alcoholic ketoacidosis and lactic acidosis

[bravotwozero]

Ok, this might be basic for a lot of you, so trying to ask this without sounding like a complete tool. I get alcoholics in the ED all the time, with an elevated anion gap, and elevated lactate levels. Is their alcoholic ketoacidosis causing the lactic acidosis as well? If I have read/interpreted things from tintinalli, it says that AKA shouldn't be causing a lactic acidosis and/or wide anion gap, so we should look for other causes. Many times, these guys won't have positive ketones in the urine.

But that doesn't make sense to me. Without fail, I admit, feed these weirdos, start a d5NS drip, gap closes, lactic acid goes down, and off they go for their likely next binge.

Penny for your thoughts...

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[InternistDO]

If I remember my first year biochemistry correctly, high levels of ethanol metabolism cause a high NADH/NAD ratio, which then inhibits gluconeogenesis and pushes pyruvate towards lactate, which causes a lactic acidosis. It is rarely severe and rapidly normalizes with glucose and cessation of drinking.

Additional source: Alcoholic ketoacidosis

 

[hoot504]

I do the same as you, and I've had a rash of these lately.

I also have some of the same questions. I do believe that significant ETOH use itself can cause a small degree of lactic acidosis. Usually these patients come in with a LA of 3 - 5, but have a gap on the order of 20 - 30. I do give consideration to other causes but generally don't find them. I send ketones and boom, there they are. At that point I typically start the D5 and admit them.

 

[Tenk]

Yeah this is why I don’t order lactates on alcoholics.

 

[Groove]

Ok, this might be basic for a lot of you, so trying to ask this without sounding like a complete tool. I get alcoholics in the ED all the time, with an elevated anion gap, and elevated lactate levels. Is their alcoholic ketoacidosis causing the lactic acidosis as well? If I have read/interpreted things from tintinalli, it says that AKA shouldn't be causing a lactic acidosis and/or wide anion gap, so we should look for other causes. Many times, these guys won't have positive ketones in the urine.

But that doesn't make sense to me. Without fail, I admit, feed these weirdos, start a d5NS drip, gap closes, lactic acid goes down, and off they go for their likely next binge.

Penny for your thoughts...

There's several proposed mechanisms such as:

1) Increased BAL decreases lactate clearance d/t hepatic dysfunction. (Ethanol oxidation leads to reduced NAD+/NADH ratio --> pushing pyruvate toward lactate.)
2) Malnutrition. Thiamine is a coenzyme for pyruvate --> acetyl CoA. If it's depleted, then again....pyruvate gets pushed to lactate.
3) Extracellular volume depletion leading to Type A lactic acidosis.
4) Secondary causes...seizures, hyperadrenergic response, hyperventilation, alkaholic keto acidosis, repeated retching, DTs etc..

I rarely admit these. I tank them up with fluids, replete their mag, thiamine, lytes, etc.. Give them some dextrose and send them on their way unless there are high risk features or something else is going on. I rarely order a lactate on these people for this very reason as it's always going to be elevated. That being said, if one is ordered at triage...I don't get too excited unless it's over 4 or 5 in these patients. Be careful in regards to your analyzer, many can't distinguish between lactate from glycolate (ethylene glycol poisoning). It's kind of like the hyperchloremia that dextramethorphan ingestions will give you, sometimes with a negative ion gap. The analyzer can't tell the difference between halides. Bromide and chloride all look the same to the machine. So... if the lactate is really high and I'm not sure what they got into... I might get an ethylene glycol level. Especially if their abg shows an acidosis. That's pretty rare though. (I usually do NOT get an abg in these people.)

 

[gro2001]

Ok, this might be basic for a lot of you, so trying to ask this without sounding like a complete tool. I get alcoholics in the ED all the time, with an elevated anion gap, and elevated lactate levels. Is their alcoholic ketoacidosis causing the lactic acidosis as well? If I have read/interpreted things from tintinalli, it says that AKA shouldn't be causing a lactic acidosis and/or wide anion gap, so we should look for other causes. Many times, these guys won't have positive ketones in the urine.

But that doesn't make sense to me. Without fail, I admit, feed these weirdos, start a d5NS drip, gap closes, lactic acid goes down, and off they go for their likely next binge.

