Getting Burned by Lactic Acid.

Abstract

A 13-year-old boy with a history of moderate, persistent asthma was transferred to our facility from an outside hospital with shortness of breath and cough of 2 days’ duration. In the emergency department at the other facility, initial vitals were temperature, 98.9°F; heart rate, 120 beats per minute; respiration rate, 40; pulse oxygen saturation, 87% on room air; and blood pressure, 191/63 and 128/41 upon repeat. Screening laboratory tests were performed: the complete blood count was within reference ranges, serum chemistry was notable for a bicarbonate concentration of 29 mEq/L, and peripheral venous lactate was 2.8 mmol/L. Chest x-ray showed central peribronchial cuffing consistent with viral infection. Because of persistent wheezing and moderately increased work of breathing, the patient was placed on continuous nebulized albuterol (20 mg/h) and given 125 mg intravenous methylprednisolone, 250 mg oral azithromycin, and 1 g intravenous magnesium sulfate. Symptoms significantly improved per their report. Given the elevated lactate on the initial laboratories, he was given a 1-L bolus of intravenous crystalloid. Multiple repeat point-of-care capillary lactate levels were obtained: 7.2, 7.5, and 7.9 mmol/L. The persistently elevated lactate levels triggered additional fluid boluses and order for blood culture. The treatment team believed the patient was ready to be …