Lactic acidosis

Background

Type A (tissue hypoperfusion)
Type B (decreased utilization)
- Alcoholism
  - ↓ Lactate utilization secondary to hepatic dysfunction
  - ↓ NAD+/NADH ratio leads to ↑ conversion of pyruvate to lactate
- Metformin
- DKA
  - Mainly due to D-lactate production, though hypovolemia contributes
- Liver disease (decreased clearance)
- Adrenergic receptor agonism; viz., albuterol, epinephrine, etc
- Malignancy
- Carbon Monoxide poisoning
- Cyanide poisoning
Type D
- episodes of encephalopathy and metabolic acidosis typically following high carbohydrate meals in patients with short bowel syndrome
- metabolic acidosis and high serum anion gap, normal lactate level, short bowel syn or other forms of malabsorption, and characteristic neurologic findings
  - Type D lactate is not detected with standard lactate levels

Any shock state
SIRS; lactate may be 2-5 mEq/L
Thiamine deficiency; more often seen in ICU settings; Thiamine is a co-factor for pyruvate dehydrogenase
Seizure
Dead gut
Hepatic failure
Malignancy
Exercise
Albuterol and other beta agonists^[1]^[2]
Toxicologic Causes:
- Cyanide
- Carbon Monoxide
- Metformin
- Didanosine
- Stavudine
- Zidovudine
- Linezolid
- Strychnine
- Emtriva
- Rotenone (Fish Poison
- NaAzide (Lab Workers)
- APAP (if Liver Fx)
- Phospine (rodenticide)
- NaMonofluoroacetate (Coyote Poison‐ give Etoh as antidote)
- INH (if patient seizes)
- Hemlock
- Valproate
- Hydrogen Sulfide
- Nitroprusside (if cyanide toxic)
- Ricin & Castor Beans
- Propofol
- Sympathomimetics (cocaine, methamphetamine)
- Jequirty peas (Abrus precatorius)
- Prunus Amygdalus plants
- Crab tree apple seeds & cassava (yucca)
- HAART-induced lactic acidosis

Beta agonists or beta stimulation
Extreme exercise
Seizures, immediate post-ictal period
Hepatic failure
- Lactate ringer's solution unlikely to cause false positive except in hepatic failure^[3]^[4]

↑ Dodda V and Spiro P. Albuterol, an Uncommonly Recognized Culprit in Lactic Acidosis. Chest. 2011;140.
↑ . Zitek T, Cleveland N, Rahbar A, et al. Effect of nebulized albuterol on serum lactate and potassium in healthy subjects. Acad Emerg Med 2016;23:718–21.
↑ Zitek T, Skaggs ZD, Rahbar A, Patel J, Khan M. Does Intravenous Lactated Ringer's Solution Raise Serum Lactate?. J Emerg Med. 2018;55(3):313-318. doi:10.1016/j.jemermed.2018.05.031
↑ Didwania A, Miller J, Kassel D, Jackson EV Jr, Chernow B. Effect of intravenous lactated Ringer's solution infusion on the circulating lactate concentration: Part 3. Results of a prospective, randomized, double-blind, placebo-controlled trial. Crit Care Med. 1997;25(11):1851-1854. doi:10.1097/00003246-199711000-00024