Ketoacidosis

Question 1

What is the primary cause of Alcoholic Ketoacidosis (AKA)?

Answer 1

AKA occurs due to chronic alcohol use and starvation, leading to depleted glycogen stores and increased ketone production.

Question 2

What are the characteristic lab findings in Alcoholic Ketoacidosis?

Answer 2

• Increased anion gap metabolic acidosis (due to ketoacid accumulation)
• Increased osmolal gap
• Ketosis with low to normal glucose levels (~<250 mg/dL)
• No significant hyperglycemia, differentiating it from diabetic ketoacidosis (DKA)

Question 3

How is Alcoholic Ketoacidosis managed?

Answer 3

• IV fluids with dextrose (D5 normal saline or D5 half-normal saline)
• Thiamine before glucose to prevent Wernicke encephalopathy
• Electrolyte repletion (K+, Mg2+, PO4)
• No need for insulin (unlike DKA)

Question 4

How does Diabetic Ketoacidosis (DKA) differ from Alcoholic Ketoacidosis?

Answer 4

• DKA has profound hyperglycemia (>250-300 mg/dL), while AKA has normal to slightly elevated glucose.
• DKA is due to insulin deficiency, while AKA results from alcohol-induced glycogen depletion and starvation ketosis.
• DKA requires insulin therapy; AKA does not.

Question 5

How does starvation ketosis present?

Answer 5

• Prolonged fasting (>2-3 days) leads to mild ketosis and normal glucose levels.
• Ketosis is mild to moderate, and bicarbonate is usually >18 mEq/L.
• No significant acidemia.

Question 6

What are the characteristic lab findings of Diabetic Ketoacidosis (DKA)?

Answer 6

• Glucose >250 mg/dL
• Ketosis (β-hydroxybutyrate)
• Anion gap metabolic acidosis (low bicarbonate)
• High serum osmolality

Question 7

What is the difference between Hyperosmolar Hyperglycemic State (HHS) and DKA?

Answer 7

• HHS has severe hyperglycemia (>600 mg/dL) but no significant ketoacidosis.
• More common in Type 2 Diabetes, with profound dehydration and altered mental status.
• Treated with aggressive IV fluids and insulin.

Question 8

What is Euglycemic Ketoacidosis, and what causes it?

Answer 8

• Ketoacidosis with normal glucose levels
• Causes:
  1) SGLT-2 inhibitors (e.g., canagliflozin, empagliflozin)
  2) Prolonged fasting with diabetes
  3) Pregnancy-related metabolic shifts

Question 9

How does lactic acidosis differ from ketoacidosis?

Answer 9

• Lactic acidosis is due to anaerobic metabolism and tissue hypoxia (shock, sepsis, metformin toxicity).
• No significant ketone production.
• High anion gap metabolic acidosis.
• Elevated lactate (>4 mmol/L).

Question 10

What is the preferred treatment for Diabetic Ketoacidosis (DKA)?

Answer 10

• IV fluids (normal saline initially, then D5 once glucose <250 mg/dL)
• IV insulin drip
• Electrolyte repletion (potassium)

Question 11

What is the key management step to avoid Wernicke encephalopathy in Alcoholic Ketoacidosis?

Answer 11

Always administer thiamine BEFORE giving glucose to prevent acute Wernicke encephalopathy.

Question 12

Which conditions present with an increased anion gap metabolic acidosis?

Answer 12

1) Alcoholic Ketoacidosis (AKA)
2) Diabetic Ketoacidosis (DKA)
3) Lactic acidosis (shock, metformin toxicity, hypoxia)
4) Salicylate toxicity (early respiratory alkalosis, later metabolic acidosis)
5) Methanol/Ethylene glycol poisoning (toxicity, increased osmolal gap)