absence of perspiration, dry mouth and decreased bowel sounds. The patient had a creatinine of 260, elevated from previous data from 90 and a CKMB of 38 000. You have heard of sodium bicarbonate use and mannitol use in the treatment of rhabdomyolysis, but you wonder if there are 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.

    Comment

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

    Clinical bottom line

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

    View this table:
    Table 1

    Rhabdomyolysis and the use of sodium bicarbonate and/or mannitol

    ▶ Homsi E, Fernanda M, Barreiro L, et al. Prophylaxis of acute renal failure in patients with rhabdomyolysis. Ren Fail 1997;19:283–8.

    ▶ Brown CV, Rhee P, Chan L, et al. Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a difference? J Trauma 2004;56:1191–6.

    ▶ 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.

    Footnotes

    • Provenance and peer review Not commissioned; not externally peer reviewed.