The Internet Book of Critical Care Podcast IBCC Episode 32 - Metformin Toxicity
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Apr 11, 2019 The podcast explores the direct, indirect, and obscured role of metformin in critical care patients. Topics discussed include the clinical presentation, evaluation, diagnosis, and management of metformin toxicity. They also delve into the challenges of choosing the appropriate fluid for volume resuscitation, indications for dialysis, and the mechanisms and use of methylene blue for shock treatment.
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Spectrum of Metformin Toxicity
- Metformin toxicity can be seen as a spectrum: direct toxicity, associated with other conditions, or an innocent bystander.
- Recognizing this spectrum helps clarify clinical confusion and guide diagnosis and treatment.
Metformin Mitochondrial Poisoning
- At toxic levels, metformin poisons mitochondria, shutting down the Krebs cycle and causing pyruvate to convert to lactate.
- Elevated lactate reflects disrupted cellular metabolism from mitochondrial dysfunction.
Understanding MELA Presentation
- Metformin-induced lactic acidosis (MELA) occurs from overdose or accumulation in chronic kidney disease.
- Patients may have severe lactic acidosis but appear clinically stable and not in shock.