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Lactic Acidosis In Dka

Lactic Acidosis In A Patient With Type 2 Diabetes Mellitus

Lactic Acidosis In A Patient With Type 2 Diabetes Mellitus

Introduction A 49-year-old man presented to the emergency department complaining of dyspnea for 2 days. He had a history of hypertension, type 2 diabetes mellitus, atrial fibrillation, and a severe dilated cardiomyopathy. He had been hospitalized several times in the previous year for decompensated congestive heart failure (most recently, 1 month earlier). The plasma creatinine concentration was 1.13 mg/dl on discharge. Outpatient medications included insulin, digoxin, warfarin, spironolactone, metoprolol succinate, furosemide (80 mg two times per day; increased from 40 mg daily 1 month earlier), metolazone (2.5 mg daily; added 1 month earlier), and metformin (2500 mg in three divided doses; increased from 1000 mg 1 month earlier). Physical examination revealed an obese man in moderate respiratory distress. The temperature was 36.8°C, BP was 119/83 mmHg, and heart rate was 96 per minute. Peripheral hemoglobin oxygen saturation was 97% on room air, with a respiratory rate of 26 per minute. The heart rhythm was irregularly irregular; there was no S3 or murmur. Jugular venous pressure was about 8 cm. There was 1+ edema at the ankles. A chest radiograph showed cardiomegaly and central venous prominence. The N-terminal pro-B-type natriuretic peptide level was 5137 pg/ml (reference range = 1–138 pg/ml). The peripheral hemoglobin concentration was 12.5 g/dl, the white blood cell count was 12,500/µl (76% granulocytes), and the platelet count was 332,000/µL. Initial plasma chemistries are shown in Table 1. The impression was decompensated congestive heart failure. After administration of furosemide (160 mg intravenously), the urine output increased to 320 ml over the next 1 hour. There was no improvement in the dyspnea. Within 2 hours, the patient’s BP fell to 100/64 mmHg Continue reading >>

Lactic Acidosis: What You Need To Know

Lactic Acidosis: What You Need To Know

Lactic acidosis is a form of metabolic acidosis that begins in the kidneys. People with lactic acidosis have kidneys that are unable to remove excess acid from their body. If lactic acid builds up in the body more quickly than it can be removed, acidity levels in bodily fluids — such as blood — spike. This buildup of acid causes an imbalance in the body’s pH level, which should always be slightly alkaline instead of acidic. There are a few different types of acidosis. Lactic acid buildup occurs when there’s not enough oxygen in the muscles to break down glucose and glycogen. This is called anaerobic metabolism. There are two types of lactic acid: L-lactate and D-lactate. Most forms of lactic acidosis are caused by too much L-lactate. Lactic acidosis has many causes and can often be treated. But if left untreated, it may be life-threatening. The symptoms of lactic acidosis are typical of many health issues. If you experience any of these symptoms, you should contact your doctor immediately. Your doctor can help determine the root cause. Several symptoms of lactic acidosis represent a medical emergency: fruity-smelling breath (a possible indication of a serious complication of diabetes, called ketoacidosis) confusion jaundice (yellowing of the skin or the whites of the eyes) trouble breathing or shallow, rapid breathing If you know or suspect that you have lactic acidosis and have any of these symptoms, call 911 or go to an emergency room right away. Other lactic acidosis symptoms include: exhaustion or extreme fatigue muscle cramps or pain body weakness overall feelings of physical discomfort abdominal pain or discomfort diarrhea decrease in appetite headache rapid heart rate Lactic acidosis has a wide range of underlying causes, including carbon monoxide poisoni Continue reading >>

