There’s a pendulum in medicine. Some things are over recognized and aggressively treated, some things are under appreciated (like subtle decreases in serum bicarb showing that the patient is becoming more acidotic and no one notices because the patient has obesity hypoventilation syndrome and their baseline bicarb is 34 and now has a bicarb of 22 and they look like poop). In this article I will cover elevated lactic acid levels and the wide differential diagnosis we should consider.
At this time, all the rage is serum lactate and lactic acidosis. Every time someone says those words, with my biochemistry knowledge lagging far behind, everyone thinks “SEPSIS!! 30cc/kg IVF STAT!!!!” If you all knew how much this upsets me whenever I see it, you’d wonder how I’m still alive because I see it all the time. I bet you see it at your shop, too. It’s very common because the pendulum has swung too far.
In order to correct this, I have embarked on discussing this topic ad nauseum in one of my lectures for Hawaii/Portland in 2020. The article in the link below from the New England Journal of Medicine has a table that has been in print in many different forms. I will not break down the pathophysiology of each one of the etiologies. ICU transfer requests in entered for an ICU transfer for MANY of these.
Examples of non-sepsis elevated lactate calls
Here are some examples for calls over the years where patients have received 30cc/kg of saline w/stable vital signs:
1. COPD patient receiving albuterol nebs. Lactic acid elevated because they’re A. huffing and puffing, and B. receiving beta-2 agonists.
2. s/p seizure patients who are post-ictal
3. hypoglycemic diabetics
4. leukemia patients just watching TV
5. cocaine/chest pain patients in the ED
6. cardiogenic shock patients on an epinephrine gtt
7. HIV pt on Stauvidine (I should have written this one up)
I’m obviously not getting into the different subgroups of lactic acidosis at this time. Let’s walk together before we run. Our job is to fix the underlying cause of the lactic acidosis, not dilute the number down with fluids. Hope you enjoyed this look at the differential diagnosis of elevated lactic acid.
-EJ
Citation:
Kraut JA, Madias NE. Lactic acidosis. N Engl J Med. 2014;371(24):2309‐2319. doi:10.1056/NEJMra1309483
Link to Abstract
Link to FULL FREE PDF
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If you want more information and my analysis on many questions lactate, lactic acid, and its metabolism, click here.
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