Penny for your thoughts...

I think the other explanations are basically right. I suspect that most of the time it's the issue of NAD+ depletion due to alcohol dehydrogenase being really active. Other explanations may play a role in some folks but more rarely. This is just speculation though.

Just to clarify something I may have misunderstood from your post: AKA can totally cause a wide anon gap acidosis.

A useful mnemonic to remember what causes anion gap acidosis I like (though usually I am not a fan of them): KULTS

Ketones
Uremia
Lactate
Toxic alcohols
Salicylate

It's nice because unlike MUDPILES it tells you what to order for workup.

 

[RustedFox]

I think the other explanations are basically right. I suspect that most of the time it's the issue of NAD+ depletion due to alcohol dehydrogenase being really active. Other explanations may play a role in some folks but more rarely. This is just speculation though.

Just to clarify something I may have misunderstood from your post: AKA can totally cause a wide anon gap acidosis.

A useful mnemonic to remember what causes anion gap acidosis I like (though usually I am not a fan of them): KULTS

Ketones
Uremia
Lactate
Toxic alcohols
Salicylate

It's nice because unlike MUDPILES it tells you what to order for workup.

As a mnemonic addict, I approve - and feel that this is better that MUDPILES because its briefer.

 

[GeneralVeers]

Elevated lactic acid = sepsis. You are going to get a nastygram for a "fall out".

 

[Groove]

Elevated lactic acid = sepsis. You are going to get a nastygram for a "fall out".

Not if they get discharged! 😉

Speaking of pointless tests..like lactates in alcoholics or asthma exacerbations. Does anybody's nurses get EKGs during codes? I'm talking about before we've even got a heart beat. The last couple of codes I've ran...some nurse will hustle to get an EKG on my asystolic patient and hand me the EKG to sign for "no STEMI" afterwards. I'm like...WTF?

 

[Fox800]

Not if they get discharged! 😉

Speaking of pointless tests..like lactates in alcoholics or asthma exacerbations. Does anybody's nurses get EKGs during codes? I'm talking about before we've even got a heart beat. The last couple of codes I've ran...some nurse will hustle to get an EKG on my asystolic patient and hand me the EKG to sign for "no STEMI" afterwards. I'm like...WTF?

wat

 

[RoyBasch]

Yeah this is why I don’t order lactates on alcoholics.

I'm pretty conservative in my practice, zebra hunter, etc.

However, I agree 100% with Tenk.

Why are you (OP) getting metabolic panels, alcohol levels, lactates, or really any additional labs besides an accucheck on drunks?

Maybe i'm just numb to these patients after having seen thousands (or maybe just the same 50 patients 200x each) training at a county hospital, but they seem to do ok with minimal workup and treatment. They sober up, get discharged, get drunk, and we see them again the next shift or the next day and they don't seem to succumb from their hyponatremia, or alcoholic transaminitis, or starvation ketosis, or lactic acidosis, or whatever chronic metabolic abnormalities you will find in these patients if you actually look.

I can only assume after drinking for many years, these patient's physiologies are oddly adapted to the chronic abnormalities and they tolerate them very well. I think if someone had an acute hyponatremia, AG/NG acidosis, or lactic acidosis from some OTHER reason, I would be much more concerned about them.

I think this is one of the rare situations where "I can't find problems I'm not looking for." Accucheck, pulse ox, obs till sober, dc, onto the next case. Unless I think the patient is likely to be admitted for some other reason (trauma/injury, withdrawl, chest pain, etc.) I don't do any labs on drunks besides an accucheck.

 

[bravotwozero]

Usually it’s because of abnormal vitals - most of the time, tachycardia. when I find this stuff, I’ll ship them off to the floor to make it someone else’s problem...

 

[TooMuchResearch]

Not if they get discharged! 😉

Speaking of pointless tests..like lactates in alcoholics or asthma exacerbations. Does anybody's nurses get EKGs during codes? I'm talking about before we've even got a heart beat. The last couple of codes I've ran...some nurse will hustle to get an EKG on my asystolic patient and hand me the EKG to sign for "no STEMI" afterwards. I'm like...WTF?

