Is There a Direct Relationship Between Lactic Acidosis and Epinephrine Administration?-Reply

In Reply.  —We thank Dr Guerin and associates for their interest in our article. We can reassure the reader that the patient's cardiac index was 2.0 L/min/m²—an excellent value for an elderly patient after cardiac bypass and who had not received pressors. We emphasized in our report that the pressors were administered empirically, not because of hypotension, oliguria, or any other evidence of poor tissue perfusion. Thus, the scenario for type A lactic acidosis is conspicuously absent. A serum bicarbonate level of 19 mmol/L (19 mEq/L) is insufficient to support a diagnosis of lactic acidosis, and may reflect the mild hyperlactatemia that accompanies general anesthesia.¹We have never seen insulin resistance of this severity in a diabetic patient, obese or otherwise, except in the rare circumstances of insulin² or insulin receptor³ antibodies. The temporal relationship between insulin resistance and epinephrine administration is compelling, and the