see: [bear - lactic acidosis](bear://x-callback-url/open-note?id=26767500-6B57-4B78-BF10-BD57A72B853A-25060-000008F2D053289C) # measurement - collect specimen in fluoride tube if analysis from a gas sample is not performed within 45 minutes - levels decrease with time after sampling - ​lactate increases with time when other tubes are used due to production by blood cells, especially with leukocytosis - **venous gas samples give results approximately 20% higher** than venous samples in fluoride tubes - laboratory usually only measures L-lactate - ​D-lactate is produced in short bowel syndrome so may not be recognised by standard assays - however the anion gap may still be elevated ## venous lactate mild 2.0 -4.0 mmol/L - [[Blood gas#anion gap|anion gap]]​ normal in 80% severe 4-10 mmol/L - AG normal in 50% ​very severe > 10 mmol/L - 100% mortality # toxic causes - [[Toluene toxicity]] - [[Lead]] or [[Iron overdose]] - [[​Lithium Toxicity]] - [[Valproate]] - [[Cyanide]] -- severe lactic acidosis - [[toxic alcohols]] — look for *lactate gap* (VBG lactate high, serum normal) - [[Aspirin overdose]] - [[carbon monoxide]] - [[Metformin overdose]] - [[Calcium channel blocker overdose]] - [[Paracetamol overdose]] # What happens when you have a NAGMA but ↑ lactate?? > ↑ bilirubin, [[hypoglycaemia|hypoglycemia]], ↓ albumin, ↑ lactate suggests *liver failure* - [[Blood gas#albumin correction|↓ albumin]] / liver failure can cause a falsely lowered [[Blood gas#anion gap]] - (suspected or confirmed low albumin), low AG, ↑ bilirubin, and ↑ lactate may indicate *liver failure* as cause - the low albumin will mask a HAGMA which you would expect with elevated lactate - *multiple myeloma* and [[​Lithium Toxicity]] are the other causes of HAGMA and LAGMA besides low albumin