From the Guidelines
Hyperlactatemia management should focus on identifying and treating the underlying cause, with an initial approach including fluid resuscitation and vasopressors as needed, aiming to normalize lactate levels as a marker of tissue hypoperfusion 1. To manage a patient with hyperlactatemia, particularly with a lactic acid level of 3.8, it's crucial to start by ensuring adequate oxygenation and optimizing hemodynamics.
- Initial fluid resuscitation with at least 30 mL/kg of IV crystalloid fluid within the first 3 hours is recommended, as per the surviving sepsis campaign guidelines 1.
- The use of vasopressors, such as norepinephrine, may be necessary to maintain a mean arterial pressure of 65 mm Hg, especially in cases of septic shock requiring vasopressors 1.
- Serial lactate measurements every 2-4 hours can help monitor the response to therapy, with a goal of normalizing levels or achieving at least a 20% reduction every 2-4 hours.
- Identifying the underlying cause of hyperlactatemia, whether it be sepsis, diabetic ketoacidosis, metformin toxicity, or another condition, is essential for guiding specific treatment strategies.
- For sepsis-induced hyperlactatemia, early administration of broad-spectrum antibiotics within one hour of recognition is critical, alongside the initial resuscitation efforts 1.
- In all cases, normalizing lactate levels as a marker of tissue hypoperfusion should be a guiding principle in management, as suggested by the surviving sepsis campaign guidelines 1.
From the Research
Management of Hyperlactatemia
To manage a patient with hyperlactatemia, such as one with a lactic acid level of 3.8, it is crucial to understand the underlying cause of the elevated lactate levels. The approach to treatment varies based on the etiology.
- Identifying the Cause: The first step is to identify the cause of hyperlactatemia. This could range from tissue hypoperfusion, sepsis, cardiac arrest, trauma, seizures, ischemia, diabetic ketoacidosis, thiamine deficiency, malignancy, liver disease, toxins, overdose, or medication-related causes 2.
- Treatment Approaches:
- Correcting Underlying Cause: The primary treatment involves correcting the underlying cause of hyperlactatemia. For example, if the cause is sepsis, treating the infection with appropriate antibiotics is crucial 3.
- Ensuring Adequate Oxygen Delivery: Ensuring adequate oxygen delivery to tissues is vital. This may involve fluid resuscitation, oxygen therapy, and mechanical ventilation if necessary 4, 3.
- Sodium Bicarbonate: The use of sodium bicarbonate to alkalinize the blood is controversial. Some studies suggest that it may not have significant benefits and could potentially have negative side effects 4, 5.
- Other Therapies: Other therapies such as peritoneal dialysis, hemodialysis, and the administration of specific drugs like dichloroacetate may be considered in certain cases 5.
Considerations in Specific Conditions
- Sepsis: In cases of sepsis, addressing the infection and ensuring adequate tissue perfusion is key. Lactate levels can be used to monitor the effectiveness of resuscitation efforts 3.
- Type B Lactic Acidosis: This condition, which occurs without tissue hypoxia, requires identification and treatment of the underlying cause, such as malignancy or medication effects 6.
Monitoring and Prognosis
- Lactate Levels: Monitoring lactate levels can provide valuable information on the patient's response to treatment and prognosis 2.
- Clinical Implications: Elevated lactate levels are associated with significant morbidity and mortality, especially in critically ill patients. Early recognition and appropriate management are crucial to improve outcomes 3, 2.