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Alcoholic ketoacidosis (AKA) is a condition seen commonly in patients with alcohol use disorder or after a bout of heavy drinking. It is a clinical diagnosis with patients presenting with tachycardia, tachypnea, dehydration, agitation, and abdominal pain. This activity illustrates the evaluation and treatment of alcoholic ketoacidosis and explains the role of the interprofessional team in managing patients with this condition.
- Identify the etiology of alcoholic ketoacidosis.
- Describe the evaluation of alcoholic ketoacidosis.
- Review the fluid and volume resuscitation and correction of electrolyte abnormalities used in the treatment of alcoholic ketoacidosis.
- Summarize the importance of collaboration and communication among the interprofessional team to enhance the delivery of care for patients affected by alcoholic ketoacidosis.
Alcoholic ketoacidosis (AKA) is a clinical syndrome seen mostly in patients with chronic alcohol use disorder and frequently seen in patients who binge drink. Typical patients are usually chronic drinkers who areunable to tolerate oral nutrition for a 1 to 3 day period. Patients often have a recent bout of heavy drinking before the period of relative starvation, with persistent vomiting and abdominal pain contributing to their inability to tolerate PO intake.
The etiology of Alcoholic ketoacidosis stems from the patient's inability to ingest, absorb and utilize glucose from their diet. The vomiting and nausea prevent adequate solute intake from the gastrointestinal tract. The alcohol further depresses gluconeogenesis in the body and keeps blood sugar levels low. An anxiety state and alcohol withdrawal further exacerbate the patient's ability to eat. The lack of nutrients other than alcohol causes the formation of ketones and elevated gap ketoacidosis in the absence of diabetes.
The prevalence correlates with the incidence of alcohol abuse in a community. No racial or sexual differences in incidence are noted. AKA can occur in adults of any age; it more often occurs in persons aged 20-60 years who are chronic alcohol abusers. Rarely, AKA occurs after a binge in persons who are not chronic drinkers.
After about of heavy drinking, patients present in a dehydrated state and then an ongoing lack of oral intake. This period of poor PO intake lasts from 1 to 3 days. The pathophysiology of AKA starts with low glycogen stores and a lack of oral food intake, which shifts the metabolism from Carbohydrates to fats and lipids. Decreased oral intake causes decreased insulin levels and increased counter-regulatory hormones such as cortisol, glucagon, and epinephrine. The lack of insulin also allows an increase in the activity of hormone-sensitive lipase. These changes are further enhanced as ethanol is metabolized to acetaldehyde and acetyl-CoA, leading to an increased NADH/NAD+ ratio. The resultant increased NADH/NAD+ ratio increases lipid metabolism. All of these changesincrease the breakdown of lipids to ketoacids. The elevated NADH/NAD+ ratio further encourages the conversion of acetoacetate to beta-hydroxybutyrate. Beta-hydroxybutyrate is the predominant ketoacid in AKA. Ketoacids further accumulate as dehydration and decreased renal perfusion limit the removal of ketoacids. The differential diagnosis includes other causes of an increased anion gap metabolic acidosis. In a patient with diabetes, there must also be a consideration of diabetic ketoacidosis (DKA). A hemoglobin A1C may help in that consideration as well.
The toxicokinetics that arepertinent to the diagnosis of AKA includethe rate of alcohol oxidation in the body. Ethyl alcohol oxidizes at a rate of 20 to 25 mg/dL per hour in most individuals. The accompanying lack of alcohol in the patient's body and the fact that for some time, the only source of calories that a patient has is ethanol both contribute to the clinical syndrome thatwe see.
History and Physical
The diagnosis of AKA is made on a clinical basis. Patients are usually tachycardic, dehydrated, tachypneic, present with abdominal pain, and are often agitated. Most patients will often have a ketone odor on their breath.
- Tachycardia is common and due to several factors, including (1) several days of ethanol ingestion, which blocks antidiuretic hormone (ADH) and causes diuresis and increased urinary frequency, (2) nausea and vomiting, which result in decreased oral intake 1 to 3 days prior to presentation, (3) abdominal pain which exacerbates decreased oral intake. Patients develop acidosis, which causes an increase in respiratory rate and fluid loss.
