Osmolal Gap Research Articles

Fomepizole単独療法で治療を完遂したメタノール中毒の1例(Fomepizole alone therapy for a case of methanol intoxication)

要旨症例は21歳の男性，自殺目的に燃料用アルコール（メタノール76.6%含有）を飲用し，当院に救急搬送された。来院時，症状が軽微かつ検査値異常を認めないために緊急血液浄化療法の適応はないと判断し，fomepizoleの投与を行い入院となった。翌日，予測血中メタノール濃度が340mg/dLと異常高値であったが，その他の異常を認めなかったためにfomepizoleの投与のみを継続した。最終的に16日間，合計30回，本薬剤の投与を行い，合併症なく退院した。2015年1月よりアルコール脱水素酵素阻害薬であるfomepizoleのメタノール中毒・エチレングリコール中毒に対する使用が本邦でも保険適応となり，アルコール類中毒に対する標準的治療は大きく変化した。本薬剤のメタノール中毒への有効性は海外で広く認知されているが，従来用いられてきたエタノールによる解毒法と比較して医療費が非常に高額となり，その使用方法には依然として議論がある。今回我々は，fomepizole単独療法と血液浄化併用療法との比較を，患者管理の視点に加え，医療費の面からも検討した。その結果，個々の症例の血中メタノール濃度や患者状態，予測される治療期間に応じて2つの治療方法を使い分ける必要があり，血液浄化療法導入となる血中メタノール濃度の基準は50mg/dL程度であると考えられた。

Acute Kidney Injury, Myocardial Infarction and Death Following Brake Fluid Poisoning; A Case Report

Background: Ethylene glycol is a toxic alcohol which is used in brake fluid, antifreeze, coolants, preservatives and chemical solvents. Ethylene glycol poisoning usually results in depression of the central nervous system, renal insufficiency and cardiopulmonary compromise, while laboratory findings include metabolic acidosis, increased anion gap, increased osmolar gap and calcium oxalate crystalluria. Case presentation: A 24-year-old previously healthy person died 13 days after self-ingestion of brake fluid (ethylene glycol). He developed multi-organ failure including acute kidney injury, metabolic acidosis, respiratory failure, myocardial infarction, low Glasgow coma scale, and elevation of liver enzymes. He also developed hypotension for which 3 inotropes were started. He had ST elevation myocardial infarction (STEMI) on day 4 of the poisoning associated with a reduction of ejection fraction of up to 25% with septal anterior wall hypokinesia. He needed intensive care treatment via ventilator and inotropic support. Five cycles of hemodialysis were carried out for acute kidney injury. His autopsy examination revealed sub-endocardial hemorrhages. Discussion: Acute kidney injury and metabolic acidosis are frequently seen following ethylene glycol poisoning from brake fluid ingestion. The cardiotoxic effect of its poisoning could be due to multiple microcalcifications of the myocardium. This clinical report highlights the severity and the sequence of events following ethylene glycol poisoning. Conclusion: STEMI may result following ethylene glycol poisoning in addition to other cardiac effects such as hypotension, tachycardia, myocarditis and ischemic changes in ECG.

Diagnostics of methyl alcohol intoxication: possibilities
 and prospects

Intake of toxic alcohols especially methyl alcohol posses a serious threat to health. Despite relatively low toxicity of methanol (hazard class III), its metabolite formic acid resulting from biotransformation of methyl alcohol by alcohol dehydrogenase is ranked among substances creating a high risk of toxic action. The long period of methanol toxification (~48 hr) makes difficult diagnostics of intoxication and therefore delays provision of emergency medical aid. It imposes high requirements on express diagnostics of methyl alcohol intoxication (Т51.1 ICD-10). The main diagnostic modality - routine evaluation of osmolar and anion gaps, has advantages and disadvantages. Drawbacks of emergency medical aid to the victims of methyl alcohol intoxication necessitates the search for new diagnostic options some of which sre discussed in the present article.