Causes Of Lactic Acidosis

Causes Of Lactic Acidosis

INTRODUCTION AND DEFINITION Lactate levels greater than 2 mmol/L represent hyperlactatemia, whereas lactic acidosis is generally defined as a serum lactate concentration above 4 mmol/L. Lactic acidosis is the most common cause of metabolic acidosis in hospitalized patients. Although the acidosis is usually associated with an elevated anion gap, moderately increased lactate levels can be observed with a normal anion gap (especially if hypoalbuminemia exists and the anion gap is not appropriately corrected). When lactic acidosis exists as an isolated acid-base disturbance, the arterial pH is reduced. However, other coexisting disorders can raise the pH into the normal range or even generate an elevated pH. (See "Approach to the adult with metabolic acidosis", section on 'Assessment of the serum anion gap' and "Simple and mixed acid-base disorders".) Lactic acidosis occurs when lactic acid production exceeds lactic acid clearance. The increase in lactate production is usually caused by impaired tissue oxygenation, either from decreased oxygen delivery or a defect in mitochondrial oxygen utilization. (See "Approach to the adult with metabolic acidosis".) The pathophysiology and causes of lactic acidosis will be reviewed here. The possible role of bicarbonate therapy in such patients is discussed separately. (See "Bicarbonate therapy in lactic acidosis".) PATHOPHYSIOLOGY A review of the biochemistry of lactate generation and metabolism is important in understanding the pathogenesis of lactic acidosis [1]. Both overproduction and reduced metabolism of lactate appear to be operative in most patients. Cellular lactate generation is influenced by the "redox state" of the cell. The redox state in the cellular cytoplasm is reflected by the ratio of oxidized and reduced nicotine ad Continue reading >>

Lactic Acidosis In Diabetic Ketoacidosis

Lactic Acidosis In Diabetic Ketoacidosis

Go to: Discussion Lactate acidosis is a common finding in DKA. Several pathophysiological mechanisms are responsible for the extremely high lactate values sometimes found in patients with ketoacidotic. Originally, elevated lactate values in patients with DKA were thought to be the result of inadequate tissue perfusion and oxygenation (due to a contracted intravascular volume, aggravated by the presence of macrovascular disease and microangiopathies, an increased amount of glycosylated Hb, and an abnormal platelet function).1–3 The resulting relative hypoxaemia stimulates the process of anaerobic glycolysis, where pyruvic acid is converted to l-lactate, yielding two ATP molecules. More recently, however, it was demonstrated that the metabolic derangements itself present in DKA might contribute as well to the elevated lactate levels.4 Various studies have reported the presence of a positive correlation between glucose levels and ketone (β-hydroxybutyrate) levels on the one hand, and lactate levels on the other hand.4 5 This could be explained by various intracellular and extracellular mechanisms. First, an increased amount of d-lactate is formed in erythrocytes. Since erythrocytes do not require insulin for glucose uptake, intracellular glucose concentrations approach ambient extracellular levels during ketoacidosis. A substantial portion of the glucose in the erythrocyte is converted to pyruvate and finally l-lactate by aerobic glycolysis to produce ATP. The remainder is metabolised by the sorbitol pathway and the pentose-phosphate shunt to produce methylglyoxal, which is a toxic endogenous glucose metabolite, that is degraded by the glyoxalase system to produce d-lactate. Methylglyoxal (and thereby d-lactate) is also formed directly in the plasma via an interaction b Continue reading >>

D-lactate: A Novel Contributor To Metabolic Acidosis And High Anion Gap In Diabetic Ketoacidosis

D-lactate: A Novel Contributor To Metabolic Acidosis And High Anion Gap In Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA),the most common and serious acute complication of diabetes, is characterized by hyperglycemia and severe high–anion-gap metabolic acidosis with ketonemia (1). In DKA, the high anion gap is attributed largely to excessive production of blood ketone bodies, and serum β-hydroxybutyrate quantification is recommended for the diagnosis and monitoring of DKA (2). However, even counting of all the ketone bodies, including β-hydroxybutyrate, does not account for the entire anion gap, suggesting that there are additional sources of anion production in DKA. We recently demonstrated that plasma d-lactate concentrations were greatly increased in DKA compared with the concentrations in diabetic patients or a healthy control group (3). Nevertheless, the clinical value of d-lactate measurement in metabolic acidosis, especially the contribution of d-lactate to the metabolic acidosis and high anion gap in DKA, is not well appreciated. We report here that decreasing d-lactate concentrations are associated with improved clinical situations, whereas increased lactate concentrations are associated with the severity of metabolic acidosis and high anion gap in patients with DKA. The study included 38 diabetic patients with DKA, 42 diabetic patients without DKA, and 40 healthy controls. The institutional ethics review board of the First Affiliated Hospital of Wenzhou Medical College approved the study, and written informed consent was obtained from all study participants. For patients with DKA, blood samples were collected at the time of admission to the emergency room and following medical treatment after admission, when the patient's condition became stabilized. Plasma methylglyoxal was assayed by LC-MS (3). Plasma d-lactate concentration was determined by an e Continue reading >>

