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ACB-CLIN-CHEM-GEN  October 2010

ACB-CLIN-CHEM-GEN October 2010

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Subject:

Re: Osmolal gap in DKA

From:

"Hallworth Mike (RLZ)" <[log in to unmask]>

Reply-To:

Hallworth Mike (RLZ)

Date:

Thu, 7 Oct 2010 12:26:34 +0100

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (329 lines)

Thanks Derek for posting this - but it should be noted that posting pdf
copies of articles to the Mailbase is a breach of the journal's
copyright, however helpful it may be.

There have been a few recent examples, and it is not good practice. The
citation is preferable.

Mike


-----Original Message-----
From: Clinical biochemistry discussion list
[mailto:[log in to unmask]] On Behalf Of McKillop, Derek
Sent: 07 October 2010 09:45
To: [log in to unmask]
Subject: Re: Osmolal gap in DKA


The following publication may be helpful as it list the contributing
factors to osmolal gap in 6 DKA patients.


Excess Osmolal Gap in Diabetic Ketoacidosis Explained. CLIN. CHEM.38/5,
755-757 (1992) D. Fraser Davidson


Derek McKillop
Principal Clinical Scientist
Dept Clinical Biochemistry
Craigavon Area Hospital
Southern Health and Social Care Trust 


 

-----Original Message-----
From: Clinical biochemistry discussion list
[mailto:[log in to unmask]] On Behalf Of Balfe, Alan
(Biochemistry CPL)
Sent: 06 October 2010 11:58
To: [log in to unmask]
Subject: Re: Osmolal gap in DKA

This means it is already included in the calculated osmolality, but it
must contribute to measured osmolality.
 
Alan Balfe
St. James's Hospital, Dublin

	-----Original Message-----
	From: Clinical biochemistry discussion list
[mailto:[log in to unmask]]On Behalf Of IMSU
	Sent: 01 October 2010 17:10
	To: [log in to unmask]
	Subject: Re: Osmolal gap in DKA
	
	
	Because it's ionised, and therefore included in the 2 x (sodium
+ potassium) bit. 

	Jonathan
	
	Sent from my iPhone

	On 1 Oct 2010, at 16:52, "Colley, Michael"
<[log in to unmask]> wrote:
	
	

		Why doesn't bHb contribute?

		

		M

		

		

		From: Clinical biochemistry discussion list
[mailto:[log in to unmask]] On Behalf Of Mohammad
Al-Jubouri
		Sent: 01 October 2010 16:51
		To: <mailto:[log in to unmask]>
[log in to unmask]
		Subject: Osmolal gap in DKA

		

		I have been informed by a colleague that acetone can
only contribute 4.7 mmol/L to measured osmolality and that
B-hydroxybutyrate doesn't contribute to measured serum osmolality. The
sample wasn't lipaemic nor hyperproteinaemic and serum was measured
using indiract ISE. There could be other unmeasured osmols such as
glycerol and organic acids.

		There is obviously a knowlege gap as well.

		

		BW

		

		Mohammad

		

		
________________________________


		From: Mohammad Al-Jubouri <[log in to unmask]>
		To: <mailto:[log in to unmask]>
[log in to unmask]
		Sent: Fri, 1 October, 2010 15:29:25
		Subject: Osmolal gap in DKA

		Looking beyond DKA, a case to share

		

		A 35-year-old male was found in his house with reduced
GCS lying on the floor. He lives alone and was not seen by a member of
his immediate family for at least 3 days and is not a known diabetic
patient. His admission blood sample clearly indicates DKA &
rhabdomyolysis as follows:

		

		Sodium     - 128 

		Potassium    4.8   

		Urea       + 26.3  

		Creatinine + 398  

		CK         + 23844  

		R. Glucose + 59.0       

		Bicarb     - <5.0         

		Chloride     98 

		pH  6.876

		Anion gap  + 34.8 

		Lactate 3.0

		Measured  S.Osmolal ity  + 379

		Calculated S. Osmolality + 342

		Osmolal gap  = 37 mosm/L         

		

		Because of the high osmolal gap, even for a DKA, and the
obscure history, a sample was analysed for ethanol, methanol & ethylene
glycol, all were not detected, however his serum acetone was 271 mg/L
and B-hydroxybutyrate 1358 mg/L. So the big osmolal gap could be
accounted for by the ketones in this case. I was not aware that DKA
could produce such a big osmoal gap due to ketones only, but I suspect
that in a late presenting DKA like this case, it reflects the severity
of ketoacidosis as it proceeded without treatment for > 48h at least.

		Your thoughts/experience are welcome.

		

		Best regards

		

		Mohammad

		

		Dr. M A Al-Jubouri, MB ChB, MSc, FRCP Edin, FRCPath
		Consultant Chemical Pathologist 

		
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