Alcoholic ketoacidosis

ACEM Fellowship

Table of Contents

Introduction

HAGMA usually seen within 1-3 days of acute alcohol cessation on the background of chronic alcoholism
Often present with nausea, vomiting and GI complaints with dehydration
Alcohol metabolism in the absence of glycogen reserves results in ketonaemia

EtOH – Acetaldehyde – Acetate – AcetylCoA – Ketones/FFA/Krebs cycle
- Requires NAD to NADH for first 2 steps
- Requires Alcohol dehydrogenase for first step
- Requires acetaldehyde dehydrogenase for second step
Thus, ethanol metabolism results in NAD depletion with high NADH:NAD ratio
Counter-regulatory hormones released in setting of glycogen depletion and concurrent illness
- Inhibits aerobic metabolism and favors anaerobic metabolism and lipolysis, converting AcetylCoA to ketone bodies
NAD is used for conversion of beta-hydroxbutyrate to acetoacetate. Given NAD depletion, get predominance of betaHB (not picked up on urine ketostix)
Once NADH:NAD ratio returns to normal, lactate levels reduce and acetoacetate is increased
Acetoacetate is converted to acetone and can cause an osmolar gap
Ketone production also stimulated by malnourished, vomiting and hypophosphataemia (all seen in alcoholics)

Criteria
- Low, normal or slightly elevated glucose
- Binge drinking ending in nausea, vomiting and decreased intake
- Positive serum ketones (although absence on nitroprusside test may miss beta-hydroxbutyrate, which predominates)
- HAGMA without alternative explanation
Always look for underlying precipitant illness
Almost always normal conscious state (if not, consider alternative diagnosis)

Thiamine 300mg IV BEFORE GLUCOSE
5% dextrose in N/S
- Glucose triggers insulin release and inhibits lipolysis to cease ketone production
- Glucose increases oxidation of NADH to NAD, further stopping ketone formation
Cerebral oedema of little concern as not hyperosmolar
Insulin is of no proven benefit and may be dangerous given normal or low glucose levels and lack of glycogen stores in case of hypoglycaemia
Monitor phosphate levels
Consider multivitamins and magnesium supplementation

Last Updated on October 8, 2021 by Andrew Crofton