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Over the past few years, the treatment of sepsis and septic shock has changed substantially. Many of the new therapies place the impetus on ED clinicians whose initial actions are critical in the long-term outcomes of these patients. As the reader identified, clinicians have traditionally used systemic inflammatory response syndrome (SIRS) criteria to facilitate the diagnosis of sepsis and to risk stratify septic patients. However, it is unknown whether SIRS criteria have any discriminatory value in patients with febrile neutropenia who, by definition, meet 2 of the 4 SIRS criteria. The Surviving Sepsis Campaign guidelines recommend measuring serum lactate level to assess sepsis severity. However, the interpretation of blood lactate levels in neutropenic oncology patients is not always straightforward. Lactic acid production normally occurs under conditions of hypoxia in all peripheral tissues, and after its release into circulation, 90% of lactic acid is metabolized in the liver, where it is converted to pyruvate, with the remaining 10% metabolized or excreted by the kidney. Unlike normal cells, tumor cells rely on anaerobic glycolysis disproportionately, even in the presence of oxygen. As a result, the tumor cells produce large quantities of lactate, and this can lead to an imbalance between lactate production by tumor cells and its utilization by the liver especially in patients with hepatic tumors or metastases.¹ Spontaneous lactic acidosis can occur in patients with hematologic and lymphoid malignancies as well as solid tumors, having been described in patients with breast, colon, ovarian, and small cell lung cancer.¹

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1. Tito Foto A. Oncology emergencies: lactic acidosis and cancer. In:  DeVita VT,  Lawrence TS,  Rosenberg S editor. Cancer: principles and practice of oncology. 8th ed.. Philadelphia: Lippincott Williams & Wilkins; 2008;p. 2451
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