Lactic acidosis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Saud Khan M.D.
Overview
The main treatment for lactic acidosis is to correct the medical problem that causes the condition. Treatment depends on the underlying mechanism of excess lactate, however it mostly involves optimizing oxygenation in tissues by providing fluids, packed red blood cells, vasopressors or inotropic agents, or both.[1]
Medical Therapy
Fluids should be given until the patient is no longer preload-dependent, however, the ability to respond to fluid and when to hold them is a controversial topic[2]. In many cases, fluid resuscitation by itself may be enough to restore hemodynamic stability, improve tissue perfusion, and reduce elevated lactate concentrations[3][4].
A more positive fluid balance early in the course of septic shock, and over 4 days has been associated with a higher mortality. Furthermore, giving fluids to patients with shock due to impaired left ventricular function (cardiogenic shock) may cause or worsen existing pulmonary edema.
There has been no significant difference found between crystalloids and colloids in fluid resuscitation in terms of lactate clearance.
Type B lactic acidosis is mainly treated by therapy aimed at the underlying condition.[1]
Emergency management
- Check airway, breathing and circulation. Immediate resuscitation as indicated.
- Put the patient on an SaO2 monitor.
- Give 100% oxygen.
- Consider intubation and ventilatory support for patients with deteriorating SaO2.
- Obtain intravenous access and give a fluid bolus of crystalloid or colloid if tachycardia, hypotension or signs of hypoperfusion such as poor capillary refill exist.
- If cardiac failure is the suspected etiology, fluid infusion needs to be controlled.
- Attach a cardiac monitor as there is a predisposition to arrhythmia.
- Refer urgently to the acute medical team.
- Arrange transfer to a high-dependency area as soon as feasible.
- Begin empirical therapy for any obvious underlying causes such as intravenous antibiotics for infection, intravenous thiamine if there is suspected deficiency (alcohol abuse). [5]
Further management.
Sodium bicarbonate may be used but remains controversial as it generates CO2 that may worsen acidosis if there is insufficient respiratory balance.
Dichloroacetate may be used to stimulate pyruvate dehydrogenase, the alternative aerobic respiratory pathway. It also has positive inotropic effects. It has been shown to improve acid-base status but this did not translate into improved outcome or survival.[6]
Carbicarb (sodium bicarbonate and sodium carbonate) is a buffering agent that appears to reduce lactate levels without CO2 generation, however, trials using this have not been reported.[6]
Haemodialysis may be indicated in association with ethylene glycol and methanol poisoning. It may also be useful when severe lactic acidosis exists with chronic kidney disease or congestive heart failure, or with metformin intoxication.
References
- ↑ 1.0 1.1 Reddy AJ, Lam SW, Bauer SR, Guzman JA (2015). "Lactic acidosis: Clinical implications and management strategies". Cleve Clin J Med. 82 (9): 615–24. doi:10.3949/ccjm.82a.14098. PMID 26366959.
- ↑ Durairaj L, Schmidt GA (2008). "Fluid therapy in resuscitated sepsis: less is more". Chest. 133 (1): 252–63. doi:10.1378/chest.07-1496. PMID 18187750.
- ↑ Vincent JL, Dufaye P, Berré J, Leeman M, Degaute JP, Kahn RJ (1983). "Serial lactate determinations during circulatory shock". Crit Care Med. 11 (6): 449–51. doi:10.1097/00003246-198306000-00012. PMID 6406145.
- ↑ Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA (2011). "Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality". Crit Care Med. 39 (2): 259–65. doi:10.1097/CCM.0b013e3181feeb15. PMID 20975548.
- ↑ Nyirenda MJ, Sandeep T, Grant I, Price G, McKnight JA (2006). "Severe acidosis in patients taking metformin--rapid reversal and survival despite high APACHE score". Diabet Med. 23 (4): 432–5. doi:10.1111/j.1464-5491.2006.01813.x. PMID 16620273.
- ↑ 6.0 6.1 Luft FC (2001). "Lactic acidosis update for critical care clinicians". J Am Soc Nephrol. 12 Suppl 17: S15–9. PMID 11251027.