CHEST Guidelines-A-35-Year-Old-Woman-With-Shock,-Pulseless-Electric

A-35-Year-Old-Woman-With-Shock,-Pulseless-Electric

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A 35-year-old woman with diabetes and a past adverse reaction to metformin presented with worsening abdominal pain, nausea, vomiting, and fatigue, accompanied by confusion and minimal responsiveness as her condition advanced. Initial assessments indicated severe metabolic acidosis, with profoundly high lactate (21.5 mmol/L) and dangerously low blood glucose levels (16 mg/dL). Despite denying recent metformin use, she later admitted to self-administration to manage her blood glucose. Physical signs were initially relatively stable, but she quickly developed marked hemodynamic instability, leading to a pulseless electrical activity arrest.<br /><br />The diagnosis was acute metformin-associated lactic acidosis (MALA), a rare but potentially fatal complication characterized by high lactate levels, metabolic acidosis, and often hypoglycemia and hypothermia. It arises from metformin's inhibition of mitochondrial respiratory chain complex 1, which disturbs cellular energy production and acid-base balance. MALA's high mortality, linked to elevated lactate levels, necessitates quick clinical recognition and immediate intervention. <br /><br />As part of her rapid treatment, she was resuscitated, received fluids, sodium bicarbonate, vasopressors, and underwent hemodialysis. Hemodialysis was critical in eliminating excess metformin and correcting metabolic acidosis, leading to her stabilization. Subsequently, she was extubated and stabilized, demonstrating the importance of timely intervention in MALA cases.<br /><br />This case underscores key learnings: Metformin toxicity must be considered in patients with disproportionate lactic acidosis relative to hemodynamics, and high lactate levels can be predictive of outcomes. Renal replacement therapy is vital for improving survival in MALA cases. Documentation of true drug allergies and precise medication reconciliation are crucial in preventing similar episodes. Following treatment, the patient was discharged and educated to avoid metformin, highlighting preventive measures post-recovery.

Keywords

metformin-associated lactic acidosis

MALA

metabolic acidosis

high lactate levels

hemodialysis

diabetes

metformin toxicity

renal replacement therapy

drug allergies

patient education