Ketoacidosis

Ketoacidosis is development of metabolic acidosis due to accumulation of serum ketoacids. Diabetic ketoacidosis may occur in elderly patients with type 1 diabetes mellitus or rarely in patients with type 2 diabetes mellitus and additional stressors, such as acute MI or sepsis. Ketoacidosis may also be caused by alcohol and starvation (alcoholic ketoacidosis). Alcoholic ketoacidosis is characterized by hyperketonemia and anion gap metabolic acidosis without significant hyperglycemia. Alcoholic ketoacidosis causes nausea, vomiting, and abdominal pain. Diagnosis is by history and findings of ketoacidosis without hyperglycemia. Treatment is IV saline solution and dextrose infusion.

Development of alcoholic ketoacidosis is attributed to the combined effects of alcohol and starvation on glucose metabolism. Alcohol diminishes hepatic gluconeogenesis and leads to decreased insulin secretion, increased lipolysis, impaired fatty acid oxidation, and subsequent ketogenesis. Counterregulatory hormones are increased and may further inhibit insulin secretion. Plasma glucose levels are usually low or normal, but mild hyperglycemia sometimes occurs.

Typically, an alcohol binge leads to vomiting and the cessation of alcohol or food intake for >= 24 h. During this period of starvation, vomiting continues and abdominal pain develops, leading the patient to seek medical attention. Pancreatitis may occur.

Diagnosis requires a high index of suspicion; absence of hyperglycemia makes diabetic ketoacidosis (DKA) improbable. Typical laboratory findings include a high anion gap metabolic acidosis, ketonemia, and low levels of K, Mg, and P. Detection of acidosis may be complicated by concurrent metabolic alkalosis due to vomiting. Lactic acid levels are often elevated because of the balance of reduction and oxidation reactions in the liver is altered.

Treatment begins with an IV infusion of 5% dextrose in 0.9% saline solution, with added thiamin and other water-soluble vitamins and with K replacement as required. Ketoacidosis and GI symptoms usually resolve rapidly. Use of insulin is appropriate only if atypical DKA is possible or if glucose levels exceed 300 mg/dL.

DKA is a relatively uncommon complication of diabetes mellitus in the elderly; in patients with type 2 diabetes, endogenous insulin production is usually sufficient to prevent unrestrained lipolysis and ketone production. However, DKA can develop in patients with severe physiologic stress (eg, infection, MI) or with the use of drugs such as glucocorticoids. Elderly patients with type 1 diabetes are at risk of DKA, particularly when insulin has been withheld; patients with cognitive impairment or those who are in institutions may be at high risk of DKA due to errors in insulin administration. Diagnosis and treatment are similar to that of NKHS, although measurement of serum ketones and pH guides treatment.

This topic was last updated February 2006.