What is the treatment for alcoholic ketoacidosis (AKA)?

Treatment of Alcoholic Ketoacidosis (AKA)

The cornerstone of treatment for alcoholic ketoacidosis is aggressive intravenous fluid resuscitation with isotonic saline, followed by dextrose administration and electrolyte replacement. 1

Initial Assessment and Management

• Begin with isotonic saline at 15-20 ml/kg/h during the first hour to restore circulatory volume and tissue perfusion 1
• Laboratory evaluation should include plasma glucose, blood urea nitrogen, creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, arterial blood gases, and complete blood count 1, 2
• Obtain bacterial cultures of urine, blood, and other sites as needed if infection is suspected as a precipitating or complicating factor 1
• Monitor fluid input/output, hemodynamic parameters, and clinical examination to assess progress with fluid replacement 1

Glucose Administration

• After initial fluid resuscitation, administer intravenous dextrose (typically 5% dextrose in saline) to reverse the ketogenic state 3, 4
• Dextrose administration at 7.0-7.5 gm/hr has been shown to provide more rapid improvement in the acidotic state compared to saline alone 3
• Target blood glucose levels of 100-180 mg/dL during treatment 1
• Unlike diabetic ketoacidosis, insulin administration is typically unnecessary in AKA and may potentially worsen hypoglycemia 5

Electrolyte Management

• Monitor potassium levels closely as total body potassium deficits are common despite potentially normal or elevated initial serum levels due to acidosis 1
• Once renal function is assured and serum potassium is known, add 20-40 mEq/L potassium to the infusion when serum levels fall below 5.5 mEq/L 1
• Monitor phosphorus levels, as they typically drop rapidly during treatment (from initial elevated levels to potentially critically low levels within 24 hours) 3
• Unlike diabetic ketoacidosis, bicarbonate administration is generally not recommended as it does not improve outcomes and may potentially worsen ketosis 5

Vitamin Supplementation

• Administer thiamine (100 mg IV) before glucose to prevent precipitation or worsening of Wernicke's encephalopathy 4
• Consider additional B-complex vitamins and folate supplementation given the common nutritional deficiencies in chronic alcohol users 4

Monitoring and Ongoing Management

• During therapy, blood should be drawn every 2-4 hours for determination of serum electrolytes, glucose, blood urea nitrogen, creatinine, and osmolality 1
• Direct measurement of β-hydroxybutyrate in blood is preferred over nitroprusside methods (which only measure acetoacetic acid and acetone) 2
• Monitor for complications, particularly electrolyte imbalances that can trigger cardiac arrhythmias 1

Resolution and Discharge Planning

• AKA typically resolves rapidly with appropriate fluid and glucose administration, usually within 24 hours 5, 6
• A structured discharge plan should be tailored to the individual to reduce length of hospital stay and readmission rates 1
• Include education on the recognition and prevention of AKA, as well as resources for alcohol use disorder treatment 1
• Schedule follow-up appointments prior to discharge to increase the likelihood that patients will attend 1

Special Considerations

• Pregnant patients may develop AKA more readily due to combined metabolic derangements of pregnancy and alcoholism 7
• The major cause of morbidity and mortality in AKA is not the acidosis itself but rather failure to adequately treat concurrent medical or surgical conditions 5