What to do when lactate levels increase again?

From the Guidelines

When lactate levels rise again, it's crucial to quickly identify and address the underlying cause, and guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion is recommended 1.

Key Steps to Address Rising Lactate Levels

• Reassess the patient for signs of tissue hypoperfusion, shock, or sepsis.
• Obtain serial lactate measurements every 2-4 hours to track trends.
• Ensure adequate fluid resuscitation with crystalloids (typically 30 ml/kg of balanced solutions like Lactated Ringer's or normal saline) if hypovolemia is suspected, as recommended by the Surviving Sepsis Campaign guidelines 1.
• If sepsis is the cause, administer broad-spectrum antibiotics immediately after obtaining cultures.
• For persistent hypotension despite fluids, start vasopressors, with norepinephrine as the first-line agent, aiming for an initial target mean arterial pressure of 65 mm Hg in patients with septic shock requiring vasopressors 1.

Additional Considerations

• Optimize oxygen delivery by maintaining adequate hemoglobin levels and ensuring proper ventilation.
• Address any specific causes such as seizures, excessive muscle activity, or medications that can elevate lactate.
• The goal is to normalize lactate levels by restoring adequate tissue perfusion and oxygen delivery, as suggested by the guidelines 1.

Evidence-Based Recommendations

• The Surviving Sepsis Campaign guidelines suggest guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion 1.
• The use of dynamic over static variables to predict fluid responsiveness is also suggested, where available 1.

From the FDA Drug Label

When such an event occurs, discontinue metformin hydrochloride tablets.

The action to take when lactate levels increase again is to discontinue metformin hydrochloride tablets 2.

• This is due to the increased risk of metformin-associated lactic acidosis.
• Discontinuation of the drug is recommended in cases of increased lactate levels, particularly in the setting of acute congestive heart failure, hypoperfusion, hypoxemia, or other conditions associated with hypoxemia.

From the Research

Lactate Level Management

When lactate levels increase again, it is crucial to understand the underlying causes and tailor the therapeutic approach accordingly. The following points highlight the key considerations:

• Lactate levels can be elevated due to various reasons, including tissue hypoperfusion, sepsis, cardiac arrest, trauma, seizure, ischemia, diabetic ketoacidosis, thiamine deficiency, malignancy, liver disease, toxins, overdose, and medication-related causes 3.
• In patients with sepsis, lactate levels are used to assess the severity of the condition and the effectiveness of resuscitation. It is recommended to check lactate levels within six hours of presentation and repeat the test four and eight hours post-diagnosis 4.
• The traditional paradigm that hyperlactatemia reflects tissue hypoxia is overly simplistic and incomplete. Lactate monitoring has gained a prominent role in sepsis definitions, screening protocols, management guidelines, and quality measures, but its use has also generated controversy and concerns 5.
• Elevated serum lactate levels are associated with poor outcomes in patients with septic shock. Early lactate area scores and serial blood lactate levels can be used as prognostic markers for patients with septic shock 6.
• Dynamic changes in lactate levels within the first 24 hours in septic patients can be used as a prognostic indicator. Latent class growth analysis can categorize sepsis patients into different groups based on their dynamic changes in lactate levels, which can help in managing sepsis patients 7.

Key Considerations

When lactate levels increase again, consider the following:

• Identify the underlying cause of lactate level elevation and tailor the therapeutic approach accordingly 3.
• Monitor lactate levels regularly in patients with sepsis to assess the severity of the condition and the effectiveness of resuscitation 4.
• Be aware of the limitations and potential drawbacks of lactate monitoring in sepsis management 5.
• Use early lactate area scores and serial blood lactate levels as prognostic markers for patients with septic shock 6.
• Consider using latent class growth analysis to categorize sepsis patients based on their dynamic changes in lactate levels 7.