Lactic acidosis

Background

• Most common cause of metabolic acidosis in hospitalized patients

Clinical Presentation

• Anorexia
• Nausea
• Vomiting
• Abdominal pain
• Lethargy
• Hyperventilation
• Hypotension

Differential Diagnosis

By Type

• Type A (tissue hypoperfusion)
  • Hypovolemia
  • Cardiac failure
  • Sepsis
• Type B (decreased utilization)
  • Alcoholism
    • ↓ Lactate utilization secondary to hepatic dysfunction
    • ↓ NAD+/NADH ratio leads to ↑ conversion of pyruvate to lactate
  • Metformin
  • DKA
    • Mainly due to D-lactate production, though hypovolemia contributes
  • Liver disease
  • Malignancy
  • Carbon Monoxide poisoning
  • Cyanide poisoning

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

• Hyperlactatemia = Lactate >2 mEq/L
• Lactic Acidosis = Lactate >4 mEq/L

Management

• Treat underlying cause

See Also

• EBQ:Lactate clearance vs central venous oxygen saturation

Source

• Tintinalli
• EMCrit Podcast Acid-Base