Dialysis vs Bicarbonate Therapy For Lactic Acidosis

In the world of critical care medicine sepsis with subsequent Type A Lactic Acidosis (fig 1.) is a common occurrence. And of course the question of should the patient be dialysis for acidosis (the A in AEIOU for emergent dialysis again) arises. This is a difficult answer and one that should be evaluated on a patient-to-patient basis given the severity of most ICU patients. But I’ll try to quickly review the data and let you decide. Fig A.

Bicarbonate Therapy

Traditionally bicarbonate infusion is given when serum pH is less than 7.1 or 7.2 to avoid some of complications of severe acidosis such arrhythmias, decreased response to cathechloamines, reduced contractility. But bicarbonate therapy in and of itself can be detrimental because it has several side-effects such as decreased cardiac output, reduced ionized cardiac output, increased CO2 generation, volume overload and increased lactate generation. Goal of therapy should be to keep pH near 7.1.

Hemodialysis (CRRT)

Hemodialysis seems to make good sense right? The patient is producing lactic acid, why not dialyze it off. Well it doesn’t work that easily. According to a paper published in JASN in 2001 only 3% of the lactate generated is dialyzed off with CRRT. So that basically means that dialyzing alone would be inefficient. Luckily we dialyze against a bicarb rich dialysate and in essence we are providing bicarbonate therapy. Where this excels as a treatment option is that it helps with volume management in the patient with oligoanuric patient, preventing volume overload.
– Adrian Baudy