什么是高乳酸血癥？
乳酸酸中毒的分型
依據(jù)有無(wú)組織低氧，把乳酸酸中毒分為 A 型和 B 型。A 型乳酸酸中毒是由于組織低氧引起的乳酸堆積，B 型不存在組織低氧，一方面是由于乳酸生成的增加，如惡性腫瘤、膿毒血癥等損害了細(xì)胞的氧利用，另一方面由于乳酸的代謝降低，如肝病等。A 型和 B 型乳酸酸中毒常存在重疊。例如在膿毒血癥中，患者既存在由微循環(huán)衰竭引起的乳酸鹽產(chǎn)生增加，又存在非單純由氧輸送減少引起的乳酸鹽清除率的降低。
雙胍類藥物治療 2 型糖尿病時(shí)可引起 B 型乳酸酸中毒。二甲雙胍在意外或故意急性過量用藥導(dǎo)致血藥濃度較高時(shí)，最可能引起乳酸酸中毒。這種情況相對(duì)容易處理，及時(shí)停藥、補(bǔ)液及利尿，大多數(shù)患者可以緩解。
部分糖尿病酮癥酸中毒患者可發(fā)生與雙胍類藥物治療無(wú)關(guān)的中度乳酸酸中毒。其中低血容量可能起了重要作用。
短腸綜合征或其他吸收不良綜合征
酸中毒在進(jìn)食后出現(xiàn)，并在禁食后緩解
特征性的神經(jīng)系統(tǒng)癥狀和體征
既往曾大劑量靜脈輸注以丙二醇為溶劑的藥物或攝入丙二醇
乳酸酸中毒的治療
對(duì)于乳酸酸中毒的治療，最首要的是糾正原發(fā)病，即改善休克、糾正心衰、輸血輸液，改善凝血等，這些是前提。
其次總結(jié)一下處理乳酸酸中毒最直接的方案——補(bǔ)堿，即碳酸氫鈉的使用。
確?；颊咄獬渥悖贿@是乳酸酸中毒患者有效使用外源性碳酸氫鹽治療的一個(gè)必要條件。在重度酸血癥患者中，確?；颊哌_(dá)到一定程度的過度通氣，使血?dú)庵?PCO2 至少降至 15 mmHg，通常降至 10-12 mmHg。
應(yīng)用碳酸氫鈉可能導(dǎo)致離子鈣濃度降低，引起不良的血流動(dòng)力學(xué)后果。故如果應(yīng)用碳酸氫鈉過程中監(jiān)測(cè)到動(dòng)脈血?dú)夥治鲋械拟}離子降低，需及時(shí)補(bǔ)充鈣離子。
關(guān)于乳酸升高的診治您還有哪些問題和經(jīng)驗(yàn)？
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排版：美超
投稿：wangmeichao@dxy.cn
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