- Dehydration causes an elevated heart rate and dry mucous membranes. A degree of alcohol withdrawal and agitation are likely to be present, resulting in an increased heart rateas well.
- Patients often become tachypneic due to acidosis, dehydration, alcohol withdrawal, and abdominal pain.
- Abdominal pain is commonly present, although it may be secondary to alcoholic gastritis or pancreatitis. Rebound tenderness is not common, and the pain is commonly epigastricin nature. If rebound tenderness or peritoneal signs are present, another cause should be sought for the pain.
Neurologically, patients are often agitated but may occasionally present lethargic on examination. Alcohol withdrawal, in combination with nausea and vomiting, makes most patients agitated. However, if an AKA patient is lethargic or comatose, an alternative cause should be sought.
Laboratory analysis plays a major role in the evaluation of a patient with suspected alcoholic ketoacidosis.
- Complete blood count (CBC) - The white blood cell count (WBC), hemoglobin, and hematocrit levels may be elevated in a dehydrated patient. An elevated mean corpuscular volume (MCV) is often seen in patients with chronic alcohol use disorder.
- Metabolic Panel - The basic metabolic panel will likely be abnormal. Potassium levels can be normal or low, as dehydration and decreased oral intake frequently decrease the serum potassium level. Bicarbonate or HCO3 will likely be decreased with the presence of metabolic acidosis. The blood urea nitrogen (BUN) to creatinine ratio may be elevated if the patient is dehydrated. Glucose levels are usually mildly elevated but are not generallyabove 250 mg/dl. The initial glucose levels are more likely to be in the normal range.
- Beta-Hydroxybutyrate - The serum beta-hydroxybutyrate (B-OH) level will be significantly elevated. The degree of elevation of B-OH will be much greater than the elevation of lactate. If the lactate is greater than 4 mmol/L, another cause of the acidosis should be investigated. Serum alcohol levels are often low or absent.
- Arterial blood gas (ABG) - The blood gas analysis will most likely reveal a pH that is low or normal. There will be a metabolic acidosis present with a decreased HCO3 level. If the patient is capable, a respiratory alkalosis will be mounted by the patient. The presence of a mixed disorder may also be present as significant vomiting can cause metabolic alkalosis.
- Urinalysis - Urinalysis may show an elevated specific gravity as the patient is usually dehydrated. The specific gravity of the urine can be in the normal range if the patient has been drinking recently enough for the effect of antidiuretic hormone (ADH) inhibition to be still present or if the patient has been able to tolerate oral fluids over the last 24 hours, but no significant solid food.
- Nitroprusside Test - The nitroprusside test can be used to document ketonuria by the detection of acetoacetate. It may be weakly positive despite the presence ofsignificant ketosis as the urine nitroprusside test may vastly underestimate the presence of beta-hydroxybutyrate, which is the major ketoacid present in AKA. Glucosuria will likely be absent.
- Electrocardiogram (EKG) - The EKG will likely show sinus tachycardia, but atrial fibrillation or atrial flutter can be seen in a dehydrated patient with chronic alcohol abuse disorder and alcoholic ketoacidosis.
- The initial chest x-ray is usually negative.
Treatment / Management
AKA should be diagnosed clinically. The patients need fluid resuscitation, close monitoring of electrolytes, and treatment to prevent alcohol withdrawal. They also need to have a complete history and physical for a complete differential diagnosis.
The diagnosis of AKA is the first step in treatment. The patient should have blood glucose checked on the initial presentation. The next important step in the management of AKA is to give isotonic fluid resuscitation. The usual choice of fluid is normal saline with dextrose. Dextrose is required to break the cycle of ketogenesis and increase insulin secretion. The dextrose will also increase glycogen stores and diminish counterregulatory hormone levels. It is essential to administer thiamine before any glucose administration to avoid Wernicke's encephalopathy preci[itation. If severe hypokalemia is present dextrose containing fluids can be held until potassium levels are normalized. Other electrolyte abnormalities concomitantly present with alcohol abuse and poor oral intake include hypomagnesemia and hypophosphatemia. Magnesium and phosphate levels should be measured and repleted if the serum levels are found low.
