Alcoholic ketoacidosis - AKA
Background
Beware
Our urinary dip sticks only measure acetoacetate (in reaction with nitroprusside on stick)
Dip stick may be negative for ketones in
- Alcoholic ketoacidosis
- Severely shocked DKA( no peripheral conversion of ß-hydroxybutyrate to acetoacetate
- Mobilisation of free fatty acids in association with increased liver capacity to convert these to ketones
- Two types ketones produced - acetoacetate and ß-hydroxybutyrate
- With alcohol metabolism there is an overall decrease in available NAD
- In AKA - NAD dependent hepatic oxidation of free fatty acids is switched to ketone formation
- Associated fall in Insulin, rise in cortisol, growth hormone , glucagon and epinephrine
Clinical findings
- Most patients alert (rarely coma)
- Tachypnoeic
- Possible concurrent sepsis etc
- Blood alcohol undetectable
- ABGs show a high anion gap acidosis (DDx)
- Glucosuria absent
Differential diagnosis
- High anion gap acidosis (link)
- Very unwell DKA
Treatment
- Thiamine ( ? Wernicke Korsakoff)
- Saline
- Glucose
- Glucose stimulates insulin release, inhibiting lipolysis and so stops ketone production
