Frequency of alcoholic ketoacidosis in the emergency department

Alcoholic Ketoacidosis (AKA) is a complication from alcohol use characterized by an elevated anion gap metabolic acidosis (AGMA). Though the underlying pathophysiology is well characterized, the frequency in patients presenting to the emergency department (ED) has not been studied. This study aims to quantify the frequency of AKA amongst patients presenting to the ED with alcohol intoxication or suspected withdrawal.

We performed a multi-center retrospective chart review of adults (age 18 and older) presenting to the ED with an alcohol-related chief complaint or diagnosis. The primary outcome was the frequency of AKA. We excluded patients with an acute medical condition that could lead to an acidosis or alter the presentation (diabetic ketoacidosis, seizure, pancreatitis, sepsis, pulmonary embolism, medication overdose, or intracranial hemorrhage). We excluded patients with withdrawal or an overdose.

We identified 905 individual patient presentations to the ED with alcohol related complaints, including both intoxication and withdrawal. The average bicarbonate was 23 meq/L and 13% of patients had a bicarbonate less than 20 meq/L. Of the included patients, 235 patients (26% +/- 3%) had an elevated anion gap. Only 349 patients had a urinalysis performed with 43% of those positive for ketones. Using a stricter diagnosis of AKA (ketonuria and an AGMA) we identified 96 patients (11% +/- 2%). In 9% of (20/235) a those with an AGMA and in 15% (14/96) with a strict diagnosis of AKA.

Alcohol ketoacidosis complicates alcohol-related ED presentations in 11-26% of cases. Diagnosis was infrequent and increased recognition of this pathology may improve the care of these patients.