Intravenous benzodiazepines can be administered based on the risk of seizures from impending alcohol withdrawal. Antiemetics such as ondansetron or metoclopramide may also be given to control nausea and vomiting.
The differential diagnosis of alcoholic ketoacidosis includes all causes of high anion gap metabolic acidosis and are as follows:
- Diabetic ketoacidosis (DKA)
- Methanol toxicity
- Ethylene glycol toxicity
- Lactic acidosis
- Salicylate poisoning
Other differential diagnoses and often concomitantly present diseases that precipitate alcohol ketoacidosis in patients include:
- Peptic ulcer disease
- Acute cholecystitis
- Acute mesenteric ischemia
- Alcohol withdrawal
In general, the prognosis for a patient presenting with AKA is good as long as the condition is identified and treated early. Delayed presentation or diagnosis may result in end-organ damage such as acute renal failure with tubular necrosis. The long-term prognosis of patients diagnosed with AKA depends on the severity of their underlying alcohol abuse disorder rather than AKA itself.The major cause of morbidity and mortality in patients diagnosed with AKA is under-recognition of concomitant diseases (that may have precipitated the AKA, to begin with). These include acute pancreatitis, gastrointestinal bleeding, and alcohol withdrawal. Mortality specifically due to AKA has been linked to the severity of serumbeta-hydroxybutyric acid in some studies. It should be used as an indicator of the severity of the disease.Identifying these high-risk patients can help set the intensity of monitoring required for the patient to ensure optimal patient outcomes are achieved.
Complications associated with AKA can occur with delayed diagnosis or under-resuscitation and failure to end ketogenesis. These include hypovolemic shock and cardiac arrest. It is essential to manage other electrolyte disturbances and alcohol withdrawal to prevent seizures and the dreaded delirium tremens. Often patients with chronic alcohol abuse disorder will have non-ischemic cardiomyopathy, which may become evident as pulmonary edema on fluid resuscitation to treat AKA. Adequate and frequent clinical as well as biochemical monitoring is required to identify these potential complications early and prevent the morbidity associated with this condition.
Deterrence and Patient Education
After the treatment of AKA, it is important to counsel the patients on alcohol abuse disorder and to refer them to alcohol abuse rehabilitation programs. Due to the limited community resources, often patients find themselves without adequate rehabilitation options as well. It is important for inpatient providers to communicate the diagnosis of AKA and associated alcohol abuse disorder with outpatient primary care providers for the patient to ensure the patient is linked with all available resources to help him/her with their alcohol abuse disorder.
Enhancing Healthcare Team Outcomes
Alcoholic ketoacidosis can affect many organ systems and is best managed by an interprofessional team of healthcare workers, including a nurse and clinician. The key is to differentiate alcoholic ketoacidosis from starvation and diabetic-ketoacidosis (DKA). Starvation ketosis is more common than AKA, but starvation ketosis is not often complicated by acidosis. Diabetic ketoacidosis can be confused with AKA. The glucose levels in AKA are rarely above 250 mg/dL. In a hyperglycemic patient, hemoglobin A1C should also be ordered to assess for the presence ofuncontrolled blood glucose levels.Also, in AKA, the beta-hydroxybutyrate to acetoacetate ratio will be much higher with ratios of up to 8:1, whereas in DKA, beta-hydroxybutyrate to acetoacetate ratios are about 3:1.
Efficient and timely management can lead to enhanced patient outcomes in patients with AKA. However, after adequate treatment, it is equally essential to refer the patient to alcohol abuse rehabilitation programs to prevent recurrence and long-term irreversible damage from alcohol abuse.