Formulas for Calculated Osmolarity and Osmolal Gap: A Study of Diagnostic Accuracy

The osmolal gap has been used for decades to screen for exposure to toxic alcohols. However, several issues may affect its reliability. We aimed to develop equations to calculate osmolarity with improved performance when used to screen for intoxication to toxic alcohols. Retrospective cohort study. 7,525 patients undergoing simultaneous measurements of osmolality, sodium, potassium, urea, glucose, and ethanol or undergoing similar measurements performed within 30 minutes of a measurement of toxic alcohol levels at a single tertiary-care center from April 2001 to June 2016. Patients with detectable toxic alcohols were excluded. Equations to calculate osmolarity using multiple linear regression. The performance of new equations compared with published equations developed to calculate osmolarity, and to diagnose toxic alcohol intoxications more accurately. We obtained 7,525 measurements, including 100 with undetectable toxic alcohols. Among them, 3,875 had undetectable and 3,650 had detectable ethanol levels. In the entire cohort, the best equation to calculate osmolarity was 2.006×Na+ 1.228×Urea+ 1.387×Glucose+ 1.207×Ethanol (values in mmol/L, R2=0.96). A simplified equation, 2.0×Na+ 1.2×Urea+ 1.4×Glucose+ 1.2×Ethanol, had a similar R2 with 95% of osmolal gap values between-10.9 and 13.8. In patients with undetectable ethanol concentrations, the range of 95% of osmolal gap values was narrower than previous published formulas, andin patients with detectable ethanol concentrations, the range was narrower or similar. We performed a subanalysis of 138 cases for which both the toxic alcohol concentration could be measured and the osmolal gap could be calculated. Our simplified equation had superior diagnostic accuracy for toxic alcohol exposure. Single center, no external validation, limited number of cases with detectable toxic alcohols. In a large cohort, coefficients from regression analyses estimating the contribution of glucose, urea, and ethanol were higher than 1.0. Our simplified formula to precisely calculate osmolarity yielded improved diagnostic accuracy for suspected toxic alcohol exposures than previously published formulas.

Targeted metabolomics in colorectal cancer: a strategic approach using standardized laboratory tests of the blood and urine.

BackgroundGlycolytic markers have been detected in colorectal cancer (CRC) using advanced analytical methods.MethodsUsing commercially available assays, by-products of anaerobic metabolism were prospectively measured in the blood and urine of 20 patients with metastatic colorectal cancer (mCRC) and 20 patients with local disease. Twenty-four-hour urine citrate, plasma lactate, ketones, venous blood gas, anion gap, and osmolar gap were investigated. Results of patients with metastatic and local CRC were compared using two-sample t-tests or equivalent nonparametric tests. In addition, plasma total CO2 concentrations in our local hospital (5,931 inpatients and 1,783 outpatients) were compared retrospectively with those in our dedicated cancer center (1,825 outpatients) over 1 year.ResultsThe average venous pCO2 was higher in patients with mCRC (50.2 mmHg; standard deviation [SD]=9.36) compared with those with local disease (42.8 mmHg; SD=8.98), p=0.045. Calculated serum osmolarity was higher in mCRC and attributed to concomitant sodium and urea elevations. In our retrospective analysis, plasma total CO2 concentrations (median=27 mmol/L) were higher in cancer patients compared to both hospital inpatients (median=23 mmol/L) and outpatients (median=24 mmol/L), p<0.0001.ConclusionPatients with mCRC had higher venous pCO2 levels than those with local disease. Although causation cannot be established, we hypothesize that pCO2 elevation may stem from a perturbed metabolism in mCRC.

Importance Of Sample Volume To The Measurement And Interpretation Of Plasma Osmolality

