Introduction Lactic acid (LA) is a commonly used biomarker and is often indicative of severity of disease in critically ill patients. Lactic acidosis which is defined as LA > 4.0 can be divided into two categories: Type A which is the more common type is caused by systemic tissue hypoperfusion most likely due to shock and Type B which is caused by impairment of cellular metabolism and or decreased clearance of LA. An important cause of Type B lactic acidosis is medications including acetaminophen, anti-retroviral drugs, antibiotics and beta-adrenergic agonists including albuterol. Often patients with severe lactic acidosis are given fluid boluses however this may worsen their condition of type B lactic acidosis. Case presentation A 39-year-old female with past medical history of Factor V Leiden, prior PE/DVTs, Seizure disorder, HTN, anxiety, HLD presented with chief complaints of shortness of breath. The patient was intubated for anaphylactic reaction to contrast in ED at 12:30 am, overnight patient had quick respiratory status recovery and was extubated at 8:45 am the same day. On Physical exam at 8:40 am, the patient was noted to have tachypnea and was unable to speak or eat due to shortness of breath. Patient was treated with albuterol nebulization. Labs from 9:05 am showed a Ph of 7.27 and a Bicarb of 13 despite patients PCO2 being 31.7. This prompted a lactic acid check which revealed a severe lactic acidosis of 11. Following this, the frequency of albuterol administration was decreased. LA was rechecked with repeat lactic coming down to 4.5 after frequency of albuterol was decreased. Discussion There are several proposed mechanisms to explain albuterol induced LA. One mechanism is thought to be due to the stimulating effect B-agonists have on glycolysis which in turn makes more pyruvate. B agonists also have a stimulating effect on lipolysis which makes more free fatty acids and in turn inhibits pyruvate dehydrogenase causing excess pyruvate to be channeled into lactic acid production. In the case of albuterol induced lactic acid, albuterol administration may inadvertently worsen respiratory distress as the body tries to compensate for the metabolic acidosis. Albuterol is a commonly used medication in asthma and COPD exacerbations, however, its ability to cause lactic acidosis by creating a hyperadrenergic state which shifts the Krebs cycle is often overlooked.