Effect of bicarbonate and lactate buffer on glucose and lactate metabolism during hemodiafiltration in patients with multiple organ failure

To compare the effects of sodium bicarbonate and lactate for continuous veno-venous hemodiafiltration (CVVHDF) in critically ill patients.

Prospective crossed-over controlled trial in the surgical and medical ICUs of a university hospital.

Eight patients with multiple organ dysfunction syndrome (MODS) requiring CVVHDF.

Each patient received the two buffers in a randomized sequence over two consecutive days.

The following variables were determined: acid-base parameters, lactate production and utilization (¹³C lactate infusion), glucose turnover (6,6²H₂-glucose), gas exchange (indirect calorimetry). No side effect was observed during lactate administration. Baseline arterial acid-base variables were equal with the two buffers. Arterial lactate (2.9 versus 1.5 mmol/l), glycemia (+18%) and glucose turnover (+23%) were higher in the lactate period. Bicarbonate and glucose losses in CVVHDF were substantial, but not lactate elimination. Infusing ¹³C lactate increased plasma lactate levels equally with the two buffers. Lactate clearance (7.8±0.8 vs 7.5±0.8 ml/kg per min in the bicarbonate and lactate periods) and endogenous production rates (14.0±2.6 vs 13.6±2.6 mmol/kg per min) were similar. ¹³C lactate was used as a metabolic substrate, as shown by ¹³CO₂ excretion. Glycemia and metabolic rate increased significantly and similarly during the two periods during lactate infusion.

Lactate was rapidly cleared from the blood of critically ill patients without acute liver failure requiring CVVHDF, being transformed into glucose or oxidized. Lactate did not exert undesirable effects, except moderate hyperglycemia, and achieved comparable effects on acid-base balance to bicarbonate.