Small sample volumes may artificially elevate plasma osmolality (Posm) measured by freezing point depression. PURPOSE: To compare different sample volumes of measured Posm (mmol/kg) to each other, and to calculated osmolarity (mmol/L) in euhydrated (EUH) and dehydrated (DEH) volunteers. METHODS: Posm was measured using freezing point depression and osmolarity calculated from measures of sodium, glucose, and blood urea nitrogen. The influence of sample volume was investigated by comparing 20 μL and 250 μL Posm samples (n = 158 pairs). Protinol (240, 280, 320 mmol/kg) and Clinitrol (290 mmol/kg) reference solutions were compared similarly (n = 246 pairs). Twenty-one volunteers were tested multiple times while EUH (n = 72) or DEH (n = 7) by - 4.0% body mass. RESULTS: The 20 μL samples of Protinol, but not Clinitrol, were significantly higher by 3 mmol/kg when compared to 250 μL samples. The 20 μL samples of plasma were 7 mmol/kg higher than 250 μL samples with a nearly constant systematic error across the range tested (slope = 0.917). Calculated osmolarity was significantly lower than 20 μL Posm (- 6.6 mmol) but not different from 250 μL Posm (<1.0 mmol). When using common criteria for EUH (<290 mmol/kg), only 19/72 EUH volunteers were correctly classified using 20 μL Posm, however, 65/72 were correctly classified using 250 μL Posm. DEH volunteers met the common > 295 mmol/kg DEH criteria in 7/7 (20 μL Posm) and 6/7 (250 μL Posm) cases studied. The average change in Posm from EUH to DEH was similar for 20 μL (11 mmol/kg) and 250 μL (10 mmol/kg) samples. CONCLUSIONS: These results demonstrate that Posm measured by freezing point depression will be ∼7 mmol/kg higher when using 20 vs. 250 μL sample volumes. Approximately half of this effect may be due to plasma proteins. Posm sample volume should be carefully considered when calculating the osmole gap or assessing hydration status. The opinions or assertions contained herein should not to be construed as official or reflecting the views of the Army or the DoD.

METHANOL POISONING;

Acute methanol poisoning produces severe metabolic acidosis, increased anionand osmolal gaps. These metabolic disturbances are due to accumulation of formic acid withhas serious neurological sequelae. If renal functions starts deteriorating that is associated withincreased mortality. Early diagnosis and treatment can reduce morbidity and mortality. Treatmentinclude infusion of sodium bicarbonate and administration of ethanol orally or parentally to inhibitthe production of formic acid from methanol. Hemodialysis is helpful in removal of methanoland its breakdown products from circulation and also in correcting acidosis. We report thecase of a boy admitted to the emergency room with a history of acute illness, characterized bynausea, vomiting, blurred vision, and shortness of breath. Arterial blood gases showed severemetabolic acidosis with high anion gap. He had ingested large quantity of alcohol containingmethanol. The patient was managed with hemodialysis and strong intravenous hydration. Heimproved well and made a full recovery.

English

Acute methanol poisoning produces severe metabolic acidosis, increased anionand osmolal gaps. These metabolic disturbances are due to accumulation of formic acid withhas serious neurological sequelae. If renal functions starts deteriorating that is associated withincreased mortality. Early diagnosis and treatment can reduce morbidity and mortality. Treatmentinclude infusion of sodium bicarbonate and administration of ethanol orally or parentally to inhibitthe production of formic acid from methanol. Hemodialysis is helpful in removal of methanoland its breakdown products from circulation and also in correcting acidosis. We report thecase of a boy admitted to the emergency room with a history of acute illness, characterized bynausea, vomiting, blurred vision, and shortness of breath. Arterial blood gases showed severemetabolic acidosis with high anion gap. He had ingested large quantity of alcohol containingmethanol. The patient was managed with hemodialysis and strong intravenous hydration. Heimproved well and made a full recovery.

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

The measurement of serum osmolality and its application to clinical practice and laboratory: literature review

ABSTRACT Introduction: Serum osmolality is an essential laboratory parameter to understand several clinical disorders such as electrolyte disturbances, exogenous intoxication and hydration status. Objective: This study aims to update knowledge about the osmolality examination through research papers published to date. Materials and methods: The survey was conducted on PubMed database. It highlights main concepts, both historical and physiological aspects, and the clinical applications of the serum osmolality test. In addition, an extensive survey of formulas for the serum osmolality calculation was conducted. Discussion: The measurement of serum osmolality is relevant in changes in intracellular and extracellular balance, as a trusted and valuable indicator of solute concentration in the blood. The mathematical equations for serum osmolality calculation acquire relevance in health services where serum is not available, and situations in which calculation of the osmolal gap is necessary, but the variability of the formulas is a significant bias. Conclusion: The measurement of serum osmolality is useful in cases of dehydration, sodium and potassium disorders, glucose alteration, exogenous poisoning, adrenal insufficiency, neurological injury, physical exercise and others.

