Why does epinephrine cause acidosis

Although these effects are unlikely to be serious in healthy patients, local anesthetics containing epinephrine should be used with caution, especially in patients with cardiovascular diseases, acid-base abnormalities, and disorders that could lead to hyperlactatemia or hyperglycemia. Furthermore, careful observation for changes in plasma lactate and glucose levels through serial follow-up of ABGA along with the intensive monitoring of vital signs should be performed in the perioperative period if epinephrine was used excessively as a vasoconstrictor during surgery.

Conflict of Interest: No potential conflict of interest relevant to this article was reported. Korean Association of Medical Journal Editors. E-mail: koreamed kamje. Published online October 25, All rights reserved. Corresponding author: Jang-Ho Son. Case 1 A year-old, kg male patient was scheduled to undergo Le Fort I osteotomy, bilateral sagittal split osteotomy BSSO , and genioplasty for the correction of mandibular prognathism with midface deficiency.

Case 2 A year-old, kg male patient was scheduled to undergo high Le Fort I osteotomy, BSSO, genioplasty, and malar augmentation for a mandibular prognathism with midface deficiency. Epinephrine-induced lactic acidosis in orthognathic surgery: a report of two cases.

Cases Report. Table 1 Serial arterial blood gas analysis during and after anesthesia in Case 1. Click for larger image Click for full table Download as Excel file.

Table 2 Serial arterial blood gas analysis during and after anesthesia in Case 2. Pharmacodynamic responses of exogenous epinephrine during mandibular third molar surgery. Haas DA. An update on local anesthetics in dentistry.

J Can Dent Assoc ;— Local anesthetics: review of pharmacological considerations. Anesth Prog ;— Effects of adrenaline on lactate, glucose, lipid and protein metabolism in the placebo controlled bilaterally perfused human leg.

Acta Physiol Oxf ;— J Acquir Immune Defic Syndr ;— Cardiovascular and metabolic effects of cervical epinephrine infiltration. Obstet Gynecol ;— Oral mucosal blood flow, plasma epinephrine and haemodynamic responses after injection of lidocaine with epinephrine during midazolam sedation and isoflurane anaesthesia. Br J Anaesth ;— Lactate in shock: a highoctane fuel for the heart?

Intensive Care Med ;— Case severe lactic acidosis during cardiac surgery. J Cardiothorac Vasc Anesth ;— Yagiela JA.

Vasoconstrictor agents for local anesthesia. Urine output is blue 20 ml for 12 hours. Hey Josh. Thanks for this article. I appreciate your perspective on this subject, as well as your willingness to buck convention a bit to provide it. I found it helpful in helping me understand where lactate fits in the process and patho physiology of sepsis. I hope you continue to share your perspective and personal understanding on subjects like these as I perceive it will benefit our society. That author is Mark A.

I believe you … Read more ». We are the EMCrit Project , a team of independent medical bloggers and podcasters joined together by our common love of cutting-edge care, iconoclastic ramblings, and FOAM. Once upon a time a year-old man was transferred from the oncology ward to the ICU for treatment of neutropenic septic shock. His MAP remained in the high 40s, he was mottled up to the knees, and he wasn't making any urine. Echocardiography suggested a moderately reduced left ventricle ejection fraction, not terrible but perhaps inadequate for his current condition.

Dobutamine has usually been our choice of inotrope in septic shock. However, this patient was so unstable that we chose epinephrine instead. However, his lactate level began to rise. He was improving clinically, so we suspected that the lactate was due to the epinephrine infusion. We continued the epinephrine, he continued to improve, and his lactate continued to rise.

His lactate level increased as high as 15 mM, at which point the epinephrine infusion was being titrated off anyway. Once the epinephrine was stopped his lactate rapidly normalized. He continued to improve briskly. By the next morning he was off vasopressors and ready for transfer back to the ward.

This was eye-opening. It seemed that the epinephrine infusion was the pivotal intervention which helped him stabilize. However, while clinically improving him, the epinephrine infusion was also driving his lactate to very high levels.

How could this be? Isn't lactate evil? Isn't the entire point of sepsis resuscitation to normalize the lactate? The classical understanding of lactate in sepsis is flawed. The following is a brief overview of newer ideas about lactate. For a more complete discussion please see articles by Paul Marik listed below in the references. Traditionally it was believed that elevated lactate is due to anaerobic metabolism, as a consequence of inadequate perfusion with low oxygen delivery to the tissues.

This has largely been debunked. Most patients with sepsis and elevated lactate have hyperdynamic circulation with very adequate delivery of oxygen to the tissues.

Studies have generally failed to find a relationship between lactate levels and systemic oxygen delivery or mixed venous oxygen saturation.

There is little evidence of frank tissue hypoxemia in sepsis. Moreover, the lungs have been shown to produce lactate during sepsis, which couldn't possibly be due to hypoxemia Marik This has significant implications for sepsis treatment. Traditional belief in inadequate oxygen delivery led to multiple interventions to improve oxygen delivery e. Lack of oxygen deficiency may explain why these interventions have not proven to be beneficial. Lactate elevation in sepsis seems to be due to endogenous epinephrine stimulating beta-2 receptors figure below.

Particularly in skeletal muscle cells, this stimulation up-regulates glycolysis, generating more pyruvate than can be used by the cell's mitochondria via the TCA cycle. Excess pyruvate is converted into lactate. This process is entirely aerobic, occurring despite adequate oxygen delivery. Lactate generation doesn't occur because the mitochondria are unable to function in the absence of oxygen. Instead, lactate generation occurs because the TCA cycle simply isn't able to keep up with a very rapid rate of glycolysis.

Lactate serves as a metabolic fuel for the heart and brain in conditions of stress. In a rat sepsis model, depletion of lactate caused cardiovascular collapse, which could be reversed by infusing sodium lactate Levy This study also found that selective blockade of beta-2 receptors decreased lactate levels and reduced survival duration.

Lactate correlates with illness severity, generally being a sign of badness. This may lead to the misconception that lactate itself is harmful. Setting: Postsurgical cardiothoracic intensive therapy unit. Patients: Thirty-six adult patients, without acidosis, requiring vasoconstrictors for the management of hypotension after cardiopulmonary bypass. Interventions: Randomized administration of either epinephrine or norepinephrine by infusion. The authors describe the case of a year-old male with a history of shellfish allergy who presented to the emergency department with dyspnea, dysphagia and urticaria shortly after ingesting shellfish.

The patient had normal vital signs but significant swelling of the airway and a lactic acid level of 3. Treatment was initiated with subcutaneous epinephrine, an epinephrine drip, diphenhydramine, famotidine, methylprednisolone, and IV fluids. It is not clear why a continuous infusion of epinephrine was selected, as the description of the case does not reflect the treatment-resistant anaphylactic and hypotensive state that would usually serve as an indication for epinephrine infusion.