Lactic acidosis natural history, complications and prognosis
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Saud Khan M.D.
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Overview
Lactic acidosis may occur rapidly within minutes or gradually, over a period of days, depending on the underlying cause. Treating the cause of the metabolic disturbance relieves symptoms which are nonspecific, and may include disorientation, muscle pains, nausea, jaundice, shallow breathing or rapid heart rate. Common complications of lactic acidosis include arrythmias, loss of consciousness, organ failure and death. Benign causes, such as temporary elevations of lactate after exercise, are harmless, however, if it occurs as part of an underlying systemic disease, it can lead to significantly worse outcomes.
Natural history
Underlying sepsis or any type of shock in a critically ill patient may lead to hyperlactaemia, which is an independent predictor of death. 80% of the patients die in intensive care when their serum lactate values reach >10 mmol/l, and if the severe lactic acidosis persists for 48 hours, mortality is 100%[1]. Increased lactate levels require immediate diagnostic work-up and classification.
The determination of the lactate serum concentrations, and close follow-up is recommended in the first hour of admission for a patient with suspected sepsis[2]. In addition, blood cultures, broad-spectrum antibiotics, fluid resuscitation and vasopressor administration are recommended within the first hour. Increased lactate levels (≥4 mmol/l) along with refractory hypotension warrant large amounts of crystalloids, and rate of infusion must be managed according to lactate clearance. Factors affecting lactate metabolism must be monitored, for example liver function impairment reduces clearance. High lactate levels on admission are associated with organ failure and mortality in patients with liver disease.
Complications
If left untreated, Type A severe lactic acidosis (lactate>4mmol/L) prognosis is usually poor. in septic shock, mortality is directly linked to both initial levels of lactate in the blood and the rate of removal of acid from the blood.
Complications that can develop as a result of lactic acidosis are:
- Cardiac arrythmia
- Change in mental state
- Organ damage/failure
- Increasing myocardial suppression due to low blood pH. Further hypoperfusion and multiorgan failure leading to even higher levels of lactate, which ultimately may lead to death.
Prognosis
In patients with baseline lactate levels above 5 mmol/l, their 12-hour lactate clearance is monitored for a predictive prognosis for survival with greater clearance signifying better prognosis (lower levels of lactate lead to better outcomes), while the absolute lactate level is an independent predictor for the severity of the underlying disease even after correction[3].
In patients with lactic acidosis linked to underlying malignancy, removal of tumor(s) leads to correction of lactate levels.
In patients with lactic acidosis caused by alcoholic ketoacidosis, administration of thiamine and dextrose is required along with rapid volume resuscitation, with literature showing no benefit of withholding dextrose till thiamine is administered, especially in hypoglycemic patients.
References
- ↑ Kluge S, de Heer G, Jarczak D, Nierhaus A, Fuhrmann V (2018). "[Lactic acidosis - update 2018]". Dtsch Med Wochenschr. 143 (15): 1082–1085. doi:10.1055/a-0585-7986. PMID 30060277.
- ↑ Levy MM, Evans LE, Rhodes A (2018). "The Surviving Sepsis Campaign Bundle: 2018 update". Intensive Care Med. 44 (6): 925–928. doi:10.1007/s00134-018-5085-0. PMID 29675566.
- ↑ Coba V, Whitmill M, Mooney R, Horst HM, Brandt MM, Digiovine B; et al. (2011). "Resuscitation bundle compliance in severe sepsis and septic shock: improves survival, is better late than never". J Intensive Care Med. 26 (5): 304–13. doi:10.1177/0885066610392499. PMID 21220270.