From the Guidelines
Lactate levels in patients receiving adrenaline (epinephrine) infusions should be monitored but not necessarily treated directly, as elevated lactate is an expected physiological response to epinephrine rather than a sign of tissue hypoxia. Regular monitoring of lactate levels every 4-6 hours is recommended during epinephrine infusion, with the understanding that levels may rise to 2-4 mmol/L or higher even with appropriate therapy 1. Clinicians should focus on treating the underlying condition requiring epinephrine rather than the lactate elevation itself. If lactate levels rise dramatically (>5 mmol/L) or continue to increase despite stable hemodynamics, additional causes of hyperlactatemia should be investigated. Epinephrine causes lactate elevation through beta-adrenergic stimulation, which increases glycolysis and inhibits pyruvate entry into the Krebs cycle, resulting in lactate production even in well-oxygenated tissues. This "type B" lactic acidosis differs from hypoxic "type A" lactic acidosis and typically resolves once the epinephrine infusion is reduced or discontinued. Maintaining adequate fluid status and ensuring appropriate epinephrine dosing (typically starting at 0.05-0.1 mcg/kg/min and titrating to effect) can help minimize excessive lactate production while achieving hemodynamic goals. Some studies suggest guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion 1, but the primary focus should remain on the underlying condition. Key considerations include:
- Monitoring lactate levels regularly
- Understanding the physiological response to epinephrine
- Focusing on the underlying condition
- Investigating additional causes of hyperlactatemia if necessary
- Maintaining adequate fluid status and appropriate epinephrine dosing. The most recent and highest quality study 1 supports the approach of monitoring lactate levels without necessarily treating them directly, emphasizing the importance of addressing the underlying condition and maintaining adequate fluid status.
From the Research
Lactate Management in Patients with Adrenaline Infusion
- Lactate levels can increase in patients receiving adrenaline infusions, as seen in studies 2, 3, which may be due to the drug's effects on oxygen delivery and consumption.
- The relationship between adrenaline and lactate is complex, and high lactate levels may not always be detrimental, as suggested by a study 4 which found that a high lactate index was associated with improved survival in septic shock patients.
- Appropriate fluid resuscitation is crucial in managing septic shock patients, and reducing catecholamine doses, including adrenaline, can be achieved through a needs-adapted volume challenge test, as demonstrated in a study 5.
- Lactate measurement can be used to monitor patients, but its prognostic value is limited, and no specific cut-off value can be recommended to predict in-hospital mortality or sequential organ failure, as found in a systematic review 6.
- Monitoring for normalization of serum lactate concentrations during goal-directed therapy in the ICU may be useful, but further studies are needed to confirm this, as suggested by a review 6.
Key Findings
- Adrenaline infusions can increase lactate levels in patients with septic shock 2, 3.
- The lactate index, calculated as the ratio of maximum lactate increase to adrenaline increase, can predict survival in septic shock patients 4.
- A volume challenge test can help reduce catecholamine doses, including adrenaline, in septic shock patients 5.
- Lactate measurement has limited prognostic value in predicting patient outcomes in the ICU 6.