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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 ------ACB discussion List Information-------- This is an open discussion list for the academic and clinical community working in clinical biochemistry. Please note, archived messages are public and can be viewed via the internet. Views expressed are those of the individual and they are responsible for all message content. 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