Alcohol levels are usually low or undetectable at the time of presentation, but some patients may present with an elevated blood alcohol level, making diagnosis more challenging. An elevated anion gap caused by ketones is essential for diagnosing AKA. As bHB predominates, the degree of ketonemia may not be appreciated, depending on the method of ketone detection (see Chap.,203 for a complete discussion). The initial anion gap is usually 16 to 33, with a mean of 21. Patients frequently have mild hypophosphatemia, hyponatremia, and/or hypokalemia. Most patients will also have elevated bilirubin and liver enzymes due to a long history of chronic ethanol use. Blood urea nitrogen and creatinine kinase levels are frequently elevated due to relative volume depletion. Serum lactate levels can be mildly elevated. Glucose levels are most often only mildly elevated, but a subset of patients will have hypoglycemia. On rare occasions, the glucose level may be greater than 200 mg/dL.

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