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Lactic Acidosis Therapy – Treatment & Causes

Lactic acidosis therapy encompasses all medical measures to treat a dangerous drop in blood pH caused by elevated lactate levels. Treatment focuses on eliminating the underlying cause and restoring metabolic balance.

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Lactic acidosis therapy encompasses all medical measures to treat a dangerous drop in blood pH caused by elevated lactate levels. Treatment focuses on eliminating the underlying cause and restoring metabolic balance.

What is Lactic Acidosis Therapy?

Lactic acidosis therapy refers to the medical management of lactic acidosis, a severe form of metabolic acidosis. In lactic acidosis, lactate (lactic acid) accumulates in the blood, causing a dangerous decrease in blood pH. A pH below 7.35 combined with a blood lactate level above 5 mmol/l is considered clinically critical and requires immediate intervention. Treatment is guided by the underlying cause and the severity of the condition.

Causes of Lactic Acidosis

Lactic acidosis is classically divided into two main types:

Type A (hypoxic lactic acidosis): Caused by insufficient oxygen delivery to tissues, e.g., in shock, cardiac arrest, severe blood loss, or sepsis. This is the most common form.
Type B (non-hypoxic lactic acidosis): Occurs without obvious oxygen deficiency, e.g., due to medications (particularly metformin), liver failure, malignancies, metabolic disorders, or toxic substances.

Symptoms of Lactic Acidosis

Symptoms can be non-specific and vary depending on severity:

Rapid, deep breathing (Kussmaul respiration) as a compensatory mechanism
Weakness and profound fatigue
Nausea and vomiting
Confusion and altered consciousness
Low blood pressure and rapid heart rate
In severe cases: loss of consciousness and organ failure

Diagnosis

Diagnosis is typically established through arterial blood gas analysis (ABG), supplemented by laboratory tests:

Detection of reduced pH (below 7.35)
Elevated blood lactate (above 2 mmol/l indicates hyperlactatemia; above 5 mmol/l indicates manifest lactic acidosis)
Low bicarbonate (HCO3-)
Elevated anion gap
Additional laboratory tests to identify the cause (renal function, liver enzymes, blood glucose, complete blood count)

Treatment of Lactic Acidosis

1. Treating the Underlying Cause (Causal Therapy)

The most important step is addressing the root cause. Without treating the triggering condition, any symptomatic therapy will only provide temporary relief:

In shock: volume replacement, vasopressors, treatment of the shock cause
In sepsis: antibiotics, source control, hemodynamic stabilization
In metformin-induced lactic acidosis: immediate discontinuation of the drug, possibly hemodialysis
In cardiac arrest: resuscitation and restoration of circulation
In liver failure: intensive care management, possibly liver transplantation

2. Ensuring Adequate Oxygenation

In Type A lactic acidosis, improving tissue oxygenation is the primary goal. This may include supplemental oxygen, mechanical ventilation, or hemodynamic stabilization.

3. Buffering with Sodium Bicarbonate

The administration of sodium bicarbonate (NaHCO3) remains controversial. It can temporarily raise the blood pH but does not address the underlying cause. Current guidelines recommend bicarbonate supplementation only when pH falls below 7.15, and as a bridging measure, as it carries risks such as hypernatremia, paradoxical intracellular acidosis, and rising CO2 levels.

4. Renal Replacement Therapy

In severe lactic acidosis, especially in cases of renal or hepatic failure and metformin intoxication, continuous renal replacement therapy (CRRT) or hemodialysis may be used. This helps remove excess lactate from the blood and stabilize the acid-base balance.

5. Intensive Care Monitoring

Patients with lactic acidosis are typically managed in an intensive care unit (ICU). Continuous monitoring of vital signs, lactate levels, blood gases, and organ function is essential. The goal is the gradual normalization of lactate and pH values.

Prognosis

The prognosis of lactic acidosis depends heavily on the underlying condition and the timing of treatment. A rapidly identified and treatable cause, such as a reversible shock state, can be fully overcome. Severe forms, such as those associated with multi-organ failure, carry a high mortality rate. Regular lactate measurements serve as an important marker for monitoring treatment response.

References

Adrogué, H. J. & Madias, N. E. (2010). Lactic Acidosis. New England Journal of Medicine, 362:1486-1494.
Dellinger, R. P. et al. (2013). Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock. Critical Care Medicine, 41(2):580-637.
Kraut, J. A. & Madias, N. E. (2014). Lactic Acidosis. New England Journal of Medicine, 371:2309-2319.

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