Robert D. Howard
Syed Rizwan A. Bokhari
9/6/2022 7:39:58 PM
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Alcoholic ketoacidosis or alcoholic ketosis is usually caused by heavy drinking, which can cause you to vomit or stop eating. For men, heavy drinking is consuming more than 4 drinks a day or more than 14 a week, and for women, it's consuming more than 3 drinks a day or more than 7 drinks a week.Can alcoholic ketoacidosis reversed? ›
Although the pathophysiology is complex, the syndrome is rapidly reversible and has a low mortality.How do you fix alcoholic ketoacidosis? ›
The usual choice of fluid is normal saline with dextrose. Dextrose is required to break the cycle of ketogenesis and increase insulin secretion. The dextrose will also increase glycogen stores and diminish counterregulatory hormone levels.What does alcoholic ketoacidosis feel like? ›
Symptoms of alcoholic ketoacidosis include: Nausea and vomiting. Abdominal pain. Agitation, confusion.How long does it take to develop alcoholic ketoacidosis? ›
About 24 to 72 hours after cessation of PO intake, AKA can develop. These patients usually have a low or absent serum alcohol concentration and can present with varying degrees of alcohol withdrawal. However, a clear sensorium is a hallmark of this condition.What is the 1 3 rule in alcoholism? ›
The formula was 0-0-1-3, which meant zero drinks if underage, zero drinks if driving, no more than one standard drink per hour, and no more than three drinks per occasion.How do you get someone out of ketoacidosis? ›
Replacing fluids you lost through frequent urination and to help dilute excess sugar in your blood. Replacing electrolytes (minerals in your body that help your nerves, muscles, heart, and brain work the way they should). Too little insulin can lower your electrolyte levels. Receiving insulin.Is alcoholic ketoacidosis permanent? ›
What Is the Prognosis for Alcoholic Ketoacidosis? The prognosis for alcoholic ketoacidosis is good as long as it's treated early. However, the long-term prognosis depends on the severity of the underlying alcohol abuse disorder.Can you get rid of ketoacidosis on your own? ›
DKA can only be treated with insulin and fluids. These are often given in a vein (IV). Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor or nurse advice line (811 in most provinces and territories) if you are having problems.What causes sudden death in alcoholics? ›
Alcohol causes arrhythmias during life, including prolongation of the QT interval, which is associated with sudden cardiac death . One would logically infer from this that alcohol induced arrhythmias are a commonly stated cause of death.
How long does it take to recover from diabetic ketoacidosis? Finally, some good news! Once you're safely admitted to the hospital for DKA, recovery is usually complete in one to three days.What are the warning signs of ketoacidosis? ›
You have many symptoms of diabetic ketoacidosis. These include excessive thirst, frequent urination, nausea and vomiting, stomach pain, weakness or fatigue, shortness of breath, fruity-scented breath, and confusion.What does ketoacidosis smell like? ›
a smell of ketones on your breath, which can smell like pear drops or nail varnish remover. confusion. drowsiness or loss of consciousness (coma)What are the mental effects of ketoacidosis? ›
People with recurrent DKA have elevated levels of anxiety and diabetes distress, greater difficulty with emotion regulation and personality dysfunction compared to matched controls.What is the progression of ketoacidosis? ›
DKA occurs mostly in type 1 diabetes mellitus. It causes nausea, vomiting, and abdominal pain and can progress to cerebral edema, coma, and death. DKA is diagnosed by detection of hyperketonemia and anion gap metabolic acidosis in the presence of hyperglycemia.What is starvation alcoholic ketoacidosis? ›
Alcoholic ketoacidosis occurs in patients with chronic alcohol abuse, liver disease, and acute alcohol ingestion. Starvation ketoacidosis occurs after the body is deprived of glucose as its primary source of energy for a prolonged time, causing fatty acids to replace glucose as the major metabolic fuel.Why do alcoholics cough so much? ›
Heavy drinking can lead to pneumonia because alcoholics have lower levels of white blood cells that help fend off pneumonia. The damaged immune system cannot fight against the disease, which can cause intense chest pain, fever, painful coughing, and even death.What are the 5 A's of alcoholism? ›
Clinical guidelines recommend addressing adolescent alcohol use in primary care; the 5 As (Ask, Advise, Assess, Assist, Arrange) may be a useful model for intervention.What is rule 34 of drinking alcohol? ›
Rule 34. If you bring crap beer to a party, you must drink at least two cans before laying into the semi-hidden craft beer in the frig.What is the 6 alcoholic drink rule? ›
If you choose to visit the destinations mentioned above, then your all-inclusive alcoholic drinks will be capped at 6 per day. They are often with allowed only with meals, meaning 3 with your lunch and 3 with your dinner.
