How to manage hyperlactatemia?

Management of Hyperlactatemia with Lactate Level of 8 on ABG

The most effective approach to reduce a lactate level of 8 on ABG is to identify and treat the underlying cause while ensuring adequate tissue perfusion through fluid resuscitation, targeting a mean arterial pressure of at least 65 mmHg, and normalizing lactate as a marker of tissue hypoperfusion. 1

Understanding Hyperlactatemia

Hyperlactatemia (lactate >2 mmol/L) is a critical marker of tissue hypoxia and hypoperfusion, with severe hyperlactatemia (>8 mmol/L) associated with extremely high mortality rates:

• Normal lactate: 0-2 mmol/L
• Moderate elevation: 2-4 mmol/L
• Severe elevation: >4 mmol/L 2
• Lactate >10 mmol/L associated with 78.2% ICU mortality 3

Step-by-Step Management Algorithm

1. Immediate Assessment and Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 1, 2
• Target mean arterial pressure (MAP) ≥65 mmHg 1, 2
• Obtain blood cultures before starting antibiotics 2
• Administer broad-spectrum antibiotics within 1 hour if infection is suspected 2

2. Identify and Treat Underlying Causes

Common causes of hyperlactatemia include:

• Sepsis (most common cause - 34%) 3
• Cardiogenic shock (19.3%) 3
• Post-cardiac arrest (13.8%) 3
• Mesenteric ischemia 2
• Medication-induced (metformin, epinephrine, albuterol) 2, 4
• Liver dysfunction (impaired lactate clearance) 2
• Diabetic ketoacidosis 2

3. Optimize Tissue Perfusion

• Use dynamic over static variables to predict fluid responsiveness 1
• Reassess hemodynamic status frequently after initial fluid resuscitation 1
• Consider vasopressors if hypotension persists despite adequate fluid resuscitation 2
• Norepinephrine is the preferred initial vasopressor 1

4. Monitor Lactate Clearance

• Target lactate clearance of at least 10% within 2-4 hours 2
• Aim for >32.8% lactate clearance within 12 hours (associated with significantly improved survival) 3
• Continue to monitor lactate levels every 2-4 hours until normalization 2

5. Specific Interventions Based on Etiology

For Septic Shock

• Complete the sepsis bundle within 3 hours 1, 2
• Continue fluid resuscitation guided by frequent reassessment 1
• Consider further hemodynamic assessment (cardiac function) if diagnosis unclear 1

For Cardiogenic Shock

• Consider inotropic support 2
• Address underlying cardiac issues (acute coronary syndrome, arrhythmias) 2

For Medication-Induced Hyperlactatemia

• Discontinue contributing medications, especially metformin in patients with renal impairment 2, 4
• Note that epinephrine-induced hyperlactatemia may be due to accelerated aerobic metabolism and may not require specific intervention beyond monitoring 5

For Liver Dysfunction

• Avoid excessive fluid administration in patients with ascites or portal hypertension 2
• Be aware that lactate normalization is significantly impaired in liver disease 2

Cautions and Considerations

• Avoid overly aggressive fluid resuscitation which may increase intra-abdominal pressure and worsen inflammatory response, particularly in abdominal sepsis 2
• Interpret lactate levels with caution when using adrenaline infusions, as they may not accurately reflect tissue perfusion 2
• Consider Type A hyperlactatemia (inadequate oxygen delivery) vs Type B hyperlactatemia (increased glycolysis driven by stress response) 6
• Sodium bicarbonate administration should be used cautiously and is generally reserved for severe acidosis, as it may produce an undesirable rise in plasma sodium concentration 7

Prognostic Implications

Lactate clearance is strongly associated with survival:

• Lactate normalization within 24 hours: 100% survival
• Lactate normalization within 48 hours: 77.8% survival
• Lactate normalization beyond 48 hours: 13.6% survival 2

Patients developing severe hyperlactatemia >24 hours after ICU admission have significantly higher mortality (89.1%) compared to those developing it within the first 24 hours (69.9%) 3