Research Information System
Journal of Medical and Surgical Intensive Care Medicine, vol.8, no.2, pp.54-56, 2017 (ESCI)
Type B lactic acidosis is an under-recognized clinical entity that must be distinguished from type A (hypoxic) lactic acidosis. A 56-year-old female with a history of colon carcinoma with liver metastasis underwent right hemicolectomy, ileocolic anastomosis, and liver metastasectomy. Two days later, she presented to the general surgical intensive care unit with fever, hypotension, and tachycardia. Arterial blood gas analysis revealed a pH of 7.35, a PaCO2 of 44.8 mm Hg, an HCO3- level of 22.1 mEq/L, a base deficit of -3.3 mmol/L, and a lactate level of 4.3 mEq/L. Liver functions were moderately elevated (AST: 647 U/L, ALT: 153 U/L) on admission. Wound culture revealed the presence of Escherichia coli, and piperacillin-tazobactam was prescribed. She received adequate fluid resuscitation with normal saline, antibiotics for treating septic shock, and norepinephrine for maintaining appropriate blood pressure. Despite achieving blood pressure appropriate for her age and improved tissue perfusion, the patient's lactate level increased to 23 mEq/L. Abdominal computed tomography with angiography showing vascular structures was concerned for possible anastomosis leakage, given the rise in lactate levels with concern for intra-abdominal pathology. There were no signs of perforation and ischemia. Because of a high suspicion that the patient's hyperlactatemia was not due to tissue hypoxia, we used the patient's blood sample to measure the vitamin B1 (thiamine) level. We did not immediately perform thiamine replacement because hyperlactatemia did not accompany acidosis. Her thiamine level was 10 mu g/L (range, 25-75 mu g/L). Then, 100 mg/day of intravenous thiamine was administered. Within 3 days, her lactate level fell to 2.5 mmol/L; within 24 h, it fell to 1.9 mmol/L. Additional history revealed that she had been taking very little nutrition by mouth before admission and that she was primarily dependent on total parenteral nutrition (TPN). There were no vitamins in her TPN; thus, she was likely to be thiamine deficient during her initial presentation.