Difference between revisions of "Alcoholic ketoacidosis"

(Differential Diagnosis)
(Management)
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==Management==
 
==Management==
 
Consider associated diseases (ie [[pancreatitis]], [[rhabdo]], [[hepatitis]], infections)  
 
Consider associated diseases (ie [[pancreatitis]], [[rhabdo]], [[hepatitis]], infections)  
#Thiamine (100mg IV)  
+
*[[Thiamine]] (100mg IV)  
##Prior to glucose to decrease risk of [[Wernicke encephalopathy]] or [[Korsakoff syndrome]]
+
**Prior to glucose to decrease risk of [[Wernicke encephalopathy]] or [[Korsakoff syndrome]]
#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
##Glucose stimulates insulin which stops lipolysis
+
**Glucose stimulates insulin which stops lipolysis
#Oral nutrition if able to tolerate
+
*Oral nutrition if able to tolerate
#[[Electrolyte abnormalities|Electrolyte replacement]]
+
*[[Electrolyte abnormalities|Electrolyte replacement]]
##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 bicarb if life-threatening acidosis (pH <7.1) unresponsive to fluid therapy
  
 
==Disposition==
 
==Disposition==

Revision as of 11:49, 8 July 2016

Background

  • Seen in patients 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
AKA crashingpatient.JPG

Clinical Features

Differential Diagnosis

Ethanol related disease processes

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)

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