How to manage lactic acidosis in starvation ketosis?

From the Guidelines

Managing lactic acidosis in starvation ketosis requires a careful approach to address both the underlying starvation state and the metabolic acidosis, with the primary goal of preventing morbidity, mortality, and improving quality of life. To achieve this, it is essential to initiate nutritional replenishment with a low-carbohydrate approach to avoid worsening acidosis, as recommended by recent guidelines 1.

• Begin with 5-10 kcal/kg/day and gradually increase over several days
• Provide thiamine (100 mg IV daily for 3-5 days) before starting carbohydrates to prevent refeeding syndrome
• Correct fluid and electrolyte imbalances with isotonic fluids like normal saline
• Monitor and replace potassium, phosphate, and magnesium as needed For severe acidosis (pH < 7.1 or bicarbonate < 12 mEq/L), consider sodium bicarbonate administration at 1-2 mEq/kg IV over 1-2 hours, though this should be used cautiously, as suggested by the Surviving Sepsis Campaign guidelines 1.
• Avoid lactated Ringer's solution as it can worsen lactate levels
• Monitor blood glucose closely and treat hypoglycemia with dextrose if needed, following the principles outlined in the evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications 1. The underlying mechanism involves inadequate carbohydrate intake leading to increased fat metabolism, ketone production, and impaired lactate clearance by the liver. This approach addresses both the metabolic derangements and the underlying nutritional deficiency while avoiding complications of refeeding, ultimately prioritizing the reduction of morbidity, mortality, and improvement of quality of life.

From the FDA Drug Label

In metabolic acidosis associated with shock, therapy should be monitored by measuring blood gases, plasma osmolarity, arterial blood lactate, hemodynamics and cardiac rhythm. Bicarbonate therapy should always be planned in a stepwise fashion since the degree of response from a given dose is not precisely predictable Initially an infusion of 2 to 5 mEq/kg body weight over a period of 4 to 8 hours will produce a measurable improvement in the abnormal acid-base status of the blood.

The management of lactic acidosis in starvation ketosis may involve the use of sodium bicarbonate (IV), with the dose depending on the severity of the acidosis.

• The initial dose is approximately 2 to 5 mEq/kg body weight over a period of 4 to 8 hours.
• Bicarbonate therapy should be planned in a stepwise fashion, with monitoring of blood gases, plasma osmolarity, arterial blood lactate, hemodynamics, and cardiac rhythm.
• The goal is to produce a measurable improvement in the abnormal acid-base status of the blood, without attempting full correction of the low total CO2 content during the first 24 hours of therapy 2.

From the Research

Management of Lactic Acidosis in Starvation Ketosis

• The management of lactic acidosis in starvation ketosis involves correcting the underlying cause, ensuring adequate oxygen delivery to tissues, and managing the metabolic acidosis [(3,4,5,6)].
• Treatment with sodium bicarbonate is controversial and has been shown to have negative side effects, such as decreasing vasomotor tone and myocardial contractility, and inducing intracellular acidosis [(3,6)].
• The use of sodium bicarbonate may be considered in severe cases of acidemia (pH < 7.2) with concomitant acute kidney injury, but its benefits are still unclear 6.
• In cases of starvation ketoacidosis, management involves close monitoring of fluid status and electrolytes, and prompt investigation and diagnosis to avoid life-threatening complications [(4,7)].
• Clinicians should be aware of the potential risks associated with a strict ketogenic diet, especially in breast-feeding mothers, and discuss these risks with patients who plan to breast-feed and lose weight following pregnancy 7.

Key Considerations

• Lactic acidosis can be a marker of significant physiologic derangements, but its treatment with sodium bicarbonate is not always necessary 6.
• Acidemia can have deleterious effects on organ systems, but it can also have positive effects, such as increasing localized blood flow and oxygen delivery 6.
• The diagnosis of starvation ketoacidosis can be easily missed, and clinicians should always check ketones in patients with an unexplained metabolic acidosis 7.

Treatment Approaches

• Continuous renal replacement therapy (CRRT) and dialysis have been advocated as treatments for lactic acidosis, but their effectiveness is still unclear 5.
• High-volume hemofiltration may not be effective for severe lactic acidosis, and lactic acidosis alone should not be considered a nonrenal indication for CRRT 5.
• Enteral feeding and rehydration can lead to prompt resolution of metabolic acidosis in cases of starvation ketoacidosis 4.