A Rare Case Of Persistent Lactic Acidosis In The Icu: Glycogenic Hepatopathy And Mauriac Syndrome

A Rare Case Of Persistent Lactic Acidosis In The Icu: Glycogenic Hepatopathy And Mauriac Syndrome

Copyright © 2016 Kirsten S. Deemer and George F. Alvarez. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Mauriac syndrome is a rare disorder that can present with the single feature of glycogenic hepatopathy in children and adults with poorly controlled diabetes mellitus. An often underrecognized finding of glycogenic hepatopathy is lactic acidosis and hyperlactatemia. Primary treatment of glycogenic hepatopathy is improved long-term blood glucose control. Resolution of symptoms and hepatomegaly will occur with improvement in hemoglobin A1C. We present here a case of a young adult female presenting to the intensive care unit with Mauriac syndrome. This case demonstrates exacerbation of lactic acidosis in a patient with glycogenic hepatopathy treated for diabetic ketoacidosis with high dose insulin and dextrose. 1. Introduction Lactic acidosis is a common finding in critically ill patients admitted to the intensive care unit (ICU) and it is associated with increased mortality [1, 2]. An anion gap and pH of less than 7.35 are not required for a definition of lactic acidosis as additional causes for anion gap and metabolic alkalosis often exist [3]. Seventy percent of lactate metabolism to glucose takes place in the liver via gluconeogenesis. Anaerobic glycolysis generates pyruvate, NADA, and H+, which is converted into lactate. When lactate production rises and exceeds that of consumption, hyperlactatemia and lactic acidosis result [3]. The most common cause of lactic acidosis in the ICU is type A. Currently there is debate among researchers surrounding the pathogenesis of some forms of type A lac Continue reading >>

Lactic Acidosis

Lactic Acidosis

Lactic acidosis is a medical condition characterized by the buildup of lactate (especially L-lactate) in the body, which results in an excessively low pH in the bloodstream. It is a form of metabolic acidosis, in which excessive acid accumulates due to a problem with the body's metabolism of lactic acid. Lactic acidosis is typically the result of an underlying acute or chronic medical condition, medication, or poisoning. The symptoms are generally attributable to these underlying causes, but may include nausea, vomiting, rapid deep breathing, and generalised weakness. The diagnosis is made on biochemical analysis of blood (often initially on arterial blood gas samples), and once confirmed, generally prompts an investigation to establish the underlying cause to treat the acidosis. In some situations, hemofiltration (purification of the blood) is temporarily required. In rare chronic forms of lactic acidosis caused by mitochondrial disease, a specific diet or dichloroacetate may be used. The prognosis of lactic acidosis depends largely on the underlying cause; in some situations (such as severe infections), it indicates an increased risk of death. Classification[edit] The Cohen-Woods classification categorizes causes of lactic acidosis as:[1] Type A: Decreased tissue oxygenation (e.g., from decreased blood flow) Type B B1: Underlying diseases (sometimes causing type A) B2: Medication or intoxication B3: Inborn error of metabolism Signs and symptoms[edit] Lactic acidosis is commonly found in people who are unwell, such as those with severe heart and/or lung disease, a severe infection with sepsis, the systemic inflammatory response syndrome due to another cause, severe physical trauma, or severe depletion of body fluids.[2] Symptoms in humans include all those of typical m Continue reading >>

Prevalence And Significance Of Lactic Acidosis In Diabetic Ketoacidosis.

Prevalence And Significance Of Lactic Acidosis In Diabetic Ketoacidosis.