DKA is a life-threatening medical emergency with a mortality rate just under 5% in individuals under 40 years of age, but with a more serious prognosis in the elderly, who have mortality rates over 20%.Do people survive ketoacidosis? ›
Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes that is most commonly seen among people with type I diabetes, although people with type II diabetes can also develop DKA. With appropriate and timely treatment, the survival rate of DKA is quite high at over 95%.At what blood sugar level does ketoacidosis start? ›
Diabetic ketoacidosis usually manifests with high blood glucose more than 250 mg/dL, but euglycemic diabetic ketoacidosis is defined as ketoacidosis associated with blood glucose level less than 250 mg/dL.Is ketoacidosis terminal? ›
Diabetic ketoacidosis (DKA) is life-threatening—learn the warning signs to be prepared for any situation. DKA is no joke, it's a serious condition that can lead to diabetic coma or even death.Can ketoacidosis cause brain damage? ›
Brain injury in diabetic ketoacidosis (DKA) is common but under recognized and affects up to 54% of patients with this complication. It's manifestations include cerebral oedema (CE) and cerebral infarction (CI). The etiology of CE in DKA has up to the present time been uncertain.Is Gatorade good for ketoacidosis? ›
Ȥ Drink calorie-free beverages (like water), and fluids containing sodium (like broth). This will help your body retain water. Ȥ Sports drinks like Gatorade and Powerade have both carbohydrate and sodium. They work well to put water back into (hydrate) your body.What happens if you don't treat ketoacidosis? ›
If you don't treat ketoacidosis, you could pass out, go into a coma, and possibly die. You should go to the hospital to treat DKA. There, you will receive emergency treatments like: Insulin through an IV to bring your ketones down.How do you flush ketones out of your body? ›
It is recommended that you drink 8 ounces of water or carb/caffeine free beverage every 30-60 minutes to help flush out the ketones. Again, ketones are a sign that your body needs more insulin. Some people might already have an insulin dosing plan in place related to ketones.What is the number one killer of alcoholics? ›
Since the death toll caused by alcohol abuse is so high, it is important to understand the ways in which alcohol can kill someone. The major causes of alcohol-related death are alcohol poisoning, cancer, car accidents, heart failure, liver damage, and violence.What is the most common cause of death among alcoholics? ›
Over half of alcohol-related deaths are because of health effects from drinking too much over time. It can lead to things like cancer, liver disease, and heart disease.
People hospitalized with alcohol use disorder have an average life expectancy of 47–53 years (men) and 50–58 years (women) and die 24–28 years earlier than people in the general population.Does fasting help ketoacidosis? ›
Most people who have easy access to food have a low risk of developing starvation ketoacidosis. However, intermittent fasting, particularly in combination with an extreme diet such as the ketogenic diet, can put a person at higher risk of developing ketoacidosis.Can dehydration cause ketoacidosis? ›
Diabetic ketoacidosis (DKA) results from dehydration during a state of relative insulin deficiency, associated with high blood levels of sugar level and organic acids called ketones.What are 3 signs of a diabetic emergency? ›
- clammy skin.
- profuse sweating.
- drowsiness or confusion.
- weakness or feeling faint.
- sudden loss of responsiveness.
These are the more severe symptoms of DKA to look out for: Fruity-scented breath. Dry skin and mouth. Fatigue and fainting: Your reasons for dizziness could be a sign of DKA.What is the most common cause of death in DKA? ›
In developed countries, the morbidity and mortality rates are low chiefly because of a streamlined interprofessional approach to the management of these patients. However, in developing countries, mortality rates of 0.3 to 2.5% are still reported. The major cause of death in most young patients is cerebral edema.Does ketosis urine smell? ›
The Science Behind Keto Crotch
Yet, science does show that going keto can change the odor of your breath and urine, making both smell like nail polish remover. That's because your body breaks down fat for energy instead of carbs.
