A Rare Reason for Hyperlactatemia in a Critical Patient after a Major Abdominal Surgery: Thiamine Deficiency/Major Abdominal Cerrahi Gecirmis Kritik Hastada Hiperlaktateminin Nadir Bir Nedeni: Tiamin Eksikligi

• Published in: Yogu︣n bakim dergisi Vol. 8; no. 2; p. 54
• Main Authors: Yildirim, Fatma, Unal, Mucahit, Karabacak, Harun, Ergul, Zafer
• Format: Journal Article
• Language: English
• Published: AVES 01-08-2017
• Subjects: Abdominal surgery; Cancer metastasis; Care and treatment; Causes of; Lactic acidosis; Thiamine deficiency
• ISSN: 1309-1689
• DOI: 10.5152/dcbybd.2017.1461

Type B lactic acidosis is an under-recognized clinical entity that must be distinguished from type A (hypoxic) lactic acidosis. A 56-year-old female with a history of colon carcinoma with liver metastasis underwent right hemicolectomy, ileocolic anastomosis, and liver metastasectomy. Two days later, she presented to the general surgical intensive care unit with fever, hypotension, and tachycardia. Arterial blood gas analysis revealed a pH of 7.35, a PaC[O.sub.2] of 44.8 mm Hg, an HC[O.sub.3]- level of 22.1 mEq/L, a base deficit of -3.3 mmol/L, and a lactate level of 4.3 mEq/L. Liver functions were moderately elevated (AST: 647 U/L, ALT: 153 U/L) on admission. Wound culture revealed the presence of Escherichia coli, and piperacillin-tazobactam was prescribed. She received adequate fluid resuscitation with normal saline, antibiotics for treating septic shock, and norepinephrine for maintaining appropriate blood pressure. Despite achieving blood pressure appropriate for her age and improved tissue perfusion, the patient's lactate level increased to 23 mEq/L. Abdominal computed tomography with angiography showing vascular structures was concerned for possible anastomosis leakage, given the rise in lactate levels with concern for intra-abdominal pathology. There were no signs of perforation and ischemia. Because of a high suspicion that the patient's hyperlactatemia was not due to tissue hypoxia, we used the patient's blood sample to measure the vitamin B1 (thiamine) level. We did not immediately perform thiamine replacement because hyperlactatemia did not accompany acidosis. Her thiamine level was 10 [micro]g/L (range, 25-75 [micro]g/L). Then, 100 mg/ day of intravenous thiamine was administered. Within 3 days, her lactate level fell to 2.5 mmol/L; within 24 h, it fell to 1.9 mmol/L. Additional history revealed that she had been taking very little nutrition by mouth before admission and that she was primarily dependent on total parenteral nutrition (TPN). There were no vitamins in her TPN; thus, she was likely to be thiamine deficient during her initial presentation. Keywords: Thiamine deficiency, hyperlactatemia, colon carcinoma, hemicolectomy Received: 16.04.2017 Accepted: 13.12.2017 Tip B laktik asidoz, tip A (hipoksik) laktik asidozdan ayirt edilmesi gereken, yeterince taninmayan bir klinik durumdur. 56 yasinda kadin hastaya kolon kanseri ve karaciger metastazi nedeni ile sag hemikolektomi, ileokolik anastomoz ve karaciger metastazektomi yapildi. Ameliyattan iki gun sonra ates, hipotansiyon ve tasikardi bulgulari ile genel cerrahi yogun bakim unitesine kabul edildi. Bilinci acikti. Giris laboratuvar testlerinde notrofil sayisi 3 x [10.sup.3]/[micro]L idi. Kan gazinda pH: 7,35, PaC[O.sub.2]: 44,8 mmHg, HC[O.sub.3]- :22.1 mEq/L baz acigi: -3,3 mmol/L ve laktat: 4,3 mmol/L idi. Bobrek fonksiyon testleri normal duzeyde, karaciger enzimler orta seviyede yukselmisti (AST: 647 U/L ALT: 153 U/L). Yara yeri kulturunde ureyen Escherichia coli icin Piperasilin tazobaktam baslandi. Hastaya izotonik sodyum klorur cozeltisi ile uygun sivi tedavisi septik sok icin uygun antibiyoterapi ve kan basincini duzenlemek icin inotrop destek saglandi. Uygun kan basinci ve doku perfuzyonu saglanmasina ragmen hastanin laktat seviyesi 23 mmol/L ye kadar yukseldi. Anastomoz kacagi suphesi ile abdomen bilgisayarli tomografi anjiografi cekildi. Perforasyon ve iskemi lehine bulguya rastlanmadi. Hastanin laktat yuksekliginin hipoksemiden kaynaklanmadigi dusunulerek Vit B1 (Tiamin) kan duzeyi gonderildi. Laktik asit yuksekligine asidoz eslik etmediginden tiamin replasmani yapilmakta acele edilmedi. Tiamin seviyesi 10 [micro]g/L (25-75 [micro]g/L) olculdu. 100 mg/gun intravenoz tiamin baslandi. 3 gun icerisinde hastanin laktat seviyesi 2,5 mmol/L'ye sonrasinda 72 saatte 1,9 mmol/L'ye geriledi. Hastanin anamnezi derinlestirildiginde oral aliminin kotu oldugu ve son iki gundur total parenteral nutrisyon (TPN) bagimli oldugu ogrenildi. Hastanin TPN'sinde ek olarak vitaminler yoktu. Muhtemelen basvurudan itibaren hastanin tiamin duzeyinin dusuk oldugu dusunuldu. Anahtar Kelimeler: Tiamin eksikligi, hiperlaktatemi, kolon karsinomu, hemikolektomi Gelis Tarihi: 16.04.2017 Kabul Tarihi: 13.12.2017