Angeletti Chiara, Vergani Cinzia, Troili Stefano, Carrocci Chiara, De Martinis Giulia, Venturoni Federica, Marinangeli Franco, Gentili Luca
Anesthesiology, Intensive Care and Pain Medicine, Civil Hospital G. Mazzini of Teramo, Teramo, Italy.
Department of Anesthesia and Intensive Care Unit, Pio XI Desio Hospital, ASST Brianza, Desio, Italy.
AME Case Rep. 2023 Sep 4;7:39. doi: 10.21037/acr-22-100. eCollection 2023.
Diabetic patients on metformin therapy may be vulnerable to lactic acidosis during acute illness. This is particularly true since the comorbid conditions among patients with diabetes and the frequent use of renin-angiotensin system blockers increase the risk of renal dysfunction.
We present two cases of metformin-associated lactic acidosis (MALA) occurred after abdominal surgery. A 74-year-old woman presented to emergency department (ED) for a transient loss of consciousness. She had vomiting, diarrhea, and lack of appetite in the last 3 days and she had had an abdominal adhesiolysis surgery 12 days before. A 78-year-old man, with history of right hemicolectomy performed 15 days before admission to ED. Patient presented with diffuse abdominal pain, diarrhea, nausea, and vomiting). Arterial blood gas analysis showed acidemia (pH 7.031), elevated anion gap (AG), lactate >15.5 mmol/L. Due to the patients' critical condition, vasopressor infusion and fluid resuscitation were started and an urgent continuous veno-venous hemodialysis with citrate and calcium (CVVHD-CiCa) treatment was provided.
A promptly differential diagnosis at ED and early treatment with vital support and CVVHD-CiCa enabled the resolution of MALA, which can often be a fatal complication in diabetic patients taking metformin. Close collaboration with the surgical and endocrinological team would be necessary for the management of the postoperative period planning the reintroduction of metformin in patients undergoing major abdominal surgery, to avoid the possibility of the onset of MALA.
接受二甲双胍治疗的糖尿病患者在急性疾病期间可能易发生乳酸性酸中毒。鉴于糖尿病患者的合并症以及肾素 - 血管紧张素系统阻滞剂的频繁使用增加了肾功能不全的风险，情况尤其如此。
我们报告两例腹部手术后发生的二甲双胍相关性乳酸性酸中毒（MALA）病例。一名74岁女性因短暂意识丧失就诊于急诊科。她在过去3天出现呕吐、腹泻和食欲不振，12天前接受了腹部粘连松解术。一名78岁男性，在入住急诊科前15天进行了右半结肠切除术。患者表现为弥漫性腹痛、腹泻、恶心和呕吐。动脉血气分析显示酸血症（pH 7.031）、阴离子间隙（AG）升高、乳酸>15.5 mmol/L。由于患者病情危急，开始使用血管活性药物输注和液体复苏，并紧急进行了柠檬酸盐和钙连续静脉 - 静脉血液透析（CVVHD - CiCa）治疗。
在急诊科迅速进行鉴别诊断并早期给予生命支持和CVVHD - CiCa治疗可使MALA得到缓解，MALA在服用二甲双胍的糖尿病患者中通常可能是致命并发症。对于接受大腹部手术患者的术后管理以及计划重新引入二甲双胍，与外科和内分泌团队密切合作是必要的，以避免发生MALA的可能性。
