From the Guidelines
Elevated lactate levels of 87 mg/dL require immediate medical attention and aggressive fluid resuscitation with at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, as recommended by the Surviving Sepsis Campaign guidelines 1. The patient should be promptly evaluated in an emergency setting for potential causes such as sepsis, shock, cardiac failure, severe dehydration, or tissue ischemia. Initial management includes:
- Securing intravenous access for fluid resuscitation with crystalloids like normal saline
- Supplemental oxygen therapy
- Continuous cardiac monitoring
- Blood cultures, complete blood count, comprehensive metabolic panel, and arterial blood gases should be obtained Treatment must address the underlying cause, such as:
- Antibiotics for suspected infection
- Vasopressors like norepinephrine for persistent hypotension
- Surgical intervention for ischemic conditions Serial lactate measurements should be performed every 2-4 hours to monitor response to treatment, with the goal of normalizing levels, as suggested by the guidelines 1. Elevated lactate is concerning because it reflects anaerobic metabolism occurring when tissues don't receive adequate oxygen, leading to increased mortality risk if not promptly addressed. Key aspects of management include:
- Frequent reassessment of hemodynamic status to guide additional fluid administration 1
- Use of dynamic over static variables to predict fluid responsiveness, where available 1
- Targeting a mean arterial pressure of 65 mm Hg in patients with septic shock requiring vasopressors 1
From the Research
Elevated Lactate Levels
Elevated lactate levels, such as 87mg/dl, can be caused by various factors, including:
- Tissue hypoperfusion, which is the most common cause of elevation 2
- Metabolic disturbances, such as tissue hypoxia, anaerobic metabolism, or impaired lactate clearance, prevalent in conditions like sepsis, shock, and trauma 3
- Medication-related causes, as discussed in the review of lactate level elevation 2
- Underlying metabolic disturbances, such as increased production or decreased removal of L-lactic acid 4
Clinical Significance
The presence of elevated lactate levels in critically ill patients has important implications for morbidity and mortality 5. Lactate monitoring is critical in managing critically ill patients in intensive care settings, as it can signify underlying metabolic disturbances 3. The clinical and prognostic importance of an elevated lactate level varies widely by disease state 2.
Diagnostic and Prognostic Value
Lactate levels can be used as a diagnostic and prognostic tool, but its utility and interpretation depend on the clinical context 3. Understanding the physiological basis of lactate production and its significance in clinical practice is essential for interpreting its diagnostic and prognostic value 3. The review of lactate monitoring in intensive care discusses the utility of lactate monitoring across various critical care scenarios and provides an overview of lactate's metabolic pathways, methods of measurement, and the clinical implications of interpreting lactate levels in different contexts 3.
Management and Treatment
Eliminating the triggering conditions remains the most effective therapy for lactic acidosis 6. Although sodium bicarbonate administration is recommended by some, it does not improve cardiovascular function or reduce mortality 6. Other buffers, such as THAM or Carbicarb, or dialysis might also provide base with fewer untoward effects 6. Targeting the mechanisms that contribute to lactic acid accumulation, such as tissue hypoxia and epinephrine-induced stimulation of aerobic glycolysis, could allow for more specific therapy 6.