Abstract PURPOSE: The prevalence and clinical significance of lactic acidosis in diabetic ketoacidosis (DKA) are understudied. The objective of this study was to determine the prevalence of lactic acidosis in DKA and its association with intensive care unit (ICU) length of stay (LOS) and mortality. METHODS: Retrospective, observational study of patients with DKA presenting to the emergency department of an urban tertiary care hospital between January 2004 and June 2008. RESULTS: Sixty-eight patients with DKA who presented to the emergency department were included in the analysis. Of 68 patients, 46 (68%) had lactic acidosis (lactate, >2.5 mmol/L), and 27 (40%) of 68 had a high lactate (>4 mmol/L). The median lactate was 3.5 mmol/L (interquartile range, 3.32-4.12). There was no association between lactate and ICU LOS in a multivariable model controlling for Acute Physiology and Chronic Health Evaluation II, glucose, and creatinine. Lactate correlated negatively with blood pressure (r = -0.44; P < .001) and positively with glucose (r = 0.34; P = .004). CONCLUSIONS: Lactic acidosis is more common in DKA than traditionally appreciated and is not associated with increased ICU LOS or mortality. The positive correlation of lactate with glucose raises the possibility that lactic acidosis in DKA may be due not only to hypoperfusion but also to altered glucose metabolism. Copyright © 2012 Elsevier Inc. All rights reserved. Continue reading >>

Hyperglycaemic Crises And Lactic Acidosis In Diabetes Mellitus

Hyperglycaemic Crises And Lactic Acidosis In Diabetes Mellitus

Hyperglycaemic crises are discussed together followed by a separate section on lactic acidosis. DIABETIC KETOACIDOSIS (DKA) AND HYPERGLYCAEMIC HYPEROSMOLAR STATE (HHS) Definitions DKA has no universally agreed definition. Alberti proposed the working definition of “severe uncontrolled diabetes requiring emergency treatment with insulin and intravenous fluids and with a blood ketone body concentration of >5 mmol/l”.1 Given the limited availability of blood ketone body assays, a more pragmatic definition comprising a metabolic acidosis (pH <7.3), plasma bicarbonate <15 mmol/l, plasma glucose >13.9 mmol/l, and urine ketostix reaction ++ or plasma ketostix ⩾ + may be more workable in clinical practice.2 Classifying the severity of diabetic ketoacidosis is desirable, since it may assist in determining the management and monitoring of the patient. Such a classification is based on the severity of acidosis (table 1). A caveat to this approach is that the presence of an intercurrent illness, that may not necessarily affect the level of acidosis, may markedly affect outcome: a recent study showed that the two most important factors predicting mortality in DKA were severe intercurrent illness and pH <7.0.3 HHS replaces the older terms, “hyperglycaemic hyperosmolar non-ketotic coma” and “hyperglycaemic hyperosmolar non-ketotic state”, because alterations of sensoria may be present without coma, and mild to moderate ketosis is commonly present in this state.4,5 Definitions vary according to the degree of hyperglycaemia and elevation of osmolality required. Table 1 summarises the definition of Kitabchi et al.5 Epidemiology The annual incidence of DKA among subjects with type 1 diabetes is between 1% and 5% in European and American series6–10 and this incidence appear Continue reading >>