At BACs of 0.08% and below, the probability appears close to 60%, but for BACs above 0.08% the probability rises to the 80% range when no food odors are present. Under more realistic field conditions, the probability of detecting alcohol odor would be much lower.Can you taste ketoacidosis? ›
This happens when the body cannot use sugar for fuel and begins using fat instead. This causes an acid called ketones to build up in the body. Excess ketones in the body can cause a sweet, fruity smell and taste in the mouth.
Diabetic ketoacidosis (DKA) is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic.
Emotional or physical trauma: If a person with diabetes experiences emotional or physical trauma, it can cause DKA due to the high amounts of cortisol (stress hormone) produced by their body. High amounts of cortisol make it difficult for your body to use insulin properly.How does ketoacidosis cause confusion? ›
As a result, the body starts burning its stores of fat for energy instead. This process produces by-products called ketones. As the level of ketones in the body increases, it can lead to dehydration and confusion. If not treated, people with ketoacidosis can become unconscious.How much do you have to drink to have a drinking problem? ›
NIAAA defines heavy drinking as follows: For men, consuming more than 4 drinks on any day or more than 14 drinks per week. For women, consuming more than 3 drinks on any day or more than 7 drinks per week.How much do you have to drink to have a problem? ›
Health care providers consider your drinking medically unsafe when you drink: Many times a month, or even many times a week. 3 to 4 drinks (or more) in 1 day. 5 or more drinks on one occasion monthly, or even weekly.How does alcoholic ketoacidosis occur? ›
Alcoholic ketoacidosis is caused by the combined effects of alcohol and starvation on glucose metabolism; it is characterized by hyperketonemia and elevated anion gap metabolic acidosis without significant hyperglycemia. Measure serum and urine ketones and electrolytes and calculate a serum anion gap.What are the diagnostic criteria for alcoholic ketoacidosis? ›
The diagnosis of alcoholic ketoacidosis (AKA) requires arterial blood gas (ABG) measurement and serum chemistry assays. Usual laboratory findings include the following : The arterial pH is less than 7.3, and the serum bicarbonate level is less than 15 mEq/L. The calculated anion gap is greater than 14 mmol/L.What are the 3 types of alcoholic? ›
Alcohols bind with other atoms to create secondary alcohols. These secondary alcohols are the three types of alcohol that humans use every day: methanol, isopropanol, and ethanol.Is a bottle of wine a day too much? ›
Drinking a bottle of wine a day may rapidly increase the likelihood of physical and chemical alcohol addiction developing. Drinking a bottle per day equates to approximately 9 units per day or 63 units per week, far in excess of UK NHS recommended guidelines (14 units per week).Are you an alcoholic if you drink every night? ›
If you feel that you need a drink every night or to get through a social event, stressful situation or personal struggle, and you have a compulsion to drink or constantly crave alcohol, maybe even daily, this could be a sign of psychological dependency.What happens on day 4 of no alcohol? ›
However, by day 4 without alcohol, most people will have got beyond any initial withdrawal symptoms. All the alcohol will have left your system by now, and your body will begin to bounce back. If you're not as focused on alcohol, you may be eating better, drinking water, moving more, and perhaps sleeping more deeply.
- Social drinking. To date, nearly all the research on drinking motives has been done on teens and young adults. ...
- Drinking to conform. ...
- Drinking for enhancement. ...
- Drinking to cope.
- swelling of the legs, ankles, and feet due to fluid retention.
- loss of appetite.
- change in urine.
- kidney pain.
People can recover from alcoholic ketoacidosis if they receive a timely diagnosis and appropriate treatment. Individuals who do not receive a prompt diagnosis followed by treatment may develop potentially fatal conditions associated with electrolyte disturbances, including: Kidney failure.How fast does lactic acidosis happen? ›
Lactic acidosis occurs when the body produces too much lactic acid and cannot metabolize it quickly enough. The condition can be a medical emergency. The onset of lactic acidosis might be rapid and occur within minutes or hours, or gradual, happening over a period of days.What is starvation ketoacidosis? ›
As the name implies, starvation ketoacidosis is a bodily response to prolonged fasting hypoglycemia, which decreases insulin secretion, shunting the biochemistry towards lipolysis and the oxidation of the by-product fatty acids to ensure a fuel source for the body.