Lactic acidosis

Background

• Most common cause of metabolic acidosis in hospitalized patients

Differential Diagnosis

By Type

• Type A
  • Impaired tissue oxygenation
    • Hypovolemia
    • Cardiac failure
    • Sepsis
    • Carbon Monoxide poisoning
    • Cyanide poisoning
• Type B
  • No impaired tissue oxygenation
    • Alcoholism
      • Lactate utilization is impaired 2/2:
        • Impaired hepatic gluconeogenesis
        • No NAD+ to convert lactate to pyruvate
    • Sepsis
    • Liver disease
    • Metformin

Complete

• Any shock state
• Seizure
• Dead gut
• Hepatic failure
• Malignancy
• Exercise
• Use of b‐agonists
• Toxicologic Causes:
  • Cyanide
  • Carbon Monoxide
  • Metformin
  • Didanosine
  • Stavudine
  • Zidovudine
  • Linezolid
  • Strychnine
  • Emtriva
  • Rotenone (Fish Poison
  • NaAzide (Lab Workers)
  • Apap (if Liver Fx)
  • Phospine (rodenticide)
  • NaMonofluoroacetate (Coyote Poison‐ give Etoh as antidote)
  • Inh (if patient seizes)
  • Hemlock
  • Depakote
  • Hydrogen Sulfide
  • Nitroprusside (if cyanide toxic)
  • Ricin & Castor Beans
  • Propofol
  • Sympathomimetics (cocaine, methamphetamine)
  • Jequirty peas (Abrus precatorius)
  • Prunus Amygdalus plants
  • Crab tree apple seeds & cassava (yucca)

Diagnosis

• Elevated lactate

Management

• Treat underlying cause

Source

• Tintinalli
• EMCrit Podcast Acid-Base