Increased Serum D-lactate Associated With Diabetic Ketoacidosis

Increased Serum D-lactate Associated With Diabetic Ketoacidosis

Get rights and content We hypothesized that serum d-lactate may be increased in vivo in diabetes mellitus as a result of increased glucose flux through the glyoxalase pathway and/or via hepatic ketone metabolism. Levels of d-lactate and related metabolic intermediates were measured in 30 cats with spontaneous diabetes mellitus and in one ketoacidotic nondiabetic cat. Serum d-lactate was significantly (P = .0051) elevated in cats with ketoacidosis (337.2 70.2 mol/L) as compared with nonketoacidotic diabetic (140.3 58.8) and control (25.0 + 6.5) cats. Two nonketoacidotic cats also had high levels of d-lactate. There was a significant linear correlation (r = .684, P = .0001) between d-lactate and -hydroxybutyrate concentrations. Serum d-lactate did not correlate with serum glucose (r = .078, P = .6825), and in vitro erythrocyte d-lactate formation did not increase in the presence of hyperglycemia. These data suggest that hepatic ketone metabolism, rather than hyperglycemia, may be a major source of serum d-lactate in diabetics. Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Abbas E. Kitabchi, PhD., MD., FACP, FACE Professor of Medicine & Molecular Sciences and Maston K. Callison Professor in the Division of Endocrinology, Diabetes & Metabolism UT Health Science Center, 920 Madison Ave., 300A, Memphis, TN 38163 Aidar R. Gosmanov, M.D., Ph.D., D.M.Sc. Assistant Professor of Medicine, Division of Endocrinology, Diabetes & Metabolism, The University of Tennessee Health Science Center, 920 Madison Avenue, Suite 300A, Memphis, TN 38163 Clinical Recognition Omission of insulin and infection are the two most common precipitants of DKA. Non-compliance may account for up to 44% of DKA presentations; while infection is less frequently observed in DKA patients. Acute medical illnesses involving the cardiovascular system (myocardial infarction, stroke, acute thrombosis) and gastrointestinal tract (bleeding, pancreatitis), diseases of endocrine axis (acromegaly, Cushing`s syndrome, hyperthyroidism) and impaired thermo-regulation or recent surgical procedures can contribute to the development of DKA by causing dehydration, increase in insulin counter-regulatory hormones, and worsening of peripheral insulin resistance. Medications such as diuretics, beta-blockers, corticosteroids, second-generation anti-psychotics, and/or anti-convulsants may affect carbohydrate metabolism and volume status and, therefore, could precipitateDKA. Other factors: psychological problems, eating disorders, insulin pump malfunction, and drug abuse. It is now recognized that new onset T2DM can manifest with DKA. These patients are obese, mostly African Americans or Hispanics and have undiagnosed hyperglycemia, impaired insulin secretion, and insulin action. A recent report suggests that cocaine abuse is an independent risk factor associated with DKA recurrence. Pathophysiology In Continue reading >>

Prevalence And Significance Of Lactic Acidosis In Diabetic Ketoacidosis

Prevalence And Significance Of Lactic Acidosis In Diabetic Ketoacidosis

The prevalence and clinical significance of lactic acidosis in diabetic ketoacidosis (DKA) are understudied. The objective of this study was to determine the prevalence of lactic acidosis in DKA and its association with intensive care unit (ICU) length of stay (LOS) and mortality.Retrospective, observational study of patients with DKA presenting to the emergency department of an urban tertiary care hospital between January 2004 and June 2008.Sixty-eight patients with DKA who presented to the emergency department were included in the analysis. Of 68 patients, 46 (68%) had lactic acidosis (lactate, >2.5 mmol/L), and 27 (40%) of 68 had a high lactate (>4 mmol/L). The median lactate was 3.5 mmol/L (interquartile range, 3.32-4.12). There was no association between lactate and ICU LOS in a multivariable model controlling for Acute Physiology and Chronic Health Evaluation II, glucose, and creatinine. Lactate correlated negatively with blood pressure (r = -0.44; P < .001) and positively with glucose (r = 0.34; P = .004).Lactic acidosis is more common in DKA than traditionally appreciated and is not associated with increased ICU LOS or mortality. The positive correlation of lactate with glucose raises the possibility that lactic acidosis in DKA may be due not only to hypoperfusion but also to altered glucose metabolism. Do you want to read the rest of this article? ... Patients with a high score on the POP scale have a high rate of morbidity and mortality ( Senanayake et al., 1993). Elevation of lactate level is not clearly defined but most studies use range between 2.0 and 2.5 mmol/L ( Kruse et al., 2011) whereas, "high" lactate has been defined to be more than 4 mmol/L in many studies ( Howell et al., 2007;Cox et al., 2012;Shapiro et al., 2005;Callaway et al., 2009). On the o Continue reading >>

Lactic Acidosis Associated With Ketoacidosis

Lactic Acidosis Associated With Ketoacidosis

Surely there are enough reasons to have a nice acidosis when you are full of ketones. But on top of all that, you can also get a lactic acidosis. There is an association of diabetic ketoacidosis and lactic acidosis that goes beyond the tendency of diabetics to be on metformin. Indeed, in one case series there was “significant” lactate levels (i.e. over 4.0 mmol/L) in 40% of the patients. Glucose levels tended to correlated with lactate levels, suggesting that the lactate here is being produced as a result of some sort of abnormal cellular carbohydrate handing. The authors of this recent paper have admitted that this association is poorly researched. There does not seem to be a good mechanism worked out at this stage. Again, endogenous catecholamine excess is implicated. It is known that adrenaline levels correlate with DKA severity. D-lactate production may also play a role. A 2011 study has correlated D-lactate levels to the size of the anion gap in diabetic ketoacidosis; the article also ventures a hypothetical mechanism as to how this comes about. In any case, a much earlier study has demonstrated that whereas the ketone body levels correlated well with pH, the lactate did not, which suggests that lactate plays a fairly minor role in the actual acidosis. Additionally, Kerry Brandis reports on the interaction of lactate and ketoacids (specifically, on how lactate production tends to reduce the concentration of acetoacetate, thus fooling the most common ketone tests Continue reading >>