Variations in Clinical Characteristics and Laboratory Results in Congestive Heart Failure: 30 Days Readmitted vs Not Readmitted

SESSION TITLE: Cardiovascular Disease SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM PURPOSE: To identify clinical variations between CHF patients readmitted versus not re-admitted within 30 days of discharge. METHODS: Data from 4,696 patients with a primary admission diagnosis of CHF were analyzed retrospectively in those re-admitted and not re-admitted. Laboratory results and clinical characteristics were then analyzed for differences between the two groups 48 and 96 hours prior to discharge. RESULTS: An analysis of patient characteristics revealed no significant difference for weight, sex, race, history of angina, atrial fibrillation, and family history of CHF or COPD between readmitted and non readmitted. Patients who had a previous MI (22% vs 13%, p<0.0001), or diabetes (51% vs 46%, p=0.013) were significantly more likely to be readmitted. Patients with hypertension were less likely to be readmitted (29% vs 38%, p<0.0001). Patient weight was higher (186±63lbs vs 180±61lbs, p=0.0006) in those not re-admitted versus re-admitted. Emergency Department (ED) visits in the previous 12 months were increased in patients re-admitted (84.22% vs 74.28%, p<0.0001), as were total hospital admissions (76.01% vs 58.72, p<0.0001). At 96 hours and 48 hours before discharge, BUN, creatinine, serum osmolality, % neutrophils, WBC and anion gap were higher in re-admitted patients (P<.001 all). First 48 hours BUN/creatinine ratio was increased (20.0±10 vs 19.1±8.4, p=0.019) in readmitted patients; whereas first 48 hours of admission, 96 hours pre-discharge, and 48 hours pre-discharge, glomerular filtration rate and hemoglobin were reduced (p<0.0001 all). CONCLUSIONS: CHF patients who were re-admitted within 30 days presented statistically significant variations in medical history, weight, and critical hospital laboratory values that separated them from patients not re-admitted. ED visits, MI history, diabetes, and hypertension were important factors. Renal function, systemic perfusion, and hematologic indicators varied significantly between re-admitted and not re-admitted patients. An attempt to achieve desired values may prove effective in reducing CHF patient re-admittance. CLINICAL IMPLICATIONS: To reduce CHF re-admissions, certain laboratory results prior to discharge should be achieved. Elucidating and obtaining these laboratory results will prove to be beneficial to the patient as well as the hospital, while preserving resources. DISCLOSURE: The following authors have nothing to disclose: Mena Yacoub, Barry Shapiro, Gus Slotman No Product/Research Disclosure Information

Erratum. A prospective randomized trial of the optimal dose of mannitol for intraoperative brain relaxation in patients undergoing craniotomy for supratentorial brain tumor resection.

OBJECTIVE Mannitol is used intraoperatively to induce brain relaxation in patients undergoing supratentorial brain tumor resection. The authors sought to determine the dose of mannitol that provides adequate brain relaxation with the fewest adverse effects. METHODS A total of 124 patients were randomized to receive mannitol at 0.25 g/kg (Group A), 0.5 g/kg (Group B), 1.0 g/kg (Group C), and 1.5 g/kg (Group D). The degree of brain relaxation was classified according to a 4-point scale (1, bulging; 2, firm; 3, adequate; and 4, perfectly relaxed) by neurosurgeons; Classes 3 and 4 were considered to indicate satisfactory brain relaxation. The osmolality gap (OG) and serum electrolytes were measured before and after mannitol administration. RESULTS The brain relaxation score showed an increasing trend in patients receiving higher doses of mannitol (p = 0.005). The incidence of satisfactory brain relaxation was higher in Groups C and D than in Group A (67.7% and 64.5% vs 32.2%, p = 0.011 and 0.022, respectively). The incidence of OG greater than 10 mOsm/kg was also higher in Groups C and D than in Group A (100.0% in both groups vs 77.4%, p = 0.011 for both). The incidence of moderate hyponatremia (125 mmol/L ≤ Na+ 5.0 mmol/L) was observed in 12.9% of patients in Group D only. CONCLUSIONS The higher doses of mannitol provided better brain relaxation but were associated with more adverse effects. Considering the balance between the benefits and risks of mannitol, the authors suggest the use of 1.0 g/kg of intraoperative mannitol for satisfactory brain relaxation with the fewest adverse effects. Clinical trial registration no.: NCT02168075 ( clinicaltrials.gov ).

