From the Guidelines
Elevated lactate levels should be managed by guiding resuscitation to normalize lactate as a marker of tissue hypoperfusion, as suggested by the Surviving Sepsis Campaign guidelines 1.
Key Principles of Management
- The primary approach is to address the source of lactic acidosis, which commonly results from tissue hypoxia or hypoperfusion.
- For type A lactic acidosis (due to tissue hypoperfusion), aggressive fluid resuscitation with crystalloids like normal saline or Ringer's lactate at 30 ml/kg is recommended initially, as stated in the guidelines 1.
- Vasopressors such as norepinephrine (starting at 0.05-0.1 mcg/kg/min) should be added if fluid resuscitation fails to restore adequate blood pressure, with a target mean arterial pressure of 65 mm Hg in patients with septic shock requiring vasopressors 1.
- Ensure adequate oxygenation with supplemental oxygen or mechanical ventilation as needed to maintain oxygen saturation above 94%.
- For type B lactic acidosis (without tissue hypoxia), focus on treating the underlying cause such as medications, liver dysfunction, or metabolic disorders.
Monitoring and Adjustment
- Serial lactate measurements every 2-4 hours help monitor response to treatment, with a goal of normalizing lactate levels or achieving at least a 20% reduction within 2 hours of intervention.
- Lactate clearance serves as an important marker of treatment effectiveness, with improved outcomes associated with reduction in lactate levels within the first 6 hours of treatment, as supported by the evidence 1.
- Sodium bicarbonate therapy (50-100 mEq IV) may be considered for severe acidosis (pH < 7.1) but remains controversial.
Rationale
The physiological basis for this approach is that lactate accumulates when oxygen delivery to tissues is insufficient, causing cells to shift to anaerobic metabolism, or when lactate clearance is impaired by liver dysfunction or other metabolic derangements.
Evidence-Based Recommendations
The Surviving Sepsis Campaign guidelines suggest guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion, with a weak recommendation and low quality of evidence 1. However, the most recent and highest quality study supports the use of lactate-guided resuscitation, with a significant reduction in mortality compared to resuscitation without lactate monitoring 1.
From the Research
Elevated Lactate Management
Elevated lactate levels can be caused by various factors, including tissue hypoperfusion, sepsis, cardiac arrest, trauma, seizure, ischemia, diabetic ketoacidosis, thiamine deficiency, malignancy, liver disease, toxins, overdose, and medication 2.
Causes of Elevated Lactate
- Tissue hypoperfusion is the most common cause of elevated lactate levels, but other etiologies or contributing factors exist 2
- Type B lactic acidosis should be considered in patients with persistently elevated lactate without evidence of inadequate oxygen delivery 3
- Medication-related causes of elevated lactate levels should also be considered 2
Management of Elevated Lactate
- The management of patients with elevated lactate levels should be tailored to the underlying cause of elevation 2
- Norepinephrine dosage may be associated with lactate clearance after resuscitation in patients with septic shock 4
- Thiamine administration may be associated with improved lactate clearance and reduced mortality in patients with septic shock 5, 6
- Supplemental thiamin may improve lactate clearance when administered in the first 24 hours, especially in patients who are deficient in thiamin 6
Treatment Strategies
- Vasopressor therapy, such as norepinephrine, may be used to support blood pressure in patients with septic shock 4
- Thiamine supplementation may be considered in patients with septic shock, especially those who are deficient in thiamin 5, 6
- Further research is needed to determine the optimal treatment strategies for elevated lactate levels in different clinical contexts 2, 6