Difference between revisions of "Alcoholic ketoacidosis"

(Management)
(Management)
 
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*Characterized by high serum ketone levels and an elevated AG
 
*Characterized by high serum ketone levels and an elevated AG
 
**Consider other causes of elevated AG, as well as co-ingestants (toxic alcohols, salicylates)
 
**Consider other causes of elevated AG, as well as co-ingestants (toxic alcohols, salicylates)
**Concomitant [[Metabolic Alkalosis|metabolic alkalosis]] can occur from dehydration (volume depletion) and emesis
+
**Concomitant [[Metabolic Alkalosis|metabolic alkalosis]] can occur from dehydration (volume depletion) and emesis, so a normal blood pH may be found
  
 
===Pathophysiology===
 
===Pathophysiology===
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*[[Vomiting]] (73%)
 
*[[Vomiting]] (73%)
 
*[[Abdominal pain]] (62%)
 
*[[Abdominal pain]] (62%)
 +
*Typically, history of binge drinking ending in nausea, vomiting, and decreased intake
 
*Not hyperosmolar as opposed to [[DKA]]
 
*Not hyperosmolar as opposed to [[DKA]]
*Large IVF admin does not predispose to cerebral edema
 
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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==Evaluation==
 
==Evaluation==
*Binge drinking ending in nausea, vomiting, and decreased intake
+
*[[Anion gap acidosis]]
*Wide anion gap [[metabolic acidosis]] (ketonemia, [[lactic acidosis]])
+
**Typically ''wide'' anion gap
*Positive serum ketones
+
**Positive serum ketones + [[lactic acidosis]]
*Wide anion gap [[metabolic acidosis]] without alternate explanation
+
***Lab measured ketone is acetoacetate
*Urine ketones may be falsely negative or low
+
***May miss beta-hydroxybutyrate
**Lab measured ketone is acetoacetate
+
***Urine ketones may be falsely negative or low
**May miss beta-hydroxybutyrate
 
 
*Typically normal osmolal gap
 
*Typically normal osmolal gap
 
*Alcohol level usually zero or not considerably high
 
*Alcohol level usually zero or not considerably high
 +
*BMP, Mg/phos
 +
**Often have concomitant [[electrolyte abnormalities]]
  
 
==Management==
 
==Management==
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*Hydration (D5NS)
 
*Hydration (D5NS)
 
**[[IVF]] should include 5% dextrose since there is a lack of glucose
 
**[[IVF]] should include 5% dextrose since there is a lack of glucose
 +
**Large IVF admin does not predispose to cerebral edema
 
**Glucose stimulates insulin which stops lipolysis
 
**Glucose stimulates insulin which stops lipolysis
 
*Oral nutrition if able to tolerate
 
*Oral nutrition if able to tolerate
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**K, Mag and Phos
 
**K, Mag and Phos
 
*Monitor for signs of [[Alcohol Withdrawal|alcohol withdrawal]]
 
*Monitor for signs of [[Alcohol Withdrawal|alcohol withdrawal]]
*Consider bicarb if life-threatening acidosis (pH <7.1) unresponsive to fluid therapy
+
*Consider [[bicarbonate]] if life-threatening acidosis (pH <7.1) unresponsive to fluid therapy
  
 
==Disposition==
 
==Disposition==

Latest revision as of 22:17, 28 September 2019

Background

  • Seen in patients with recent history of binge drinking with little/no nutritional intake
  • Anion gap metabolic acidosis associated with acute cessation of EtOH consumption after chronic abuse
  • Characterized by high serum ketone levels and an elevated AG
    • Consider other causes of elevated AG, as well as co-ingestants (toxic alcohols, salicylates)
    • Concomitant metabolic alkalosis can occur from dehydration (volume depletion) and emesis, so a normal blood pH may be found

Pathophysiology

  • Ethanol metabolism depletes NAD stores[1]
    • Results in inhibition of Krebs cycle, depletion of glycogen stores, and ketone formation
    • Suppresses gluconeogenesis and may result in hypoglycemia
    • High NADH:NAD also results in increased lactate production
      • Lactate higher than normal but not as high as in shock or sepsis
    • Acetoacetate is metabolized to acetone so elevated osmolal gap may also be seen
AKA crashingpatient.JPG

Clinical Features

  • Nausea (75%)
  • Vomiting (73%)
  • Abdominal pain (62%)
  • Typically, history of binge drinking ending in nausea, vomiting, and decreased intake
  • Not hyperosmolar as opposed to DKA

Differential Diagnosis

Ethanol related disease processes

Evaluation

  • Anion gap acidosis
    • Typically wide anion gap
    • Positive serum ketones + lactic acidosis
      • Lab measured ketone is acetoacetate
      • May miss beta-hydroxybutyrate
      • Urine ketones may be falsely negative or low
  • Typically normal osmolal gap
  • Alcohol level usually zero or not considerably high
  • BMP, Mg/phos

Management

Consider associated diseases (ie pancreatitis, rhabdomyolysis, hepatitis, infections)

Disposition

  • Discharge home after treatment if able to tolerate POs and acidosis resolved
  • Consider admission for those with severe volume depletion and/or acidosis
  • Hypoglycemia is poor prognostic feature, indicating depleted glycogen stores

See Also

References

  1. McGuire LC, Cruickshank AM, Munro PT. Alcoholic ketoacidosis. Emerg Med J. 2006 Jun;23(6):417-20.