Correct!
3. Inhibition of nitric oxide synthetase, and nitric oxide production
After approximately 9 hours of continuous renal replacement therapy the patient’s acidosis was minimally improved, hypotension persisted, and a subsequent bolus of methylene blue was administered but with no improvement in blood pressure. A small supply of sodium bicarbonate was able to be obtained with regular pushes given to maintain MAPs in the 50’s. After 14 hours, the acidosis began to correct and the patient’s hypotension began to resolve. Vasopressors were titrated off within 30 hours of admission.
This is a case of metformin associated lactic acidosis (MALA) in the setting of iatrogenically induced acute renal failure due to rapid initiation of multiple potentially nephro-toxic medications. Treatment for MALA is mainly supportive to allow time for metabolism of metformin and correction of metabolic acidosis. With such a profound acidosis CRRT requires significantly more time to affect acid base levels and multiple interventions were required in an effort to allow time for this reversible cause of metabolic acidosis to clear. The patient in question had a return of renal function to baseline, is no longer dialysis dependent, and was discharged home.
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