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- We recommend the intravenous administration of an isotonic solution at a high fluid rate (Grade 1B). We suggest starting intravenous fluid replacement prior to extrication of the victim whenever possible (Grade 2B). We suggest giving isotonic saline rather than an isotonic alkaline solution (Grade 2C). Although the exact rate has not been defined by controlled studies, we suggest administering fluid at 1 L/hour initially. Since severe hyperkalemia is relatively common, intravenous solutions containing potassium, such as Ringer's lactate, are contraindicated. (See 'Prior to extrication' above.) After the victim has been removed from the rubble and urine output has been documented, we suggest switching from isotonic saline to an isotonic bicarbonate solution (Grade 2C). The optimal regimen and rate of administration are unknown. Following extrication, we administer the intravenous solution at 500 mL/hour for the first day, if there is no evidence of fluid overload and the patient can be closely monitored. We recommend close monitoring of serum bicarbonate, calcium, potassium, and serum and urine pH. We recommend discontinuing the alkaline solution if symptomatic hypocalcemia develops. (See 'Use of bicarbonate' above.)
- If urinary flow is 20 mL/hour among victims removed from the rubble, we suggest adding mannitol to the intravenous alkaline solution (Grade 2C). We add 50 mL of 20 percent mannitol (1 to 2 g/kg per day [total, 120 g], given at a rate of 5 g/hour). If mannitol is given, the maximum rate of fluid administration is 500 mL/hour. Mannitol is contraindicated in patients with oligoanuria.
We recommend discontinuing mannitol if the desired diuresis cannot be achieved (approximately 200 to 300 mL/hour) (Grade 1B). (See 'Use of mannitol' above.)
- Once the patient can be closely monitored (such as hospital or triage setting), the administration of intravenous fluid should be adjusted to maintain the urinary output at approximately 200 to 300 mL/hour. If the urine output goal is achieved, we suggest continuing fluid therapy until the disappearance of myoglobinuria (either clinically or biochemically). This usually requires several days.
We suggest placement of a central venous pressure (CVP) catheter once the patient is in a hospital setting and closely monitoring input and all losses (urinary volume plus other losses together) of the previous day. In this setting, therapy should be based on CVP measurements, biochemical analysis, close monitoring of fluid intake and output, and body weight. (See 'Urine output goal' above.) We recommend monitoring plasma potassium and calcium several times daily until stabilized. We recommend treating hyperkalemia as discussed elsewhere. (See "Treatment and prevention of hyperkalemia".) Patients with symptomatic hypocalcemia or severe hyperkalemia may require calcium supplementation. In patients with asymptomatic hypocalcemia, we suggest not providing calcium supplementation (Grade 2C). (See "Treatment of hypocalcemia", section on 'Therapeutic approach' and "Treatment and prevention of hyperkalemia".) Dialysis is initiated for the usual indications, including volume overload, hyperkalemia, severe acidemia, and uremia. Among patients with heme pigment-induced AKI due to crush injury, we suggest intermittent hemodialysis rather than other renal replacement modalities (Grade 2C). (See "Renal replacement therapy (dialysis) in acute kidney injury (acute renal failure): Indications, timing, and dialysis dose" and "Acute hemodialysis prescription".)
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