How to decrease severely elevated lactate levels (lactic acidosis)?

From the Guidelines

To decrease severely increased lactate levels, the primary approach is to identify and treat the underlying cause, which is often tissue hypoxia or poor perfusion, and guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion 1.

Key Steps to Decrease Lactate Levels

• Ensure adequate oxygenation and ventilation
• Restore circulation with fluid resuscitation using crystalloids like normal saline or Ringer's lactate at 20-30 ml/kg, as recommended by the Surviving Sepsis Campaign guidelines 1
• If hypotension persists despite fluid administration, consider vasopressors such as norepinephrine (starting at 0.05-0.1 mcg/kg/min) to maintain a mean arterial pressure of 65 mm Hg, as suggested by current guidelines 1
• Treat any underlying infection with appropriate antibiotics, and consider discontinuing metformin in diabetic patients with lactic acidosis
• In cases of severe acidosis (pH < 7.1), sodium bicarbonate (1-2 mEq/kg IV over 1-2 hours) may be considered, though its use remains controversial 1
• Continuous renal replacement therapy might be needed in cases of renal failure or persistent severe acidosis
• Thiamine supplementation (200-500 mg IV daily for 3-5 days) can help in alcoholic patients or those with suspected thiamine deficiency

Monitoring and Adjustments

• Regular monitoring of lactate levels, arterial blood gases, and hemodynamic parameters is essential to guide therapy 1
• Lactate clearance serves as an important marker of treatment effectiveness, with the goal of normalizing levels within 24-48 hours
• Adjust treatment strategies based on patient response, including adjustments to fluid resuscitation, vasopressor support, and antibiotic therapy, to optimize outcomes and reduce morbidity and mortality.

From the FDA Drug Label

In cardiac arrest, a rapid intravenous dose of one to two 50 mL vials (44.6 to 100 mEq) may be given initially and continued at a rate of 50 mL (44. 6 to 50 mEq) every 5 to 10 minutes if necessary (as indicated by arterial pH and blood gas monitoring) to reverse the acidosis. Sodium bicarbonate is further indicated in the treatment of certain drug intoxications, including ... in severe primary lactic acidosis In metabolic acidosis associated with shock, therapy should be monitored by measuring blood gases, plasma osmolarity, arterial blood lactate, hemodynamics and cardiac rhythm. Bicarbonate therapy should always be planned in a stepwise fashion since the degree of response from a given dose is not precisely predictable Initially an infusion of 2 to 5 mEq/kg body weight over a period of 4 to 8 hours will produce a measurable improvement in the abnormal acid-base status of the blood.

To decrease severely increased lactates, sodium bicarbonate (IV) can be administered. The dosage is as follows:

• In cardiac arrest, a rapid intravenous dose of 44.6 to 100 mEq may be given initially and continued at a rate of 44.6 to 50 mEq every 5 to 10 minutes if necessary.
• In less urgent forms of metabolic acidosis, the amount of bicarbonate to be given to older children and adults over a four-to-eight-hour period is approximately 2 to 5 mEq/kg of body weight. The therapy should be monitored by measuring blood gases, plasma osmolarity, arterial blood lactate, hemodynamics, and cardiac rhythm 2, 2.

From the Research

Decreasing Severely Increased Lactates

To decrease severely increased lactates, it is essential to understand the underlying cause of the elevation. According to 3, lactate levels can be elevated for many reasons, including tissue hypoperfusion, sepsis, cardiac arrest, trauma, seizure, ischemia, diabetic ketoacidosis, thiamine deficiency, malignancy, liver disease, toxins, overdose, and medication.

Treatment Approaches

• Fluid resuscitation is a common approach to decrease lactate levels, especially in patients with shock or hypovolemia. Studies such as 4 and 5 compared the use of colloids and crystalloids in fluid resuscitation, with mixed results.
• The use of colloids, such as hydroxyethyl starch, may be beneficial in certain cases, but it can also increase the risk of acute kidney injury, as reported in 5.
• Crystalloids, on the other hand, may require larger volumes to achieve the same effect, but they are generally considered safer, as noted in 5.

Monitoring and Management

• Close monitoring of lactate levels, as well as other markers of tissue hypoperfusion, is crucial in guiding resuscitation efforts, as emphasized in 6 and 7.
• The interpretation of lactate levels should take into account the clinical context and the presence of other signs of tissue hypoperfusion, such as altered consciousness, mottled skin, oliguria, and elevated lactate levels, as discussed in 3 and 7.

Key Considerations

• The management of patients with elevated lactate levels should be tailored to the underlying cause of the elevation, as recommended in 3.
• A comprehensive approach to resuscitation, including fluid therapy, vasopressor support, and other interventions, may be necessary to decrease lactate levels and improve patient outcomes, as suggested in 6 and 7.