Evidence-based Guidelines For The Diagnosis And Treatment Of Diabetes Mellitus

Evidence-based Guidelines For The Diagnosis And Treatment Of Diabetes Mellitus

19 Acute Metabolic Complications of Diabetes 1. Diabetic Ketoacidosis (DKA) 1) Diagnosis ï¬ Diabetic ketoacidosis (DKA) is defined as a state in which a severe shortage of insulin and an increase in counter regulatory hormones combine to induce hyperglycemia (≥ 250 mg/dL), hyperketonemia (increased β-hydroxy-butyric acid), and acidosis (pH, < 7.30; bicarbonate concentration, < 18 mEq/L) requiring emergency care.a (grade A; consensus) 2) Treatment ï¬ Patients with DKA are to be given water and sodium supplementation with saline-based infusions.a (grade A; consensus) ï¬ It is important to ensure appropriate potassium supplementation in patients with DKA.a (grade A; consensus) ï¬ Acidosis is not to be corrected in patients with DKA.1,a (grade A) ï¬ Low-dose insulin (intravenous infusion of regular insulin) is to be given continuously to patients with DKA. (grade A; consensus) 3) Complications Associated with DKA ï¬ Patients with DKA may be associated with brain edema, hyperchloremic metabolic acidosis, and hypokalemia, and should therefore be monitored for consciousness, vital signs, and electrolytes over time during the course of treatment. (grade A; consensus) 2. Hyperosmolar Hyperglycemic Syndrome (HHS) 1) Diagnosis ï¬ Hyperosmolar hyperglycemic syndrome (HHS) is likely to occur when patients with type 2 diabetes become hyperglycemic due to infection, cerebrovascular disease, surgery, high-calorie infusions, and inappropriate use of diuretics or steroids. While HHS is known to be common in the elderly, it is also drawing attention as an initial symptom of pediatric type 2 diabetes (particularly in African-Americans). (grade A; consensus) ï¬ HHS leads to varying levels of impaired consciousness, polydipsia due to dehydration, polyuria, and genera Continue reading >>

Lactic Acidosis: Background, Etiology, Epidemiology

Lactic Acidosis: Background, Etiology, Epidemiology

Author: Kyle J Gunnerson, MD; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, MCCM more... In basic terms, lactic acid is the normal endpoint of the anaerobic breakdown of glucose in the tissues. The lactate exits the cells and is transported to the liver, where it is oxidized back to pyruvate and ultimately converted to glucose via the Cori cycle. In the setting of decreased tissue oxygenation, lactic acid is produced as the anaerobic cycle is utilized for energy production. With a persistent oxygen debt and overwhelming of the body's buffering abilities (whether from chronic dysfunction or excessive production), lactic acidosis ensues. [ 1 , 2 ] (See Etiology.) Lactic acid exists in 2 optical isomeric forms, L-lactate and D-lactate. L-lactate is the most commonly measured level, as it is the only form produced in human metabolism. Its excess represents increased anaerobic metabolism due to tissue hypoperfusion. (See Workup.) D-lactate is a byproduct of bacterial metabolism and may accumulate in patients with short-gut syndrome or in those with a history of gastric bypass or small-bowel resection. [ 3 ] By the turn of the 20th century, many physicians recognized that patients who are critically ill could exhibit metabolic acidosis unaccompanied by elevation of ketones or other measurable anions. In 1925, Clausen identified the accumulation of lactic acid in blood as a cause of acid-base disorder. Several decades later, Huckabee's seminal work firmly established that lactic acidosis frequently accompanies severe illnesses and that tissue hypoperfusion underlies the pathogenesis. In their classic 1976 monograph, Cohen and Woods classified the causes of lactic acidosis according to the presence or absence of adequate tissue oxygenation. (See Presentationand Differe Continue reading >>

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