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Management of lactic acidosis

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Management of lactic acidosis

  2. 2. DEFINITION • Lactic acidosis is a pathological state diagnosed when the serum concentration of lactate or lactic acid is persistently 5mmol/L or greater and there is significant acidemia and serum pH< 7.35. (Normal lactate concentration is 2.0 mmol/L).
  3. 3. FORMATION OF LACTIC ACID • Red blood cells, brain and skin are major sources of lactic acid at rest while during exercise skeletal muscles release significant amount of lactic acid. • Kidney and liver utilize lactic acid and convert it into carbon dioxide and water and use it for gluconeogenesis. • Lactic acid and pyruvic acid are inter convertible and the reaction is catalyzed by the enzyme lactate dehydrogenase.
  4. 4. PATHOPHYSIOLOGY OF LACTIC ACIDOSIS Increased lactic acid generation • Reduced oxygen delivery (hypotension, shock, hypoxemia, anemia, carbon monoxide poisoning) • Increased tissue demand (exercise, seizures, sepsis)
  5. 5. Decreased lactic acid utilization • • • • Liver dysfunction Reduced perfusion cellular dysfunction Enzymatic or cofactor deficiency: Inherited, Acquired Combination • Malignancy, diabetes, alcohol, other drugs
  6. 6. CLINICALLY IMPORTANT CAUSES OF LACTIC ACIDOSIS • • • • • • • • Vigorous exercise Tissue hypoxia Cardio-respiratory arrest Carbon monoxide poisoning Drugs and toxins Terminal cirrhosis or hepato-cellular failure Neoplastic diseases Congenital deficiency of enzymes
  7. 7. SIGNS AND SYMPTOMS • • • • • • • • general malaise loss of weight and loss of appetite myalgia weakness and fatigue nausea, vomiting abdominal pains tachypnoea tachycardia
  8. 8. MANAGEMENT OF LACTIC ACIDOSIS • The most important therapy in management of lactic acidosis is correction of underlying cause. • In hypovolumic or cardiogenic shock, restoration of perfusion and adequate tissue oxygenation will reverse lactic acidosis. • In septic shock, antibiotic treatment, surgical drainage/debridement will help in reversal of lactic acidosis.
  9. 9. • Giving intravenous thiamine in cases of total parentral nutrition will help in resolution of lactic acidosis. • In status asthmaticus, high dose of beta 2 agonist should be tapered gradually to reduce lactate levels. • In shock, vaso constrictors should be added only after volume replacement as they worsen the acidosis.
  10. 10. ALKALI THERAPY • Start bicarbonate infusion to keep pH above 7.10 • The side effects of bicarbonate therapy is acute hypercapnia, volume overload and cardiac depression. • When lactic acidosis is accompanying pulmonary oedema, cardiopulmonary arrest, seizures, biguanide therapy, ethanol ingestion, and diabetic ketoacidosis bicarbonate therapy is not recommended.
  11. 11. HAEMODIALYSIS • Haemodialysis is rarely indicated as a treatment for lactic acidosis. • It may be used in drug toxicity to speed up elimination of drug/toxin. • It is helpful when fluid overload and cardiac or renal insufficiency is present.
  12. 12. RECENT ADVANCES • Glucose, insulin infusion, nitropruside infusion, hemodialysis, peritoneal dialysis have all been used in order to treat lactic acidosis but their efficacy is unproven. • Thiamine, lipoic acid and dichloroacetate have been used as they increase the activity of pyruvate dehydrogenase enzyme.
  13. 13. DICHLOROACETATE • Dichloroacetate (DCA) is an activator of pyruvate dehydrogenase. • It can lower concentration of lactic acid in patients by improving the lactate utilization but when used in large clinical trial it did not show any effect on mortality. • DCA, however, may be helpful in lactic acidosis in children with severe malaria.
  14. 14. TRIS HYDROXYMETHYL AMINOMETHANE (THAM) • It is a weak alkali and theoretical has the advantage over bicarbonate as it produces less carbon dioxide. • Clinical trials do not prove THAM to be more effective than bicarbonate.
  15. 15. CARBICARB • Carbicarb is an equimolar combination of sodium carbonate and sodium bicarbonate that produces less carbon dioxide than sodium bicarbonate alone. • It has theoretical advantage but trials have not demonstrated any reduction in mortality or morbidity.

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