Lactate Overview

Will the real please step forward? Dr. Andrew Ferguson MEd FRCA DIBICM FCCP Attending Intensivist

Dogma…. ,[object Object],[object Object],[object Object],[object Object],[object Object]

Useless end-product or essential fuel?

The traditional view… ,[object Object],[object Object],[object Object],[object Object],“ current thinking continues to interpret hyperlactacidemia as hypoxia and to support stimulation of cardiac output and enhancement of oxygen delivery as therapy” James JH, Luchette FA, McCarter F, Fischer JE. Lactate is an unreliable indicator of tissue hypoxia in injury or sepsis . Lancet 1999; 354: 505-508

So doesn’t that mean that…? ,[object Object],[object Object],[object Object],[object Object]

Basal lactate production Total = 1290 mmol / 24 hours for 70 kg

How is lactate produced? If pyruvate production > oxidation in CAC then lactate formation increases PDH

SO… Anything that increases glycolysis can increase lactataemia once pyruvate oxidation is overwhelmed NOT just anaerobic metabolism!

Another way to look at it… Schurr A. Lactate: the ultimate cerebral oxidative energy substrate? Journal of Cerebral Blood Flow & Metabolism 2006; 26: 142-152

Lactate/pyruvate ratio ,[object Object],[object Object],[object Object],[object Object],[object Object],Lactate/pyruvate = K x (NADH/NAD) x H + Cardiogenic shock L/P ratio 40:1 Consistent with hypoxia Resuscitated septic shock L/P ratio 14:1 Not consistent with hypoxia

When lactate hypoperfusion ,[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],When lactate hypoperfusion

Epinephrine and lactate production

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Epinephrine and lactate production

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],When lactate hypoperfusion

Lactate Metabolism LIVER 60% KIDNEYS 30% Excretion renal threshold = 5-6 mmol/L MUSCLE 10%

What happens to the lactate? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Classification of lactic acidosis Type A Lactic Acidosis Associated with malperfusion / dysoxia Type B Lactic Acidosis In the absence of malperfusion / dysoxia B1 – Disease states e.g. DKA, leukaemia, lymphoma, thiamine deficiency B2 – Drugs e.g. metformin, cyanide, b agonists, HAART B3 – Inborn errors of metabolism

Prognostic value ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

So what do we do about it? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Lactate Overview

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Lactate Overview