Ulutas Med J The Ulutas Medical Journal Ulutas Med J 2149-0430 2149-388X Hayriye Zehra Ulutaş 10.5455/umj.20181112014400 283175 Letter to the Editor Emergency care Lactic Acidosis with Broad-Anion Gap https://orcid.org/0000-0002-8338-4606 Ozcan Oguzhan Conceptualization Data curation Formal analysis Funding acquisition Investigation Methodology Project administration Resources Software Supervision Validation Visualization Writing – original draft Writing – review & editing 1 https://orcid.org/0000-0002-2745-362X Karakus Ali Conceptualization Data curation Formal analysis Funding acquisition Investigation Methodology Project administration Resources Software Supervision Validation Visualization Writing – original draft Writing – review & editing 2 https://orcid.org/0000-0002-8970-1684 Kuvandik Güven Conceptualization Data curation Formal analysis Funding acquisition Investigation Methodology Project administration Resources Software Supervision Validation Visualization Writing – original draft Writing – review & editing 3 https://ror.org/056hcgc41 Mustafa Kemal University, Faculty of Medicine, Department of Medical Biochemistry, Hatay, Turkey https://ror.org/056hcgc41 Mustafa Kemal University, Faculty of Medicine, Department of Emergency Medicine, Hatay, Turkey https://ror.org/056hcgc41 Mustafa Kemal Üniversitesi, Faculty of Medicine, Hatay 29 03 2018 2018 4 1 64 65 12 11 2017 15 12 2017 14 01 2018 © 2018 The Author(s) 2018 https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed under the CC BY-NC 4.0 licence.

Lactic acidosis is a life-threatening metabolic acidosis and can be improved by appropriate medical treatment. It is generally defined as a serum lactate concentration above 4 mmol/L. It is associated with increased anaerobic metabolism due to several conditions such as decreased blood flow, drugs, toxins and septic shock. Impaired tissue oxygenation and decreased lactate clearance primarily by the liver can lead to increased lactate levels. Arterial blood gas analysis is very important to evaluate a patient's lactate levels and oxygenation. Early diagnosis of these patients would help to prevent morbidity and mortality.

 Lactic acidosis anion gap metabolic acidosis Funding information was not reported in the published version of this article.

Dear Editor, Lactic acidosis is a life-threating metabolic acidosis with a broad-anion gap. In this study we aimed to present a case of broad-anion gap lactic acidosis and delirium.

A 36-year-old male admitted to emergency with impaired consciousness and agitations. Blood pressure was 90/60 mmHg, heart rate was 115 beats per minute and sinus tachy-cardia rhythm was observed in the electrocar-diography (ECG) examination. Clinical examination revealed a confused patient who has a moderate clinical condition and Glasgow Coma Scale score of 9 in admission.

Medical history revealed that the patient had tree epileptic seizures during last three-year period and has been medicated with anti-epileptics (levatiracetam 750 mg, 2x1 and car-bamazepine 400 mg, 2x1). According to state-ment of parents there was no past medical history included diabetic mellitus, hypertension and any addiction of alcohol and medication. He was given intravenous diazepam 10 mg, midazolame 5 mg, haloperidol 5 mg and chlor-promazine 5 mg for sedation but agitations had not been controlled. Therefore, continuous infusion of propofol administered and intu-bation was performed.

Initial laboratory investigation results included a serum glucose level of 186 mg/dL; pH: 6.9; HCO 3 : 6.5mEq/L; PCO 2 : 33.4 mmHg; PO 2 , 104.6 mmHg; Lactate:24.66mmol/L; WBC:21,76 x10 3 /uL; NEUT, 13,09 x10 3 /μL and serum CRP level of 31.1 mg/L. Calculated anion gap was 32 mmol/L. Other serum chemistry and hema-tological results were within normal limits and showed in Table-1.

Patient was diagnosed with broad-anion gap lactic acidosis. Intravenous fluid (SF, 0.9%) and bicarbonate therapy (5 flacon within 100 cc dextrose, 5%) were started immediately and the patient was transported to the intensive care unit for monitoring. During hospitalization, proper fluid and bicarbonate treatment was continued. Consecutive blood gas analyses results were also shown in Table-1. No signi-ficant abnormalities were seen in cranial com-puterized tomography (CT) but the signs of lobar pneumonia were observed in chest radio-graphy. Patient was considered to be lactic acidosis seconder to pneumonia. The patient was discharged after being treated with proper antibiotherapy for three days.

Blood gas analaysis and other laboratory results Table 1: Blood gas analaysis and other laboratory results

Lactic acidosis is a life-threatening metabolic acidosis and can be improved by appropriate medical treatment. It is generally defined as a serum lactate concentration above 4 mmol/L. It is associated with increased anaerobic metabolism due to several condition such as decreased blood flow, drugs, toxins and sep-tic shock. Impaired tissue oxygenation and decreased lactate clearance primarily by the liver can lead to increased lactate levels (Figure 1). Arterial blood gas analysis is very important to evaluate a patient’s lactate levels and oxygenation. Early diagnosis of these patients would help to prevent morbidity and mortality.

Glucose metabolism in different stage of oxygenation

Figure 1: Glucose metabolism in different stage of oxygenation References Sargın G, Yavaşoğlu I, Kadıkoylu G, Bolaman Z. Lactic Acidosis: A Short Review of Cases. Yoğun Bakım Dergisi 2011;3:63-66. Web: http://www.intranet.tdmu.edu.ua Time pH Pa02 (mmHg) PaCO2 (mmHg) HCO3 (mEq/L) SO2 (%) Lactate (mmol/L) Initial 6,9 104,6 33,4 6,5 93,3 24,66 2. hour 7,26 98,3 41,5 18,2 96,6 7,34 2. day 7,38 215,2 33,4, 22,4 98,7 0,97 Glucose Pyruvate Lactate Impaired Oxygenation N ormal Ox ygenati on Acetyl CoA Krebs Cycle