What are the implications of hyperlactatemia (elevated lactic acid level)?

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From the Guidelines

High lactic acid levels require immediate medical attention, and treatment should focus on addressing the underlying cause, improving tissue oxygenation, and supporting circulation, with a strong recommendation to target a mean arterial pressure (MAP) of 65 mm Hg in patients with septic shock requiring vasopressors 1.

Key Considerations

  • The management of high lactic acid levels involves guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion, although this is a weak recommendation based on low-quality evidence 1.
  • Lactate-guided resuscitation has been shown to reduce mortality in patients with septic shock, with a significant reduction in mortality seen in lactate-guided resuscitation compared to resuscitation without lactate monitoring 1.
  • The use of lactate levels as a surrogate for tissue perfusion is supported by the fact that increased lactate levels are associated with worse outcomes, regardless of the source 1.

Treatment Approaches

  • For type A lactic acidosis (caused by tissue hypoxia), treatment includes fluid resuscitation with normal saline or lactated Ringer's solution, oxygen supplementation, and treating the underlying cause such as sepsis or shock.
  • For type B lactic acidosis (occurring without hypoxia), management focuses on removing the offending agent or treating conditions like liver disease or diabetes.
  • Sodium bicarbonate may be used cautiously in severe cases, although its use is controversial, and hemodialysis might be necessary in cases of drug-induced lactic acidosis or severe renal impairment.

Important Considerations

  • Lactic acid builds up when oxygen delivery to tissues is insufficient, forcing cells to produce energy anaerobically, or when the liver cannot clear lactate effectively.
  • Common causes of high lactic acid levels include shock, severe infection, heart failure, liver disease, certain medications, and intense exercise.
  • Targeting a MAP of 65 mm Hg is recommended as it has a lower risk of atrial fibrillation, lower doses of vasopressors, and similar mortality compared to higher MAP targets 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

  • High lactic acid level is associated with severe primary lactic acidosis, a condition for which sodium bicarbonate is indicated.
  • The treatment of metabolic acidosis, including severe primary lactic acidosis, with sodium bicarbonate should be accompanied by measures to control the basic cause of the acidosis.
  • Vigorous bicarbonate therapy is required in severe primary lactic acidosis to rapidly increase plasma total CO2 content 2.

From the Research

Causes of High Lactic Acid Levels

  • High lactic acid levels can be caused by various factors, including tissue hypoperfusion, sepsis, cardiac arrest, trauma, seizure, ischemia, diabetic ketoacidosis, thiamine deficiency, malignancy, liver disease, toxins, overdose, and medication 3
  • Type B lactic acidosis should be considered in patients with persistently elevated lactate levels without evidence of inadequate oxygen delivery, as seen in a case of a 12-year-old boy with relapsed and refractory pre-B-cell acute lymphoblastic leukemia 4

Prognostic Factors

  • Initial lactate level, lactate clearance, C-reactive protein, and procalcitonin are associated with hospital mortality in critically ill patients with sepsis 5
  • Lactate clearance at a discrete time point seems to be a more reliable prognostic index than initial lactate value in severe sepsis patients with lactic acidosis who are supplementing with sodium bicarbonate 5
  • Vasopressor use is significantly associated with mortality after adjusting for confounding variables 5

Treatment and Management

  • The choice of resuscitative fluids can impact mortality in emergency department patients with sepsis, with balanced resuscitative fluids associated with decreased incidence of hyperchloremic metabolic acidosis 6
  • A higher proportion of balanced fluids during resuscitation is associated with lower odds of mortality in septic patients 6
  • Large amounts of crystalloids should be given for increased lactate levels (≥ 4 mmol/l) and refractory hypotension, and the administration of fluids can be adjusted according to lactate clearance 7
  • Lactate metabolism is prolonged in patients with liver function impairment, and lactate levels on admission to intensive care are significantly associated with the number of failing organs and mortality in patients with cirrhosis 7

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

7
Research

[Lactic acidosis - update 2018].

Deutsche medizinische Wochenschrift (1946), 2018

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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