From the Guidelines
Metabolic acidosis secondary to alcohol use is a life-threatening condition that requires immediate attention, and the primary cause is the accumulation of ketone bodies in the blood, resulting in a high anion gap metabolic acidosis, which can be managed with proper hydration, glucose administration, and cessation of alcohol intake, as supported by the most recent evidence 1.
Causes of Metabolic Acidosis
The causes of metabolic acidosis secondary to alcohol use include:
- Excessive alcohol consumption leading to an accumulation of ketone bodies in the blood
- Depletion of glycogen stores, resulting in ketogenesis
- Electrolyte imbalances, particularly potassium, magnesium, and phosphate deficiencies
- Lactic acidosis, which can occur due to poor tissue perfusion and hypoxia
Consequences of Metabolic Acidosis
The consequences of metabolic acidosis secondary to alcohol use include:
- High anion gap metabolic acidosis, which can lead to severe acidemia and organ dysfunction
- Electrolyte imbalances, which can cause cardiac arrhythmias and muscle weakness
- Dehydration, which can lead to hypovolemic shock and organ failure
- Increased risk of alcohol withdrawal symptoms, which can be life-threatening if not managed properly
Management of Metabolic Acidosis
The management of metabolic acidosis secondary to alcohol use involves immediate intravenous fluid resuscitation with isotonic saline (0.9% NaCl) at a rate of 1-2 liters in the first hour, followed by maintenance fluids based on the patient's hydration status, as well as dextrose-containing fluids (D5W or D5NS) to replenish glycogen stores and suppress ketogenesis 1. Additional management strategies include:
- Thiamine (100 mg IV) administration to prevent Wernicke's encephalopathy
- Electrolyte replacement, particularly potassium, magnesium, and phosphate, to correct imbalances
- Bicarbonate therapy, which is generally not recommended unless pH is severely low (<7.1)
- Monitoring for alcohol withdrawal symptoms and managing them with benzodiazepines as needed
- Long-term management, including alcohol cessation counseling and nutritional support to prevent recurrence of this potentially life-threatening condition.
From the Research
Causes of Metabolic Acidosis Secondary to Alcohol (Ethanol) Use
- Metabolic acidosis can occur due to increased endogenous acid production, exogenous acid administration, base losses, and depression of renal acid secretion 2
- Alcohol-induced acidosis is a mixed acid-base disturbance, with metabolic acidosis due to lactic acidosis, ketoacidosis, and acetic acidosis 3
- Ethanol ingestion can lead to the overproduction of organic acids, resulting in metabolic acidosis 4
- Theoretical constraints on ethanol metabolism in the liver suggest that "overproduction" of NADH is best averted by converting ethanol to B-hydroxybutyric acid 3
Consequences of Metabolic Acidosis Secondary to Alcohol (Ethanol) Use
- Metabolic acidosis can lead to life-threatening complications, including decreased cardiac output, arterial dilatation with hypotension, altered oxygen delivery, decreased ATP production, predisposition to arrhythmias, and impairment of the immune response 4
- Severe but rapidly reversible lactic acidosis and associated alcohol-induced ketoacidosis can occur 5
- Chronic metabolic acidosis can result in increased muscle degradation and abnormal bone metabolism 4
- Treatment of alcohol acidosis should include replacement of sodium, chloride, potassium, phosphorus, magnesium, and thiamine, along with attention to concomitant clinical problems 3
Diagnosis and Treatment of Metabolic Acidosis Secondary to Alcohol (Ethanol) Use
- Diagnosis is made by a synthesis of the clinical history, physical examination, other hematological values, serum and urinary chemistries, and arterial blood gases and electrolytes 2
- Calculation of the anion and osmolal gaps can be effectively used to further narrow the diagnostic possibilities 2
- Treatment may include intravenous thiamine, intravenous fluids, and bicarbonate, although the use of alkalinizing agents remains controversial 5, 4