From the Guidelines
I strongly recommend ordering lactic acid over Procal in the management of septic shock, as it serves as a more objective surrogate for tissue perfusion and is associated with worse outcomes when elevated. The Surviving Sepsis Campaign guidelines 1 emphasize the importance of lactate monitoring in septic shock, as it can help identify patients with tissue hypoxia or other causes of increased lactate levels.
Key Points to Consider
- Lactate levels are not a direct measure of tissue perfusion, but increased levels are associated with worse outcomes 1
- Lactate-guided resuscitation has been shown to reduce mortality in patients with septic shock 1
- The use of lactate monitoring can help individualize the management of septic shock, particularly in patients with elevated lactate levels 1
- Procal, on the other hand, is not mentioned in the guidelines as a recommended marker for tissue perfusion or septic shock management 1
Clinical Implications
- Ordering lactic acid levels can help guide resuscitation efforts and improve outcomes in patients with septic shock 1
- The results of lactate monitoring should be used in conjunction with other clinical parameters, such as blood pressure and urine output, to individualize patient management 1
- Elevated lactate levels should prompt further evaluation and management to address the underlying cause of the elevation 1
From the Research
Lactic Acidosis Treatment
- The treatment of lactic acidosis involves addressing the underlying cause of the condition, such as sepsis or low-flow states, rather than just treating the symptoms 2, 3.
- Sodium bicarbonate therapy is not recommended for patients with pH at least 7.15, and its use is controversial even in more severe acidemia 3.
- The use of other buffers, such as THAM or Carbicarb, or dialysis may be considered as alternative treatments for lactic acidosis 2.
- Selective NHE1 inhibitors have shown promise in animal studies, improving cardiovascular function, ameliorating lactic acidosis, and reducing mortality 2.
Pathophysiology of Lactic Acidosis
- Lactic acidosis is caused by an imbalance between the production and removal of lactic acid, which can be due to various factors such as tissue hypoxia, epinephrine-induced stimulation of aerobic glycolysis, and impaired renal function 4, 5.
- The classification of lactic acidosis can be based on whether the pathophysiology is due to increased production or decreased removal of lactic acid 4.
Clinical Implications and Management
- Elevated serum lactate levels are a marker of risk and a target of therapy in hospitalized patients 6.
- The treatment of lactic acidosis should focus on addressing the underlying cause, and a strategy for its treatment should be outlined based on the mechanisms underlying lactate elevations and the risks associated with lactic acidosis 6.