From the Guidelines
Managing rising lactate levels in a malaria patient with MODS on epinephrine requires immediate attention to reduce morbidity and mortality, and the first step is to consider reducing or discontinuing epinephrine if hemodynamically feasible, as it contributes significantly to lactate production, as suggested by the principles outlined in 1 and 1. The patient's lactate levels are rising (3.6,4.8, and 5.6) while on epinephrine at 0.3 micrograms per kg per minute, indicating potential tissue hypoperfusion. Key considerations include:
- Reducing or discontinuing epinephrine if possible, to minimize its contribution to lactate production, and replacing it with alternative vasopressors like norepinephrine or vasopressin, which have less impact on lactate metabolism, as implied by the discussion on vasoactive agents in 1.
- Ensuring adequate fluid resuscitation with crystalloids, as recommended in 1, to support blood pressure and organ perfusion, while monitoring for signs of fluid overload.
- Optimizing antimalarial therapy to rapidly reduce parasite load, which is crucial in managing the underlying cause of MODS in malaria patients.
- Correcting metabolic abnormalities, such as hypoglycemia, and considering bicarbonate therapy for severe acidosis, as part of a comprehensive approach to support organ function and reduce lactate levels.
- Providing adequate oxygen support to improve tissue perfusion and reduce anaerobic metabolism, which contributes to lactate production. The goal is to guide resuscitation to normalize lactate levels, as suggested in 1 and 1, recognizing that elevated lactate is associated with increased mortality in shock states, and that lactate-guided resuscitation can be effective in improving outcomes.
From the Research
Management of Rising Lactate Levels
- In a malaria patient with MODS on epinephrine, managing rising lactate levels is crucial for improving outcomes.
- According to 2, lactate levels can be a reliable marker of sepsis severity and a marker of resuscitation, but it is an unreliable marker of tissue hypoxia/hypoperfusion.
- The study 3 compared the effects of norepinephrine and dobutamine to epinephrine on hemodynamics, lactate metabolism, and gastric tonometric variables in septic shock, and found that epinephrine infusion was associated with an increase in lactate levels.
Epinephrine and Lactate Levels
- The study 4 found that epinephrine doses above a threshold near 10 mcg/kg increased lactate, worsened acidosis, and resulted in poor recovery.
- Another study 5 found that patients with sepsis without shock and increased epinephrine levels or an increased muscle-to-serum lactate gradient are likely to evolve towards septic shock.
- The study 3 also found that the lactate/pyruvate ratio increased in the epinephrine group, indicating a markedly inadequate splanchnic oxygen utilization.
Treatment Considerations
- Based on the study 6, loading doses of 75 microg/kg milrinone lactate and starting infusion rates of 0.75 to 1.0 microg/kg/min for patients with normal renal function may be considered.
- However, the study 3 suggests that norepinephrine and dobutamine may be more appropriate than epinephrine alone in hyperdynamic dopamine-resistant septic shock.
- The study 2 emphasizes the importance of early aggressive hemodynamic resuscitation using elevated plasma lactate as a marker to manage critically ill patients.