INS and lactic acidosis: Lactic acid elevation is common in diabetic ketoacidosis; however, the lactic acidosis is rarely the major contributor to the overall acidotic state.7 Therefore, outside of glycogenic hepatopathy, significant lactic acid elevation would be concerning for an underlying hypoperfusion, secondary to hypovolemia, hypotension and hyperventilation.7 Hyperglycemia and high levels of insulin can decrease gluconeogenesis and decrease the rate of conversion of pyruvate to glucose.