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THE MORNING REPORT

The Best in FOAM Education

  • Aneesa Ali, DO

Ketoacidosis

Basics

▸Acidosis is defined as pH < 7.35

▸Bicarbonate decreases in acidosis

▸Anion Gap = Na - [Cl + HCO3]

▸Ketones are anions - acetoacetate and beta-hydroxybutyrate

▸Acetone is produced as a byproduct --> sweet odor breath

▸Insulin deficiency is present in all types of ketoacidosis

Alcoholic Ketoacidosis

▸Occurs in chronic alcoholics or binge drinkers

▸Pathophysiology:

▸Decreased nutritional intake contributes to a low-insulin state which promotes ketogenesis.

▸Alcohol metabolism generates NADH which impairs conversion of lactate to pyruvate and impairs gluconeogenesis which then leads to ketogenesis

▸Volume depletion decreases kidney perfusion and excretion of ketoacids in the urine


Starvation ketosis

▸Fasting > 24 hours

▸Pathophysiology:

▸Once glycogen stores are depleted, the liver converts fatty acids to ketones

▸Typically starvation causes a lesser degree of ketosis than DKA and alcoholic ketoacidosis


Presentation

▸GI symptoms: abdominal pain, vomiting

▸Generally fluid down - tachycardia, hypotension, dry mucous membranes, poor skin turgor

▸Significant acidosis can cause altered mental status

▸Labs: Anion gap acidosis, elevated lactic acid, elevated beta-hydroxybutyrate, electrolyte abnormalities,

▸Hypo - or euglycemia typically


Management

▸Fluid resuscitation: isotonic fluids preferred

▸Glucose repletion: increases insulin production --> decreases ketogenesis

▸Repletion of electrolytes

▸K can decrease as more insulin is produced

▸Not recommended to give sodium bicarbonate, even in significant acidosis

▸Allow the patient to eat


References

▸LITFL - Ketoacidosis

▸CorePendium - Alcoholic Ketoacidosis, Acid-Base

▸“Ketone bodies: a review of physiology, pathophysiology and application of monitoring to diabetes” Laffel et al, 2000


Aneesa Ali, DO

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