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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.
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