How to manage a patient with elevated lactate (lactic acidosis) and alkalosis?

From the Guidelines

Managing a patient with elevated lactate (lactic acidosis) and alkalosis requires immediate attention to the underlying cause, with a focus on fluid resuscitation and addressing both conditions simultaneously. The primary goal is to identify and treat the etiology of lactic acidosis, which may include sepsis, shock, tissue hypoxia, or medication effects, as suggested by the Surviving Sepsis Campaign guidelines 1. Key steps include:

• Administering fluid resuscitation with isotonic crystalloids, typically 30 ml/kg bolus for septic shock, to improve tissue perfusion and oxygen delivery, as recommended by the guidelines 1.
• Maintaining adequate oxygenation and ventilation, targeting normal oxygen saturation levels.
• Initiating broad-spectrum antibiotics within one hour of recognition for sepsis-induced lactic acidosis.
• Starting vasopressors, such as norepinephrine, if hypotension persists despite fluid resuscitation, with an initial target mean arterial pressure of 65 mmHg in patients with septic shock requiring vasopressors 1.
• Simultaneously addressing the alkalosis component by identifying its cause, which may be respiratory or metabolic, and correcting electrolyte abnormalities, particularly potassium and chloride deficiencies.
• Providing chloride-containing fluids for metabolic alkalosis due to volume depletion and avoiding bicarbonate administration unless severe acidosis is present with hemodynamic instability.
• Serial monitoring of arterial blood gases, lactate levels, and vital signs is essential to assess response to treatment, guiding further management based on the patient's clinical status and laboratory results, as emphasized by the guidelines 1 and a systematic review of fluid management recommendations 1.

From the Research

Management of Elevated Lactate and Alkalosis

• The management of a patient with elevated lactate (lactic acidosis) and alkalosis involves addressing the underlying cause of the condition, ensuring adequate oxygen delivery to tissues, and correcting any metabolic imbalances 2, 3.
• Sodium bicarbonate therapy is not recommended for the treatment of lactic acidosis, as it has not been shown to have any salutary effects and may have negative side effects 2, 4.
• Respiratory alkalosis, which can occur in conjunction with lactic acidosis, is often caused by hyperventilation and can be managed by correcting the underlying etiology, such as treating any underlying pulmonary or extrapulmonary disorders 3.
• Continuous renal replacement therapy (CRRT) and dialysis have been advocated as treatments for lactic acidosis, but evidence is lacking, and their effectiveness is unclear 5.
• In patients with lactic acidosis, tissue oxygenation is not improved by sodium bicarbonate administration, and hemodynamic variables are not significantly affected 4.

Key Considerations

• Correction of the underlying cause of lactic acidosis and alkalosis is crucial for effective management 2, 3.
• Awareness of the potential complications of respiratory alkalosis, such as hyperventilation and autocycling of the ventilator, is essential for preventing and detecting hazards 6.
• The use of sodium bicarbonate therapy should be approached with caution, as it may not be effective and may have negative side effects 2, 4.