Lactic acidosis

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Background

Clinical Features

Differential Diagnosis

Elevated Serum Lactate - New Page.jpeg

Lactic acidosis

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 (decreased clearance)
    • Adrenergic receptor agonism; viz., albuterol, epinephrine, etc
    • Malignancy
    • Carbon Monoxide poisoning
    • Cyanide poisoning
  • Type D
    • episodes of encephalopathy and metabolic acidosis typically following high carbohydrate meals in patients with short bowel syndrome
    • metabolic acidosis and high serum anion gap, normal lactate level, short bowel syn or other forms of malabsorption, and characteristic neurologic findings
      • Type D lactate is not detected with standard lactate levels

Complete List

  • Any shock state
  • Seizure
  • Dead gut
  • Hepatic failure
  • Malignancy
  • Exercise
  • Albuterol and other beta agonists[1]
  • 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)
    • HAART-induced lactic acidosis

Evaluation

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

Lactate False Positives

  • Beta-agonists or beta stimulation
  • Extreme exercise
  • Seizures, immediate ictal period
  • Hepatic failure
    • Lactate ringer's solution unlikely to cause false positive except in hepatic failure

Management

  • Treat underlying cause

Disposition

  • Depends on underlying cause

See Also

External Links

References

  1. Dodda V and Spiro P. Albuterol, an Uncommonly Recognized Culprit in Lactic Acidosis. Chest. 2011;140.