What is included in emergency treatment of lactic acidosis?

Updated: Aug 18, 2020
  • Author: Bret A Nicks, MD, MHA; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Lactic acidosis is most commonly associated with tissue hypoperfusion and states of acute circulatory failure. Treatment of lactic acidosis requires prompt identification of the primary illness, appropriately directed therapy, and serial reassessment. Restoration of tissue oxygen delivery, thereby causing cessation of acid production, remains the primary therapeutic focus when tissue hypoperfusion is the cause of the lactic acidemia. Many aspects of early goal-directed therapy (EGDT) for sepsis are well described and associated with improved outcomes. Appropriate measures include treatment of shock, restoration of circulating fluid volume, improved cardiac function, identification of sepsis source, early antimicrobial intervention, and resection of any potential ischemic regions. [8, 14]  Reassessment of lactate levels for clearance assists ongoing medical management.

When findings of systemic hypoperfusion are not present, consider possible toxin-induced or bowel-associated impairment of cellular metabolism causing a lactic acidosis, such as biguanide therapy (metformin), malignancy (lymphoma, leukemia, solid malignancies), alcoholism, HIV medications (reverse transcriptase inhibitors), or short gut (malabsorptive) syndromes.

A study by Xu et al indicated that in the emergency department, anion gap screening is a poor modality for lactic acidosis detection. The report defined elevated lactate as 2.5 mmol/L or higher or as 4 mmol/L or above and found that, depending on how elevated lactate was defined and what elevated anion gap cutoff was used, anion gap screening missed 40-80% of elevated lactates. The positive predictive value of anion gap screening for an anion gap of 12 mmol/L or above was approximately 40%, while that for an anion gap of 16 mmol/L or over was about 60%. The investigators therefore recommended that lactate analysis be performed with each set of electrolyte and/or blood gas evaluations. [15]

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