0071643192.pdf

ALCOHOLIC KETOACIDOSIS

PHYSIOLOGY

■ Chronic alcohol consumption and inadequate nutrition →decreased insulin

and increased glucagons and ethanol inhibition of gluconeogenesis →lypo-

lysis→increased ketone (acetoacetate and β-hydroxybutyrate) production →

nausea and vomiting →severe dehydration and acidosis.

SYMPTOMS ANDEXAM

■ Nausea and vomiting

■ Lethargy or altered mental status

■ History of alcohol consumption but not usually intoxicated at time of evaluation

DIFFERENTIAL

■ DKA

■ Lactic and uremic acidosis

■ Alcohol intoxication

DIAGNOSIS

■ Key points in diagnosing alcoholic ketoacidosis and differentiating this

from DKA are based on these facts:

■ A low bicarbonate level (<10) indicating acidosis

■ A high anion gap (>16) primarily from β-hydroxybutyrate

■ The nitroprusside test is negative or weakly positive because it does not

test for this ketone. The test often becomes positive as patient becomes

more hydrated and there is a shift from acetoacetate to β-hydroxybutyrate.

■ Alow or negative blood alcohol level

■ Blood glucose is usually only minimally elevated (<200 mg/dL).

■ Concomitant hypokalemia, hyponatremia, and hypophosphatemia may be

present.

TREATMENT

■ Insulin is not required.

■ IV hydration with D5NS: The combination of fluid and carbohydrate cor-

rects the ketoacidosis quicker than fluid alone

■ Thiamine 50–100 mg IV to prevent Wernicke encephalopathy

■ Correction of electrolyte losses

■ Bicarbonate only if the patient is severely ill or acidotic

LACTIC ACIDOSIS

Lactate is a byproduct of anaerobic metabolism. Both acute and chronic con-

ditions can cause elevated lactate levels. A normal lactate level is typically

given as <2 mEq/L. Levels >4–5 mEq/L are considered significantly elevated.

Typically, such patients will have an increased anion gap acidosis.

Acute conditions:

■ Inadequate tissue perfusiondue to either hypotension or hypoxia

■ Toxic causes of disruption in cellular metabolism such as cyanide

■ Exercise

■ Hyperventilation

■ Glucose, saline, or bicarbonate infusions that contain lactate

■ Insulin or epinephrine injections

ENDOCRINE, METABOLIC, FLUID, AND

ELECTROLYTE DISORDERS

Nondistilled alcohol (beer,

wine) contains lots of

carbohydrates, which is why

AKA doesn’t usually occur

while a patient is still drunk.

The primary treatment of

alcoholic ketoacidosis is the

administration of glucose and

volume. Give D5NS.