Alcoholic ketoacidosis

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  • Seen in pts with recent h/o binge drinking with little/no nutritional intake
  • Anion gap metabolic acidosis a/w 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
    • Concomitant metabolic alkalosis can occur from dehydration (volume depletion) and emesis


  • Ethanol metabolism depletes NAD stores
    • Results in inhibition of Krebs cycle, depletion of glycogen stores, and ketone formation
    • 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


  • Binge drinking ending in nausea, vomiting, and decreased intake
  • Wide anion gap metabolic acidosis (ketonemia, lactic acidosis)
  • Positive serum ketones
  • Wide anion gap metabolic acidosis without alternate explanation
  • Urine ketones may be falsely negative or low
    • Lab measured ketone is acetoacetate
    • May miss beta-hydroxybutyrate

Differential Diagnosis

  1. Isopropyl Alcohol
    1. Results in ketosis
  2. Methanol, Ethylene Glycol
    1. Do not produce ketosis
  3. Sepsis
  4. Salicylate Toxicity
  5. DKA
  6. Hyperosmolar hyperglycemic state
  7. Starvation Ketosis
  8. Uremia


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

  1. Thiamine (100mg IV)
    1. Prior to glucose to decrease risk of Wernicke encephalopathy or Korsakoff syndrome
  2. Hydration (D5NS)
    1. IVF should include 5% dextrose since there is a lack of glucose
    2. Glucose stimulates insulin which stops lipolysis
  3. Oral nutrition if able to tolerate
  4. Electrolyte replacement
    1. K, Mag and Phos
  5. Monitor for signs of alcohol withdrawal
  6. Consider bicarb if life-threatening acidosis (pH <7.1) unresponsive to fluid therapy


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

See Also


  • Woods, William A., Perina, Debra G. Tintinalli's Emergency Medicine: A Comprehensive Study Guide: 8th Ed. online, McGraw-Hill Education, 2016. Ch. 226.