A prospective randomized trial of the optimal dose of mannitol for intraoperative brain relaxation in patients undergoing craniotomy for supratentorial brain tumor resection.

OBJECTIVE Mannitol is used intraoperatively to induce brain relaxation in patients undergoing supratentorial brain tumor resection. The authors sought to determine the dose of mannitol that provides adequate brain relaxation with the fewest adverse effects. METHODS A total of 124 patients were randomized to receive mannitol at 0.25 g/kg (Group A), 0.5 g/kg (Group B), 1.0 g/kg (Group C), and 1.5 g/kg (Group D). The degree of brain relaxation was classified according to a 4-point scale (1, bulging; 2, firm; 3, adequate; and 4, perfectly relaxed) by neurosurgeons; Classes 3 and 4 were considered to indicate satisfactory brain relaxation. The osmolality gap (OG) and serum electrolytes were measured before and after mannitol administration. RESULTS The brain relaxation score showed an increasing trend in patients receiving higher doses of mannitol (p = 0.005). The incidence of satisfactory brain relaxation was higher in Groups C and D than in Group A (67.7% and 64.5% vs 32.2%, p = 0.011 and 0.022, respectively). The incidence of OG greater than 10 mOsm/kg was also higher in Groups C and D than in Group A (100.0% in both groups vs 77.4%, p = 0.011 for both). The incidence of moderate hyponatremia (125 mmol/L ≤ Na+ < 130 mmol/L) was significantly higher in Group D than in other groups (38.7% vs 0.0%, 9.7%, and 12.9% in Groups A, B, and C; p < 0.001, p = 0.008, and p = 0.020, respectively). Hyperkalemia (K+ > 5.0 mmol/L) was observed in 12.9% of patients in Group D only. CONCLUSIONS The higher doses of mannitol provided better brain relaxation but were associated with more adverse effects. Considering the balance between the benefits and risks of mannitol, the authors suggest the use of 1.0 g/kg of intraoperative mannitol for satisfactory brain relaxation with the fewest adverse effects. Clinical trial registration no.: NCT02168075 ( clinicaltrials.gov ).

Eight fatalities due to drinking methanol-tainted alcohol in Pakistan: A case report

Methanol has a widespread commercial use as a solvent in paints, varnishes, anti-freeze solutions and denaturant for ethanol. Exposure may occur due to accidental, suicidal ingestion or as a result of consuming adulterated liquor. Fatalities were reported in Pakistan in an incident after consuming methanol-tainted liquor. Postmortem specimens of eight deceased males, ages ranged from 16 to 40yrs, were submitted for toxicological analysis. Presence of blurred vision, severe metabolic acidosis with decreased serum bicarbonate level, increased serum osmolality and mean anion gap before death strongly suggested methanol toxicity. Headspace gas chromatograph coupled to flame ionization detector was used to quantify volatiles in blood and stomach contents of victims. Lethal levels of methanol in addition to ethanol were detected. The most probable mechanism of methanol-related deaths was sudden cessation of respiration due to inhibition of cytochrome oxidase that led to histotoxic hypoxia.

An Unusual Case of an Increased Anion and Osmolar Gap

An Unusual Case of an Increased Anion and Osmolar Gap

Ethylene Glycol Poisoning: An Unusual Cause of Altered Mental Status and the Lessons Learned from Management of the Disease in the Acute Setting.

