Lactic acidosis, ketoacidosis, and energy turnover: "figure" you made the correct diagnosis only when you have "counted" on it--quantitative analysis based on principles of metabolism.

Three cases are presented to illustrate that quantitative analysis based on physiologic principles can help resolve certain controversies in clinical medicine. For example, in case 1, a patient with severe hypoxia, the rate of production of lactic acid is so high that only restoration of delivery of oxygen is rational therapy. If the degree of hypoxia exceeds 5.6% of demand, dichloroacetate will not lessen the degree of acidosis. Further, even when delivery of oxygen is returned to normal, the rate of fall in lactate and rise in bicarbonate in plasma will be relatively slow. In case 2, a patient with diabetic ketoacidosis, our discussion stresses that the rate of production of ketoacids is not that rapid and that the degree of ketoacidosis is influenced to a major degree by decreasing the rate of oxidation of ketoacids in brain and kidneys. Case 3, a patient with severe hyperglycemia, illustrates that insulin will only promote the oxidation of glucose at a rapid rate once the levels of fatty acids and ketoacids decline to low levels. Accelerated transport of glucose by insulin is only a permissive action for the oxidation of glucose.