Interactive bedside framework for elevated beta-hydroxybutyrate. Decide first whether this is uncomplicated ketosis versus ketoacidosis, then separate DKA, euglycemic DKA, starvation ketosis, alcoholic ketoacidosis, and mixed high-gap acidosis.
AllDKAEuglycemicStarvationAlcoholMixed gap acidosisBack to Main Page
Interactive diagnostic assistant
Activate the assistant to combine BHB, glucose, pH/bicarbonate, anion gap, and context. It will withhold likely diagnosis/mechanism language until confidence is above 50%.
Ketone / acid-base pattern
Calculate gap if needed
Context and symptoms
Calculated anchors
Ketosis syndrome
Anion gap formula AG = Na - Cl - HCO3. If a direct AG is entered, the assistant uses the direct value.
Flowchart
Step 1
Ask whether elevated BHB is causing acidosis
Pair BHB with pH, serum bicarbonate / CO2, anion gap, glucose, lactate, and clinical acuity. Ketosis without acidosis is a different problem from ketoacidosis.
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Step 2
Get the core diagnostic frame
BMP/CMP, glucose, VBG/ABG, serum BHB, UA/urine ketones, Mg/Phos/K, lactate, creatinine, osmolality/osm gap if needed, and ECG when potassium or ischemia is concerning.
Diabetes-associated branch
DKA
Classic DKA / DKA-HHS overlap
Diabetes or hyperglycemia, BHB usually at least 3 mmol/L, and metabolic acidosis. Look hard for the precipitant.
Euglycemic
Euglycemic DKA
Do not require marked hyperglycemia when SGLT2i, pregnancy, prolonged fasting, vomiting, or partial insulin treatment is in the story.
Low-carbohydrate / nutrition branch
Starvation
Starvation ketosis / ketoacidosis
Poor intake or ketogenic diet with normal/low glucose; usually milder acidosis, but stress, pregnancy, and illness can amplify it.
Alcohol
Alcoholic ketoacidosis
Alcohol use, depleted glycogen, poor nutrition, nausea/vomiting, high-gap acidosis, and normal/low/mildly high glucose.
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Mixed
Check for another high-gap acidosis
Lactate, uremia, salicylates, toxic alcohols, shock, ischemia, renal failure, and sepsis can coexist with ketonemia or be the main driver of the gap.
Teaching pearl: serum BHB tracks clinically important ketoacidosis better than urine acetoacetate; urine ketones can lag behind the blood-redox picture.