Ethylene glycol is found in many household products and is a common toxic ingestion. Acute ingestions present with altered sensorium and an osmolal gap. The true toxicity of ethylene glycol is mediated by its metabolites, which are responsible for the increased anion gap metabolic acidosis, renal tubular damage, and crystalluria seen later in ingestions. Early intervention is key; however, diagnosis is often delayed, especially in elderly patients presenting with altered mental status. There are several laboratory tests which can be exploited for the diagnosis, quantification of ingestion, and monitoring of treatment, including the lactate and osmolal gaps. As methods of direct measurement of ethylene glycol are often not readily available, it is important to have a high degree of suspicion based on these indirect laboratory findings. Mainstay of treatment is bicarbonate, fomepizole or ethanol, and, often, hemodialysis. A validated equation can be used to estimate necessary duration of hemodialysis, and even if direct measurements of ethylene glycol are not available, monitoring for the closure of the anion, lactate, and osmolal gaps can guide treatment. We present the case of an elderly male with altered mental status, acute kidney injury, elevated anion gap metabolic acidosis, and profound lactate and osmolal gaps.

Poisoning from alcohol based hand sanitizer in a hospitalized patient

Introduction: Alcohol based hand sanitizers help to decrease infection rates in hospitals. They contain isopropanol (isopropyl alcohol) or ethanol (ethyl alcohol) in high concentrations, and are easily accessible to patients and staff in health care settings. Case Report: A 31-year-old female with history of alcohol abuse, seizure disorder and depression presented with symptoms of alcohol intoxication. Initial laboratory results were normal except an ethanol level of 311 mg/dl. She was admitted to the detoxification unit for ethyl alcohol intoxication. It was noted by the staff that she was trying to drink from the wall mounted hand sanitizers and was also seen sucking on alcohol wipes intermittently. On the third day in the detoxification unit, she was found to have lethargy, disorientation, tachycardia, hypotension, and tachypnea. She was given intravenous fluids and intubated for airway protection and transferred to intensive care unit. Laboratory tests showed normal pH, negative anion gap, normal glucose, large serum ketone, measured serum osmolality 340 mOsm/kg, osmolal gap 53 mOsm/kg, ethanol 13 mg/dl. She was treated for supraventricular arrhythmia, aspiration pneumonia. She did not require hemodialysis as acute kidney injury was mild, and osmolal gap and ketones came down with supportive care. Subsequently, she was extubated and recovered completely. Conclusion: Alcohol based hand sanitizers should be used carefully under surveillance in detoxification and psychiatric units. Poisoning due to isopropanol can be managed effectively if recognized early. Elevated osmolal gap, absence of acidosis, and positive ketones are important clues which help in diagnosing isopropanol poisoning. (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 7 No. 1, January 2016. ISSN – [0976-3198] Int J Case Rep Images 2016;7(1):40–42. www.ijcasereportsandimages.com Katikaneni et al. 40 CASE REPORT OPEN ACCESS Poisoning from alcohol based hand sanitizer in a hospitalized patient Madhavi Katikaneni, Hugo Villanueva

Severe Toxicity with Guanidine Thiocyanate Ingestion

Objective: To describe the toxicity of deliberate guanidine thiocyanate ingestion and it's treatment including dialysis. Case report: A 52-year-old male presented to hospital with abdominal pain after giving a history of ingesting bottled water. His initial vital signs and examination were normal. Soon after the patient became confused and agitated, necessitating intubation and ventilation for presumed encephalitis. His chloride was unmeasurable and the ionised calcium was low at 0.59 mmol/L (reference range [RR] 1.15-1.32 mmol/L). His pH and osmolar gap were normal. Analysis of the ingested water on two chemistry analysers gave discrepant chloride readings (129 mmol/L and 49 mmol/L) suggesting interference from a cross reacting analyte, which subsequently was proven to be thiocyanate with a concentration of 1485mg/L and 538mg/L in the bottled water and admission serum respectively (RR 0.1-4 mg/L). Dialysis in the form of continuous veno-venous haemodiafiltration (CVVHDF) was instituted based on this high level. Serial thiocyanate levels demonstrated zero order elimination kinetics pre dialysis and first order kinetics with a half-life of 5.4 h during dialysis. The patient made a full recovery and admitted to the addition of guanidine thiocyanate to the bottled water. Discussion: Guanidine thiocyanate appears to cause an encephalopathic type presentation with discordant and/or error chloride readings and ionised hypocalcaemia. Dialysis could be considered in the management of its toxicity.

