A retrospective analysis of glycol and toxic alcohol ingestion: utility of anion and osmolal gaps

Krasowski, Matthew D.; Wilcoxon, Rebecca; Miron, Joel

doi:10.1186/1472-6890-12-1

Cited by 57 publications

(61 citation statements)

References 50 publications

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“…This method requires expensive equipment and educated technical staff; therefore, ethanol is generally measured with the enzymatic method. In some laboratories, the enzymatic method is not possible, and so the calculated osmolal gap provides a practical approach, but it must be remembered that there are several conditions that can increase the osmolal gap other than ethanol, such as diabetes mellitus, dehydration, or hypernatremia [12][13][14].…”

Section: Discussionmentioning

confidence: 99%

Comparison of measured ethanol and calculated ethanol using osmolal gap and osmolarity formulas

Börü¹

2017

Int J Med Biochem

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Comparison of measured ethanol and calculated ethanol using osmolal gap and osmolarity formulasO smolality is the concentration of the osmoles of solute dissolved per kilogram of pure water (mOsmol/kg H 2 O), whereas osmolarity is the concentration of the osmoles of solute dissolved per liter of solution (mOsmol/L). These 2 terms can be used interchangeably, but osmolality is a more accurate term thermodynamically. Solution concentrations are expressed on the basis of weight, and therefore, it is independent of temperature and pressure. In contrast, solution concentrations are expressed on the basis of volume in osmolarity, and changes in volume can occur depending on the thermal expansion of the solution. As a result, osmolarity can lead to incorrect results in cases of hyperlipidemia or hyperproteinemia, or in the presence of osmotically active substances, such as alcohol or mannitol [1][2][3].The osmolal gap is the difference between measured osmolality and calculated osmolality. Normally, the osmolal gap is less than 10 mOsmol/kg H 2 O [4].A high concentration of alcohol, such as ethanol, methanol, isopropanol, ethylene glycol, or propylene glycol causes hyperosmolality and a high osmolal gap in proportion with the Objectives: Osmolality can be measured with an osmometer, and it can also be calculated using formulas that include the level of some osmotically active serum components. The difference between measured and calculated osmolality is referred to as the osmolal gap. The osmolal gap indirectly indicates the presence of osmotically active substances other than sodium, urea, and glucose. The aim of this study was to calculate the osmolal gap using 6 osmolarity formulas published in the literature and compare the measured ethanol concentrations with various ethanol calculation formulas that include the osmolal gap. Methods: Serum ethanol, glucose, potassium, sodium, and urea levels were measured. Serum osmolarity was calculated with 6 formulas and converted to osmolality (mOsmol/L-mOsmol/kg H 2 O) using a converting factor. The osmolal gap was determined using measured and calculated osmolality with 6 different formulas for each sample. The osmolal gap values were multiplied by the ethanol coefficient used to ascertain the effect of ethanol on serum osmolality in order to obtain the amount of ethanol in the samples. Results: A positive correlation was observed between the 24 calculated ethanol levels and measured ethanol levels. No statistically significant difference was seen between the measured ethanol levels and 1 of the formulas, but there were systematic differences between them. Conclusion: Estimating the ethanol concentration with this type of approach is particularly inappropriate in forensic cases. The osmolal gap should only be used for screening toxic alcohols as an adjunct to clinical decision-making in emergency departments when ethanol cannot be measured, as in a case of alcohol intoxication.

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Section: Discussionmentioning

confidence: 99%

Comparison of measured ethanol and calculated ethanol using osmolal gap and osmolarity formulas

Börü¹

2017

Int J Med Biochem

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“…A retrospective study reported the sensitivity and specificity of the osmolal gap for toxic alcohol ingestion to be 0.82 and 0.85, respectively, with a cutoff of Ͼ14 mOsm/kg (10 ). Other causes of increased osmolal gap that should be considered include alcoholic and diabetic ketoacidosis (acetone accumulation), renal failure, shock, and mannitol infusion (10 ).…”

Section: Methanol Toxicitymentioning

confidence: 99%

Fill in the Gaps: An Unresponsive 55-Year-Old Man

Gau

Scott

2018

Clinical Chemistry

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A 55-year-old man with a history of chronic obstructive pulmonary disease that did not require home oxygen, as well as hypertension, was brought to our emergency department after being found unresponsive at home. The patient's family said he was in his usual state of health until today, when they noticed increased dyspnea consistent with his chronic obstructive pulmonary disease. They believed it was caused by recent overexertion cleaning tools with various chemicals. His breathing became worse as the day progressed, and he was found overnight to be diaphoretic and unresponsive, prompting a 9-1-1 call. The family denied sick contacts, recent travel, and toxin ingestion.Examination in the emergency department showed a chronically ill man in severe distress, with rapid shallow respirations, prompting immediate intubation. He exhibited no purposeful movements and no response to noxious stimuli, but his pupils were responsive to light. Vital signs included a heart rate of 86 beats/min; respirations, 26 breaths/min; blood pressure, 196/112 mmHg; and oxygen saturation, 95% by pulse oximetry. Point-ofcare glucose was 176 mg/dL (reference interval, 70 -199 mg/dL). An electrocardiogram showed sinus rhythm without ST segment changes. Initial laboratory testing included a basic metabolic panel, lactic acid, and arterial blood gases (Table 1). A white blood cell count was 20.8 K/mm 3 (3.9 -9.9 K/mm 3 ). Using the calculated total CO 2 from the arterial blood gas, the anion gap was 27 mmol/L (2-15 mmol/L). Serum osmolality was 329 mOsm/kg (275-300 mOsm/kg), with a calculated osmolal gap of 52 mOsm/kg. Other initial blood testing included a hepatic function panel, lipase, troponin I, B-type natriuretic peptide, and acetaminophen; all were unremarkable. Urinalysis was notable for 1ϩ ketones and 2ϩ protein. Computed tomography of the head and abdomen showed no acute abnormalities. A chest radiograph showed a normal cardiac silhouette and no evidence of pneumonia, effusion, or pneumothorax. DiscussionElectrical charge in the blood is balanced by cations and anions in the form of protons (Hϩ), electrolytes, and organic compounds (1 ). The anion gap is estimated by subtracting plasma chloride plus bicarbonate concentrations (the main blood anions) from the plasma sodium concentration (the main blood cation):

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“…[46][47][48][49][50][51][52][53][54][55] Knowing, however, that the normal range for osmolar gap can be as low as À5 or À10 mOsm, it is possible for a patient to present with a toxic ingestion and an osmolar gap that is within the reference range but actually represents a significant change from their normal baseline. For example, a patient with a pre-existing osmolar gap of À5 mOsm who then ingests ethylene glycol and has a blood ethylene glycol concentration of 50 mg/L may only increase their osmolar gap to 5 mOsm which remains below the reference interval of 10 mOsm.…”

Section: -4952-57mentioning

confidence: 99%

“…There have been more than 15 different formulae proposed and the validity of each of these has long been debated. [46][47][48][49][50][51][52][53][54][55] Most of the formulae in widespread use include contributions from sodium, urea and glucose with a few including ethanol. 45 In general, the variability of each of these formulae is explained by differing coefficients for the relative contribution of each of the substrates.…”

Section: Indirect Testingmentioning

confidence: 99%

Challenges in the diagnosis of ethylene glycol poisoning

McQuade

Dargan

2013

Ann Clin Biochem

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Ethylene glycol poisoning, while uncommon, is clinically significant due to the associated risk of severe morbidity or lethality and it continues to occur in many countries around the world. The clinical presentation of ethylene glycol toxicity, while classically described in three phases, varies widely and when combined with the range of differential diagnoses that must be considered makes diagnosis challenging. Early and accurate detection is important in these patients, however, as there is a need to start antidotal treatment early to prevent serious harm. In this article, we will review the literature and provide guidance regarding the diagnosis of ethylene glycol poisoning. While gas chromatography is the gold standard, the usefulness of this test is hampered by delays in access due to availability. Consequently, there are several surrogate markers that can give an indication of ethylene glycol exposure but these must be interpreted with caution and within the clinical context. An in-depth review of these tests, particularly the detection of a raised osmolar gap or an raised anion gap acidosis, will form the main focus of this article.

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A retrospective analysis of glycol and toxic alcohol ingestion: utility of anion and osmolal gaps

Cited by 57 publications

References 50 publications

Comparison of measured ethanol and calculated ethanol using osmolal gap and osmolarity formulas

Comparison of measured ethanol and calculated ethanol using osmolal gap and osmolarity formulas

Fill in the Gaps: An Unresponsive 55-Year-Old Man

Challenges in the diagnosis of ethylene glycol poisoning

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