From the Guidelines
The treatment for rising lactic acidosis should focus on addressing the underlying cause while supporting the patient's physiological functions, and sodium bicarbonate therapy is not recommended for patients with hypoperfusion-induced lactic acidemia with pH ≥ 7.15, as stated in the Surviving Sepsis Campaign guidelines 1. The primary goal is to identify and treat the primary condition causing lactic acid buildup, such as sepsis, shock, severe hypoxemia, or medication toxicity.
- Ensure adequate tissue oxygenation by maintaining appropriate hemodynamics through fluid resuscitation with crystalloids like normal saline or lactated Ringer's solution.
- Vasopressors such as norepinephrine (starting at 0.05-0.1 mcg/kg/min) may be necessary if fluid resuscitation alone is insufficient.
- Discontinue medications that may contribute to lactic acidosis, particularly metformin in cases of renal dysfunction. While sodium bicarbonate therapy (typically 50-100 mEq IV) remains controversial, it may be considered for severe acidosis (pH < 7.1) to temporarily stabilize hemodynamics, as suggested by some studies 1. In cases of refractory lactic acidosis, renal replacement therapy may be necessary. Continuous monitoring of lactate levels, arterial blood gases, and vital signs is essential to assess treatment response. The fundamental principle of treatment is that correcting the underlying cause will allow the body to clear excess lactate naturally, as the liver metabolizes lactate back to glucose when adequate oxygen and perfusion are restored. It is also important to note that other conditions, such as acute mesenteric ischemia, can cause lactic acidosis, and the treatment should be tailored to the underlying cause, as recommended by the World Society of Emergency Surgery 1.
From the FDA Drug Label
Sodium Bicarbonate Injection, USP is indicated in the treatment of metabolic acidosis which may occur in severe renal disease, uncontrolled diabetes, circulatory insufficiency due to shock or severe dehydration, extracorporeal circulation of blood, cardiac arrest and severe primary lactic acidosis Vigorous bicarbonate therapy is required in any form of metabolic acidosis where a rapid increase in plasma total CO2 content is crucial - e. g., cardiac arrest, circulatory insufficiency due to shock or severe dehydration, and in severe primary lactic acidosis or severe diabetic acidosis.
The treatment for rising lactic acidosis is sodium bicarbonate (IV), specifically vigorous bicarbonate therapy to minimize risks inherent to the acidosis itself. Treatment should be superimposed on measures designed to control the basic cause of the acidosis 2.
- Key points:
- Sodium bicarbonate is indicated for severe primary lactic acidosis
- Vigorous bicarbonate therapy is required for a rapid increase in plasma total CO2 content
- Treatment should address the underlying cause of the acidosis
From the Research
Treatment of Rising Lactic Acidosis
The treatment of lactic acidosis is primarily focused on addressing the underlying cause and ensuring adequate oxygen delivery to tissues. Some studies suggest the following approaches:
- Correcting the underlying cause of lactic acidosis 3, 4, 5
- Optimizing oxygen delivery to tissues 3, 5
- Reducing oxygen demand through sedation and mechanical ventilation 4
- Using sodium bicarbonate to alkalinize the blood, although its effectiveness is controversial 4
- Administering thiamine in cases of suspected thiamine deficiency 6
- Using dichloroacetate as an adjunct in the treatment of lactic acidosis, which has been shown to reduce lactate levels and improve acidemia 7
Specific Therapies
Some specific therapies that have been explored for the treatment of lactic acidosis include:
- Continuous renal replacement therapy (CRRT) and dialysis, although their effectiveness is debated 3
- Bicarbonate therapy, which may not be effective in improving outcomes 4
- Thiamine supplementation, which can be beneficial in cases of thiamine deficiency 6
- Dichloroacetate administration, which has been shown to be safe and effective in reducing lactate levels and improving acidemia 7
Monitoring and Management
Monitoring lactate levels and managing the underlying cause of lactic acidosis are crucial in the treatment of this condition. Some key considerations include: