How do you treat hyperlactatemia?

Treatment of Hyperlactatemia

The primary treatment of hyperlactatemia is identifying and aggressively treating the underlying cause—not the lactate number itself—with restoration of tissue perfusion through fluid resuscitation and hemodynamic optimization being the cornerstone of management. 1, 2

Immediate Assessment and Resuscitation

When you encounter elevated lactate, your first priority is determining whether this represents tissue hypoperfusion (Type A) or a metabolic/drug-induced cause (Type B):

Initial Resuscitation Protocol (Sepsis/Shock Context)

• Begin immediate fluid resuscitation with at least 30 mL/kg IV crystalloid within the first 3 hours if sepsis-induced hypoperfusion is suspected 1
• Target a mean arterial pressure ≥65 mmHg as your hemodynamic goal 1
• Aim for urine output ≥0.5 mL/kg/hr as a marker of adequate perfusion 1
• Guide resuscitation to normalize lactate as a marker of tissue hypoperfusion, though this is a weaker recommendation than the other targets 1

Lactate Monitoring Strategy

• Remeasure lactate within 2-6 hours to assess trajectory and response to therapy 2, 3
• Lactate clearance at 12 hours is highly predictive of mortality: a clearance <32.8% is associated with 96.6% ICU mortality 4
• Blood lactate levels >5 mmol/L are abnormal and >10 mmol/L represent severe, life-threatening hyperlactatemia with mortality rates of 65-78% 2, 4, 5

Critical Distinction: Type A vs Type B

Type A (Tissue Hypoxia/Hypoperfusion)

The most common causes requiring urgent intervention:

• Septic shock (34% of severe hyperlactatemia cases): Administer antibiotics within 3 hours, obtain cultures, provide aggressive source control 2, 4
• Cardiogenic shock (19.3% of cases): Consider inotropic support and afterload reduction 4
• Post-cardiac arrest (13.8% of cases): Continue post-resuscitation care protocols 4
• Mesenteric ischemia: If lactate >2 mmol/L with abdominal pain and elevated BUN, obtain immediate CT angiography—diagnostic delay is the dominant mortality factor (30-70% mortality) 2

Type B (Non-Hypoxic Causes)

Immediately discontinue offending medications when identified:

• Metformin: Hemodialysis is definitive treatment for metformin-associated lactic acidosis 2
• Nucleoside reverse transcriptase inhibitors (NRTIs) in HIV patients: Stop stavudine/didanosine immediately—mortality is extremely high without intervention 2, 3
• Aminoglycosides (e.g., neomycin): Discontinue immediately if persistent lactic acidosis despite adequate resuscitation 3

The Bicarbonate Controversy: When NOT to Treat

Do not administer sodium bicarbonate for pH ≥7.15 in hypoperfusion-induced lactic acidemia. 2

The Surviving Sepsis Campaign explicitly recommends against bicarbonate use because:

• It does not improve hemodynamics or reduce vasopressor requirements 2
• It may paradoxically increase lactate production 2
• It causes hypernatremia, volume overload, and CO₂ generation 2
• No study has ever shown survival benefit 2

Special Clinical Scenarios

D-Lactic Acidosis (Short Bowel Syndrome)

• Restrict mono/oligosaccharides, encourage polysaccharides (starch) 1, 2
• Administer thiamine supplements 1, 2
• Give broad-spectrum antibiotics to reduce colonic bacterial overgrowth 1, 2

Pediatric Considerations

• Target ScvO₂ >70% and cardiac index 3.3-6.0 L/min/m² 1
• Ensure hemoglobin ≥10 g/dL for adequate oxygen delivery 1
• Provide D10% containing isotonic IV solution at maintenance rate for glucose delivery, with insulin titration if hyperglycemic (keep glucose 80-150 mg/dL) 1

Common Pitfalls to Avoid

• Never ignore persistent hyperlactatemia even without hypotension—it may indicate occult tissue hypoperfusion or organ dysfunction 2
• Do not continue aggressive fluid resuscitation when Type B lactic acidosis is the cause—you're treating the wrong problem 3
• Patients developing severe hyperlactatemia >24 hours after ICU admission have significantly higher mortality (89.1%) than those with early hyperlactatemia (69.9%), suggesting a different pathophysiology 4
• Renal impairment dramatically increases risk of metformin-associated lactic acidosis—the drug is contraindicated when eGFR <30 mL/min/1.73m² 2

Prognostic Implications

• Severe hyperlactatemia (>10 mmol/L) carries 65-78% ICU mortality 4, 5
• Lactate clearance at 12 hours has an AUC of 0.78-0.91 for predicting mortality—this is one of your most powerful prognostic tools 4, 5
• When 12-hour lactate clearance is inadequate and mortality risk approaches 95%, consider goals of care discussions with patients and families within 72 hours of ICU admission 1