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lactic acidosis

Also see D-lactic acidosis Classification: 1) type A: hypoperfusion, hypoxia 2) type B: perfusion & oxygenation adequate Etiology: 1) cardiopulmonary arrest 2) shock 3) pulmonary edema 4) severe hypoxemia 5) carbon monoxide poisoning 6) vascular insufficiency a) mesenteric ischemia b) ischemia of extremity 7) anemia 8) conditions that cause an increase in metabolic rate a) generalized seizures b) strenous exercise c) severe asthma d) hypothermic shivering 9) toxins/drugs (type B) a) cyanide b) salicylates c) ethylene glycol, propylene glycol d) methanol e) nucleoside reverse transcriptase inhibitors 1] abacavir (Ziagen) 2] didanosine (Videx, ddI) 3] stavudine (Zerit, d4T) 4] zidovudine (Retrovir, AZT) f) metformin (Glucophage) with serum creatinine > 1.5 mg/dL - rare, but 30-50% mortality [2] g) norepinephrine (Levophed) h) propofol (Diprivan) i) linezolid 10) metabolism of nitroprusside 11) other conditions (type B) a) hematologic malignancy - lymphoma b) diabetes mellitus (generally with DKA) c) hypoglycemia d) D-lactate producing bacteria in short bowel syndrome e) G6PD deficiency f) liver failure Pathology: - impaired tissue perfusion & oxygenation - impaired oxidative phosphorylation - impaired elimination of pyruvate via pyruvate carboxylase - patients with liver or renal failure are predisposed to lactic acidosis since these are the major organs involved in catabolism of lactate Laboratory: 1) plasma lactate* > 4 mg/dL (0.44 mmol/L) [2] - GRS11 [6] dismisses a value of 1.2 mmol/L as near normal 2) arterial blood gas: decreased pH 3) electrolytes: increased anion gap 4) hyperphosphatemia, hyperuricemia, hyperkalemia may occur 5) salicylate in serum if respiratory alkalosis with compensatory anion-gap metabolic acidosis (or suspected salicylate tocxicity) [7] * plasma L-lactate (does not measure D-lactate produced by intestinal bacteria) [2] Management: 1) supportive measures - adequate hydration 2) treat underlying condition 3) bicarbonate for persistent severe metabolic acidosis (pH < 7.1) [2] 4) renal dialysis

Related

D-lactic acidosis lactate in serum/plasma

Specific

congenital infantile lactic acidosis

General

metabolic acidosis

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 59
  2. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018.
  3. Rachoin JS, Weisberg LS, McFadden CB. Treatment of lactic acidosis: appropriate confusion.s;irato J Hosp Med. 2010 Apr;5(4):E1-7 PMID: 20394011
  4. Kraut JA, Madias NE. Lactic acidosis. N Engl J Med. 2014 Dec 11;371(24):2309-19. Review. PMID: 25494270 - Kraut JA, Madias NE. Lactic acidosis. N Engl J Med. 2015 Mar 12;372(11):1078-9. PMID: 25760366 Free Article
  5. Seheult J, Fitzpatrick G, Boran G. Lactic acidosis: an update. Clin Chem Lab Med. 2017 Mar 1;55(3):322-333. Review. PMID: 27522622 Free Article
  6. Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  7. NEJM Knowledge+ Endocrinology