Endgames Case Report

Life threatening lactic acidosis

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c857 (Published 25 March 2010) Cite this as: BMJ 2010;340:c857
  1. M Lemyze, specialist registrar in critical care medicine1,
  2. J F Baudry, specialist registrar in critical care medicine2,
  3. F Collet, specialist registrar in critical care medicine2,
  4. N Guinard, specialist registrar in critical care medicine2
  1. 1Department of Critical Care Medicine, Schaffner Hospital, 62300 Lens, France
  2. 2Department of Critical Care Medicine, Broussais Hospital, 35400 Saint Malo, France
  1. Correspondence to: M Lemyze malcolmlemyze{at}yahoo.fr

    An 83 year old woman with diabetes presented to the emergency department with progressive shortness of breath and a two week history of diarrhoea. Her drugs included aspirin, 75 mg four times a day; a combination of irbesartan with hydrochlorothiazide, 300/25 mg four times a day; and metformin, 1000 mg three times a day. She had no previously known renal insufficiency, but on arrival she was oliguric, disoriented, and confused.

    Her respiratory rate was 32 breaths/min, blood pressure was 76/46 mm Hg, heart rate was 125 beats/min, and rectal temperature reached 36.8°C. She had cool and clammy extremities and a persistent skinfold—additional evidence of severe dehydration. Arterial blood gases showed a profound lactic acidosis, with pH 6.72, partial pressure of carbon dioxide (PCO2) 14 mm Hg, partial pressure of oxygen (PO2) 106 mm Hg, bicarbonate 12 mmol/l, and a high lactate concentration of 17.4 mmol/l. Laboratory results showed a normal blood glucose concentration of 9 mmol/l, a serum urea of 22 mmol/l, a serum creatinine of 779 μmol/l, an increased serum potassium concentration of 6.8 mmol/l, and a decreased prothrombin activity of 43% (prothrombin time of 21 seconds). Chest and abdominal examination, chest radiography, urine dipstick, plasma C reactive protein (<5 mg/l), and procalcitonin (<0.5 μg/l) concentrations showed no evidence of an infection.

    Questions

    • 1 What are the differential diagnoses in severe lactic acidosis?

    • 2 What is the most likely diagnosis?

    • 3 What is the prognosis of this acute critical illness?

    • 4 How should this patient be managed?

    Answers

    1 What are the differential diagnoses in severe lactic acidosis?

    Short answer

    In the differential diagnosis of severe lactic acidosis, poor tissue perfusion and oxygenation are the main considerations, and these occur in septic shock, acute heart failure, unrecognised bowel ischaemia, and acute liver failure. Some drugs can also cause life threatening lactic acidosis, especially metformin and nucleoside reverse transcriptase inhibitors.

    Long answer

    As originally …

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