Difference between revisions of "Starvation ketoacidosis"

(Created page with "==Background== When insulin levels are low and glucagon levels are high (such as in a fasting state), long chain fatty acids and glycerol from triglycerides are released from...")
 
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==Clinical Features==
 
==Clinical Features==
Nausea and vomiting
+
*Nausea and vomiting
Abdominal pain
+
*Abdominal pain
Dehydration
+
*Dehydration
Altered mental status
+
*Altered mental status
Fatigue
+
*Fatigue
Kussmaul breathing
+
*Kussmaul breathing
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
Diabetic ketoacidosis
+
*Diabetic ketoacidosis
Alcoholic ketoacidosis
+
*Alcoholic ketoacidosis
Lactic acidosis
+
*Lactic acidosis
Toxic alcohol (methanol or ethylene glycol) ingestion
+
*Toxic alcohol (methanol or ethylene glycol) ingestion
Uremic acidosis
+
*Uremic acidosis
Aspirin toxicity
+
*Aspirin toxicity
  
 
==Evaluation==
 
==Evaluation==
Serum chemistry (elevated anion gap)
+
*Serum chemistry (elevated anion gap)
Glucose (usually euglycemic or hypoglycemic)
+
*Glucose (usually euglycemic or hypoglycemic)
Urinalysis (ketonuria)
+
*Urinalysis (ketonuria)
Serum beta-hydroxybutyrate
+
*Serum beta-hydroxybutyrate
Lactate
+
*Lactate
Salicylate level (if overdose suspected)
+
*Salicylate level (if overdose suspected)
Serum osmolality (if toxic alcohol ingestion suspected)
+
*Serum osmolality (if toxic alcohol ingestion suspected)
  
 
==Management==
 
==Management==
 
Dextrose and saline solutions
 
Dextrose and saline solutions
Dextrose- will cause increase in insulin and decrease in glucagon secretion, which will reduce ketone production and increase ketone metabolism (beta-hydroxybutyrate and acetoacetate will regenerate bicarbonate, causing partial correction of metabolic acidosis)
+
*Dextrose
Saline- will provide volume resuscitation and will in turn reduce secretion of glucagon (which promotes ketogenesis)
+
**Will cause increase in insulin and decrease in glucagon secretion, which will reduce ketone production and increase ketone metabolism
Rate of infusion dependent on volume status  
+
**Beta-hydroxybutyrate and acetoacetate will regenerate bicarbonate, causing partial correction of metabolic acidosis
If hypokalemic, need to correct before administering glucose (as glucose stimulates insulin production which will drive K into cells and worsen hypokalemia)
+
*Saline or lactated ringer
 +
**Will provide volume resuscitation and will in turn reduce secretion of glucagon (which promotes ketogenesis)
 +
 
 +
Considerations
 +
*Rate of infusion dependent on volume status  
 +
*If hypokalemic, need to correct before administering glucose (as glucose stimulates insulin production which will drive K into cells and worsen hypokalemia)
  
 
==Disposition==
 
==Disposition==
If mild, can be discharged after correction of acidosis, electrolytes, and hypovolemia
+
*If mild, can be discharged after correction of acidosis, electrolytes, and hypovolemia
If severe, admit for close monitoring
+
*If severe, admit for close monitoring
  
 
==See Also==
 
==See Also==

Revision as of 22:53, 6 October 2017

Background

When insulin levels are low and glucagon levels are high (such as in a fasting state), long chain fatty acids and glycerol from triglycerides are released from peripheral fat stores and are transported to the liver. The fatty acids undergo beta-oxidation and generate acetyl-CoA. However, with excessive amounts of acetyl-CoA, the Krebs cycle may become oversaturated, and instead the acetyl-CoA enter the ketogenic pathway resulting in production of ketone bodies.

Mild ketosis (1mmol/L) results after fasting for approximately 12 to 14 hours. However, the ketoacid concentration rises with continued fasting and will peak after 20 to 30 days (8-10mmol/L). The main ketone body that accumulates in beta-hydroxybutyrate.

Eating disorders, prolonged fasting, severely calorie-restricted diet, restricted access to food (low socioeconomic and elderly patients)

Clinical Features

  • Nausea and vomiting
  • Abdominal pain
  • Dehydration
  • Altered mental status
  • Fatigue
  • Kussmaul breathing

Differential Diagnosis

  • Diabetic ketoacidosis
  • Alcoholic ketoacidosis
  • Lactic acidosis
  • Toxic alcohol (methanol or ethylene glycol) ingestion
  • Uremic acidosis
  • Aspirin toxicity

Evaluation

  • Serum chemistry (elevated anion gap)
  • Glucose (usually euglycemic or hypoglycemic)
  • Urinalysis (ketonuria)
  • Serum beta-hydroxybutyrate
  • Lactate
  • Salicylate level (if overdose suspected)
  • Serum osmolality (if toxic alcohol ingestion suspected)

Management

Dextrose and saline solutions

  • Dextrose
    • Will cause increase in insulin and decrease in glucagon secretion, which will reduce ketone production and increase ketone metabolism
    • Beta-hydroxybutyrate and acetoacetate will regenerate bicarbonate, causing partial correction of metabolic acidosis
  • Saline or lactated ringer
    • Will provide volume resuscitation and will in turn reduce secretion of glucagon (which promotes ketogenesis)

Considerations

  • Rate of infusion dependent on volume status
  • If hypokalemic, need to correct before administering glucose (as glucose stimulates insulin production which will drive K into cells and worsen hypokalemia)

Disposition

  • If mild, can be discharged after correction of acidosis, electrolytes, and hypovolemia
  • If severe, admit for close monitoring

See Also

External Links

References


https://www.uptodate.com/contents/fasting-ketosis-and-alcoholic-ketoacidosis/abstract/4

Owen OE, Caprio S, Reichard GA Jr, et al. Ketosis of starvation: a revisit and new perspectives. Clin Endocrinol Metab 1983; 12:359.