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The initiation of mechanical ventilation in the setting of profound metabolic acidosis can be a particular challenge in the transport environment. The classic teaching is that patients with severe acidemia should not be intubated, if possible, because they are often able to better maintain their own compensatory minute ventilation compared with clinician management with the mechanical ventilator. In this case, a patient had profound metformin-associated lactic acidosis with a pH of 6.51 and required intubation for deteriorating mental status with an inability to protect her airway. Maintaining adequate minute ventilation can be directly in conflict with the evidence-based approach of low tidal volume ventilation for all patients. When patients have profound metabolic acidosis without evidence of acute respiratory distress syndrome, increasing the tidal volume slightly to allow for more efficient respiration can be an effective strategy to maintain acid-base status. Copyright © 2023 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.


Michael A Frakes, Jackson McWade, Vahé Ender, Jason E Cohen, Susan R Wilcox. Ventilator Management in Metformin-Associated Lactic Acidosis: A Case Report. Air medical journal. 2023 Jul-Aug;42(4):300-302

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PMID: 37356894

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