Etiology and therapeutic approach to elevated lactate levels

Abstract

Lactate levels are commonly evaluated in acutely ill patients. Although most often used in the context of evaluating shock, lactate levels can be elevated for many reasons. While tissue hypoperfusion may be the most common cause of elevation, many other etiologies or contributing factors exist. Clinicians need to be aware of the many potential causes of lactate level elevation as the clinical and prognostic importance of an elevated lactate level varies widely by disease state. Moreover, specific therapy may need to be tailored to the underlying cause of elevation. The present review is based on a comprehensive PubMed search between the dates of January 1, 1960, to April 30, 2013, using the search term lactate or lactic acidosis combined with known associations, such as shock, sepsis, cardiac arrest, trauma, seizure, ischemia, diabetic ketoacidosis, thiamine, malignancy, liver, toxins, overdose, and medication. We provide an overview of the pathogenesis of lactate level elevation followed by an in-depth look at the varied etiologies, including medication-related causes. The strengths and weaknesses of lactate as a diagnostic/prognostic tool and its potential use as a clinical end point of resuscitation are discussed. The review ends with some general recommendations on the management of patients with elevated lactate levels.

Keywords: DKA; ScvO(2); central venous oxygen saturation; diabetic ketoacidosis.

Figure 1

Aerobic and anaerobic metabolism^a. ^aATP = Adenosine triphosphate; CoA = Coenzyme A; PDH = Pyruvate dehydrogenase

Figure 2

Elevated lactate (>4 mmol/L) in different diseases and its association with in-hospital mortality^–,a,b. ^aED = Emergency Department ^bThe mortality in post-cardiac arrest shown here is calculated based on data from Cocchi et al. and not specified in the original article.