Alcoholic ketoacidosis: Difference between revisions
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*Not hyperosmolar as opposed to DKA | *Not hyperosmolar as opposed to DKA | ||
*Large IVF admin does not predispose to cerebral edema | *Large IVF admin does not predispose to cerebral edema | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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#Starvation Ketosis | #Starvation Ketosis | ||
#[[Uremia]] | #[[Uremia]] | ||
==Diagnosis== | |||
*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 | |||
==Management== | ==Management== | ||
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==Disposition== | ==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 | :[[Hypoglycemia]] is poor prognostic feature, indicating depleted glycogen stores | ||
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*[[Wernicke-Korsakoff Syndrome]] | *[[Wernicke-Korsakoff Syndrome]] | ||
== | ==References== | ||
<references/> | |||
[[Category:Endo]] | [[Category:Endo]] | ||
[[Category:FEN]] | [[Category:FEN]] | ||
[[Category:Tox]] | [[Category:Tox]] |
Revision as of 00:46, 22 February 2016
Background
- 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
Pathophysiology
- 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
Clinical Features
- Nausea (75%)
- Vomiting (73%)
- Abdominal pain (62%)
- Not hyperosmolar as opposed to DKA
- Large IVF admin does not predispose to cerebral edema
Differential Diagnosis
- Isopropyl Alcohol
- Results in ketosis
- Methanol, Ethylene Glycol
- Do not produce ketosis
- Sepsis
- Salicylate Toxicity
- DKA
- Hyperosmolar hyperglycemic state
- Starvation Ketosis
- Uremia
Diagnosis
- 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
Management
Consider associated diseases (ie pancreatitis, rhabdo, hepatitis, infections)
- Thiamine (100mg IV)
- Prior to glucose to decrease risk of Wernicke encephalopathy or Korsakoff syndrome
- Hydration (D5NS)
- IVF should include 5% dextrose since there is a lack of glucose
- Glucose stimulates insulin which stops lipolysis
- Oral nutrition if able to tolerate
- Electrolyte replacement
- K, Mag and Phos
- Monitor for signs of alcohol withdrawal
- Consider bicarb if life-threatening acidosis (pH <7.1) unresponsive to fluid therapy
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
- Beer Potomania Syndrome
- Alcohol (ETOH) Intoxication
- Alcoholic ketoacidosis
- Alcohol withdrawal
- Alcohol withdrawal: Inpatient management
- Alcohol withdrawal: Outpatient management
- Alcohol withdrawal seizures
- Altered mental status
- Delerium tremens
- EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal
- Sedative/Hypnotic
- Wernicke-Korsakoff Syndrome