What is the initial treatment for lactic acidosis?

Updated: Aug 18, 2020
  • Author: Bret A Nicks, MD, MHA; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Answer

Answer

In addition to acute resuscitative and general supportive measures, identification and discontinuation of any offending agents and treatment of known pathology should occur promptly. Treatment should include source control (ie, administration of appropriate antibiotics, surgical drainage or debridement, chemotherapy for malignancy, discontinuation of potentially causative medications, dietary modification in inborn errors of metabolism), fluid resuscitation, and further differential diagnosis exploration and reassessment.

Although treatment with buffering agents remains controversial, their use should be considered in certain instances with the assistance of appropriate medical consultation. In addition, there is a growing body of literature showing the benefit of acute medical management, appropriate intervention (including early goal directed therapy) and lactate clearance. [10]

Aside from resuscitation measures, including adequate intravenous access, fluid resuscitation, and airway stabilization in all potentially ill patients, hemoperfusion or hemodialysis may be indicated in association with ethylene glycol, methanol, salicylate, and other related poisonings. Dialysis may also be useful when severe lactic acidosis exists in the setting of renal failure or congestive heart failure and, additionally, with severe metformin intoxication. In a study of patients with metformin-related lactic acidosis and acute kidney failure, Angioi et al found the mortality rate reduced in association with sustained low-efficiency dialysis (SLED), administered until serum lactate, bicarbonate, and potassium had normalized. [11]

A study by Uusalo and Järvisalo indicated that continuous renal replacement therapy (CRRT) with citrate-calcium anticoagulation is especially effective in treating metformin-associated lactic acidosis (MALA) when other comorbidities are not present. In the 23 patients in the study, all of whom were admitted to the intensive care unit (ICU), metformin was the only cause found for lactic acidosis. The 90-day mortality rate was determined to be 4.3%, and the 1-year mortality rate, 13.0%. According to the investigators, the fact that the 90-day mortality rate in this study was lower than the in-hospital mortality rates (17.2%‐51.8%) seen in previous reports on patients with MALA may be attributable to the fact that the authors’ study excluded individuals with sepsis, septic shock, liver failure, cardiac failure, and marked chronic renal disease. [11]


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