De-escalation and Transition Planning in Rhabdomyolysis Recovery

1. Introduction

The recovery phase in rhabdomyolysis management shifts focus from aggressive resuscitation to restoring homeostasis and functional independence. Structured de-escalation and transition protocols are crucial to prevent complications such as rebound acute kidney injury (AKI), fluid overload, and Post-ICU Syndrome (PICS).

Key Interdisciplinary Goals:

• Restore renal and muscle function without iatrogenic injury.
• Minimize long-term morbidity, including chronic kidney disease and PICS.

2. Weaning and De-escalation of Intensive Therapies

Tapering intravenous (IV) fluids and renal replacement therapy (RRT) should be guided by objective criteria for renal recovery and meticulous monitoring protocols to avoid rebound injury or fluid imbalance.

Criteria for IV Fluid Tapering:

• Urine output ≥0.5 mL/kg/hr sustained over 6–12 hours.
• Downward-trending or normalized creatine kinase (CK) levels.
• Stable or improving serum creatinine and electrolytes.
• Hemodynamic stability off vasopressors.

Fluid Weaning Protocol

RRT Discontinuation Triggers:

• Native urine output >400 mL/day or consistently >0.5 mL/kg/hr.
• Downward trajectory of serum creatinine and BUN.
• Resolution of refractory hyperkalemia, metabolic acidosis, and significant volume overload.
• Hemodynamic stability without escalating vasopressor requirements.

Loop Diuretics for Fluid Offloading:

Considered for patients who are euvolemic or mildly hypervolemic with evidence of some renal recovery, to facilitate fluid removal.

• Agent: Furosemide is commonly used.
• Mechanism: Inhibits the Na⁺-K⁺-2Cl⁻ cotransporter in the thick ascending limb of the Loop of Henle.
• Dosing: Initial dose of 20–80 mg IV bolus; may be titrated based on urine output response.
• Monitoring: Closely monitor electrolytes (especially K⁺, Mg²⁺, Ca²⁺), volume status (daily weights, fluid balance), and hearing (risk of ototoxicity at high doses or rapid infusion).

Pitfall: If there is no significant diuresis after one to two appropriate bolus doses, discontinue loop diuretics to avoid potential adverse effects like electrolyte disturbances or worsening renal function in non-responsive patients.

3. Conversion from Intravenous to Enteral Medications

An early switch from IV to enteral (oral or via feeding tube) medications supports gut integrity, reduces catheter-associated risks, and can lower healthcare costs. Medication choices must be tailored based on bioavailability, potential interactions with enteral feeds, and patient-specific factors.

Assess GI Tolerance:

• Gastric residual volume <200 mL (if applicable).
• Presence of active bowel sounds, absence of signs of ileus or obstruction.
• Hemodynamic stability with minimal or no vasopressor support.

Select Enteral Access:

• Nasogastric tube (NGT): Suitable for short-term use in patients with low aspiration risk.
• Percutaneous endoscopic gastrostomy (PEG) tube: Preferred for long-term enteral access.
• Post-pyloric tube (e.g., nasojejunal): Considered for patients at high risk of aspiration or with gastroparesis.

Enteral Conversion Considerations

Conversion Steps:

• Hold enteral feeds 1–2 hours before and after administering drugs known for significant feed interactions (e.g., fluoroquinolones, phenytoin).
• Adjust doses for differences in bioavailability and first-pass metabolism where indicated (e.g., beta-blockers, opioids).
• Monitor drug levels (if applicable) or clinical effect within 24–48 hours of conversion to ensure therapeutic efficacy and safety.

4. Mitigation of Post-ICU Syndrome (PICS)

Post-ICU Syndrome (PICS) encompasses new or worsened impairments in physical, cognitive, and/or psychological function that arise after critical illness and persist beyond hospital discharge. Early identification of at-risk patients and proactive interventions are key to preserving long-term function.

High-Risk Features for PICS:

• Age >65 years.
• Duration of mechanical ventilation >7 days or use of deep sedation.
• Presence of severe sepsis, ARDS, or multi-organ failure.
• Pre-existing cognitive or functional impairments.

Early Mobilization:

• Initiate within 24–48 hours of ICU admission or stabilization, as tolerated.
• Daily physical therapy (PT) and occupational therapy (OT) consults: progress from passive range-of-motion exercises to active exercises, sitting at the edge of the bed, transferring to a chair, and ambulation.

Delirium Prevention and Management (ABCDEF Bundle)

Nutritional & Psychosocial Support:

• Dietitian-guided nutritional support, aiming for protein intake of 1.2–2.0 g/kg/day and appropriate caloric targets to prevent muscle wasting.
• Psychological assessment and support; interventions for anxiety, depression, and PTSD.
• Sleep hygiene interventions: promote normal sleep-wake cycles, minimize nighttime disruptions.

5. Medication Reconciliation and Discharge Counseling

Pharmacist-led medication reconciliation and comprehensive patient education are vital components of a safe transition from hospital to home, aiming to reduce medication errors and preventable readmissions.

Structured Medication Reconciliation:

1. Compare Lists: Systematically compare the patient’s pre-admission medication list (home meds), medications administered during hospitalization, and the proposed discharge medication list.
2. Resolve Discrepancies: Identify and resolve any discrepancies, including omissions, duplications, dosing errors, or drug interactions.
3. Review Nephrotoxic Agents: Critically evaluate the need for and discontinue potentially nephrotoxic agents (e.g., NSAIDs, certain antibiotics) unless absolutely essential and no safer alternatives exist, especially in patients recovering from AKI. Statins, if indicated for cardiovascular risk, are generally continued.

Patient/Caregiver Education:

• Clearly explain the indication, dosing schedule, administration instructions, potential side effects, and monitoring requirements for each discharge medication.
• Educate on warning signs of recurrent rhabdomyolysis (e.g., new or worsening muscle pain/weakness, dark tea-colored urine) or AKI (e.g., decreased urine output, swelling).
• Utilize the “teach-back” method to confirm understanding. Provide written materials tailored to the patient’s health literacy level.

Address Social Determinants of Health:

• Verify insurance coverage for prescribed medications and inquire about affordability.
• Confirm access to a local pharmacy for obtaining medications.
• Involve social work or case management to address financial, transportation, or other socioeconomic barriers to care.

Follow-Up Planning:

• Schedule outpatient laboratory tests (e.g., renal function panel, CK, electrolytes) within 7–14 days post-discharge, or sooner if clinically indicated.
• Arrange specialist referrals as needed (e.g., nephrology for ongoing AKI/CKD management, physical therapy for rehabilitation, mental health services for PICS-related psychological issues).
• Consider telehealth or home health visits for high-risk patients to monitor recovery and adherence.