But now you know it's not a STEMI, amirite?

 

[TooMuchResearch]

I'm pretty conservative in my practice, zebra hunter, etc.

However, I agree 100% with Tenk.

Why are you (OP) getting metabolic panels, alcohol levels, lactates, or really any additional labs besides an accucheck on drunks?

Maybe i'm just numb to these patients after having seen thousands (or maybe just the same 50 patients 200x each) training at a county hospital, but they seem to do ok with minimal workup and treatment. They sober up, get discharged, get drunk, and we see them again the next shift or the next day and they don't seem to succumb from their hyponatremia, or alcoholic transaminitis, or starvation ketosis, or lactic acidosis, or whatever chronic metabolic abnormalities you will find in these patients if you actually look.

I can only assume after drinking for many years, these patient's physiologies are oddly adapted to the chronic abnormalities and they tolerate them very well. I think if someone had an acute hyponatremia, AG/NG acidosis, or lactic acidosis from some OTHER reason, I would be much more concerned about them.

I think this is one of the rare situations where "I can't find problems I'm not looking for." Accucheck, pulse ox, obs till sober, dc, onto the next case. Unless I think the patient is likely to be admitted for some other reason (trauma/injury, withdrawl, chest pain, etc.) I don't do any labs on drunks besides an accucheck.

I think most of our drunks are 50-60+ years old with a long list of chronic conditions and evidence of age indeterminate head trauma, so we tend to order some stuff.

 

[Groove]

Usually it’s because of abnormal vitals - most of the time, tachycardia. when I find this stuff, I’ll ship them off to the floor to make it someone else’s problem...

Nothing wrong with that, especially if you have a shop that will take those admits. Drunks make me a bit paranoid from time to time. I had one dumped off other day...typical story...typical drunk. Ended up with a large acute on chronic SDH. (Not a scratch on his head btw) One of my partners had one last year that got sat on for hours waiting to "sober up" and on re-eval had an abnormal neuro exam. MRI with acute CVA. Most of these pt's are fine..but it's such a high risk population. I view them like Lupus pt's...damn near anything can go wrong with them. I had one other day with long PR, QTc and QRS and ridiculously low mag. Then again, all these guys have low mag. Sometimes I don't even bother checking it, I just load them if their intervals are borderline or they had a seizure. I scan a large percentage of these guys, probably more than my partners. I try to get everything done anticipating difficulty ambulating them and discharging. There's nothing more frustrating than the 2-3h re-eval where they just aren't acting right & you've got skeleton labs/workup and are only then realizing that you're going to have to admit.

 

[thegenius]

I'm pretty conservative in my practice, zebra hunter, etc.

However, I agree 100% with Tenk.

Why are you (OP) getting metabolic panels, alcohol levels, lactates, or really any additional labs besides an accucheck on drunks?

Maybe i'm just numb to these patients after having seen thousands (or maybe just the same 50 patients 200x each) training at a county hospital, but they seem to do ok with minimal workup and treatment. They sober up, get discharged, get drunk, and we see them again the next shift or the next day and they don't seem to succumb from their hyponatremia, or alcoholic transaminitis, or starvation ketosis, or lactic acidosis, or whatever chronic metabolic abnormalities you will find in these patients if you actually look.

I can only assume after drinking for many years, these patient's physiologies are oddly adapted to the chronic abnormalities and they tolerate them very well. I think if someone had an acute hyponatremia, AG/NG acidosis, or lactic acidosis from some OTHER reason, I would be much more concerned about them.

I think this is one of the rare situations where "I can't find problems I'm not looking for." Accucheck, pulse ox, obs till sober, dc, onto the next case. Unless I think the patient is likely to be admitted for some other reason (trauma/injury, withdrawl, chest pain, etc.) I don't do any labs on drunks besides an accucheck.

“Don’t look under the hood”

I would love to never check labs on these guys....but when I do its because....well just a fear you are going to miss something.

I wholeheartedly agree though these drunks love a sandwich, sometimes 1-2L IVF w / wo dextrose, and just time. All those abnormalities just go away.

It’s just seems like some of the time there is need to get labs like they are suicidal, they are complaining of something, they have a tender abdomen, stuff like that.