Causes of Lactate Elevation, Lactic Acidosis - Differential ...
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Causes of Lactate Elevation, Lactic Acidosis - Differential Diagnosis
The most common causes of hyperlactatemia are usually: 
 - hypoxemia
 - tissue hypoperfusion
 - toxic-induced impairment of cellular metabolism,
 - regional ischemia or the mechanism is unknown
 - Many other causes are listed as Type A and B categories
Lactate levels depend on:
 - ongoing production
 - removal from the blood by excretion (e.g., urine, sweat) 
 - its metabolism (e.g., uptake by cells as a direct source of energy, conversion to glucose by the liver)
Why do we emphasize this parameter? The use of lactate as a clinical prognostic tool was suggested in 1964 by Broder and Weil - they observed that a lactate excess of > 4 mmol/L was associated with poor outcomes in patients with undifferentiated shock. ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3975915/ )
Therefore, time and time again we might see an urgency to bolus these values as we somehow equate that an elevated lactate means the patient is in impending shock.
What we should be teaching is that elevated lactate is encountered in a multitude of clinical presentations and disease states one of which is the critically ill patient with shock/hypoxemia/Sepsis etc. Persistent hyperlactatemia is particularly difficult to interpret.
Causes of elevated lactate apart from tissue hypoperfusion have been recognized and should be considered in the appropriate clinical context.
One of these is the contribution of liver or renal injury in the production and clearance of Lactate. Both of these organs can ↑ lactate
With ↑ Lactate, our response should be to  determine the underlying cause. 
 - hypoperfusion/ hypoxemia -> focus on improving perfusion 
 - shock->treatments include fluid administration, vasopressors, or inotropes. 
 - regional ischemia, surgery may be needed to restore circulation
If drugs, seizures, malignancy, or thiamine deficiency are the cause: stop, reverse and treat the offending agent.
Multiple conditions can contribute to lactic acidosis, therefore carefully: 
 - evaluate the patient’s complete medical history
 - conduct a thorough physical assessment
 - assess other laboratory or diagnostic tests before beginning treatment.
Join the resistance simply to bolus!

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Contributed by

Dr. Ravi Singh K
@rav7ks
Academic Hospitalist and APD @SinaiBmoreIMRes, Clinical reasoning,Simulation and POCUS enthusiast - https://twitter.com/rav7ks
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