Severe Ketoacidosis in a Patient with an Eating Disorder.

Severe ketoacidosis with a blood pH below 7.0 is only rarely seen in other diseases except type 1 diabetes. This paper reports a case of severe ketoacidosis secondary to an eating disorder. A 46-year-old woman presented to the emergency department with an acute onset of shortness of breath. She has a history of an eating disorder, an anxiety disorder, and hypothyroidism. Her body mass index was 19. Examination of the initial vital signs revealed the following: pulse, 91 beats/min; body temperature, 34.9℃; respiratory rate, 35 breaths/min; oxygen saturation, 100% on room air; and blood pressure, 130/70 mmHg. Urinalysis revealed specific gravity of >1.030, pH of 5.5, negative results for glucose, and positive results for ketone bodies (>150 mg/dL). Her serum glucose level was 4.9 mmol/L. Venous blood gas analysis revealed the following: pH, 6.96; HCO3−, 5 mmol/L, pCO2, 22 mmHg; base deficit, 27 and anion gap, 21. the patient showed a high anion gap metabolic acidosis with proper respiratory compensation. Results of the blood analysis are shown in Table 1. The osmolar gap was 20, which suggested unmeasured anions. However, tests for ethanol, salicylate, ethylene glycol, and methanol levels were negative. The serum ketone test was positive. These laboratory parameters made us rule out diabetic ketoacidosis and alcoholic ketoacidosis as the cause of the metabolic acidosis. Initially, the patient received a 5% dextrose solution in normal saline (D5W NS). After 12 hours of hospitalization on D5W NS, venous blood gas analysis revealed improved results: pH, 7.18; HCO3−, 5 mmol/L; and pCO2, 13 mmHg, with a base deficit of 23. TABLE 1 Biochemical markers Initially, the family and the patient told us that the patient had been doing much better in the last 2 weeks regarding her eating habits. We asked her repeatedly and she finally admitted to giving her food to her dog underneath the table. Moreover, she had been taking stool laxatives. In a patient with ketonemia, low glucose levels excluded diabetic ketoacidosis as the cause of severe metabolic acidosis.1 Negative results for laboratory tests for toxicology and toxic alcohol levels led us to consider starvation as the etiology of the acid-base imbalance.2 Ketoacidosis secondary to starvation is due to diminished insulin secretion that leads to an increase in lipolysis and ketogenesis.3 Eating disorders not otherwise specified are a category of eating disorder that includes patients with early aberrant eating patterns and weight management habits who do not meet the criteria for anorexia or bulimia nervosa.4 It occurs in approximately 3-5% of women aged between 15 and 30 years in Western countries.5 Patients with bulimia ten to abuse laxatives. It prevents the absorption of calories, which may aggravate starvation ketoacidosis.6 In conclusion, starvation should be considered as one of the causes of severe ketoacidosis in individuals with an eating disorder, even when the patient denies diet restriction.

Renal tubular acidosis is highly prevalent in critically ill patients.

IntroductionHyperchloremic acidosis is frequent in critically ill patients. Renal tubular acidosis (RTA) may contribute to acidemia in the state of hyperchloremic acidosis, but the prevalence of RTA has never been studied in critically ill patients. Therefore, we aimed to investigate the prevalence, type, and possible risk factors of RTA in critically ill patients using a physical-chemical approach.MethodsThis prospective, observational trial was conducted in a medical ICU of a university hospital. One hundred consecutive critically ill patients at the age ≥18, expected to stay in the ICU for ≥24 h, with the clinical necessity for a urinary catheter and the absence of anuria were included.Base excess (BE) subset calculation based on a physical-chemical approach on the first 7 days after ICU admission was used to compare the effects of free water, chloride, albumin, and unmeasured anions on the standard base excess. Calculation of the urine osmolal gap (UOG) - as an approximate measure of the unmeasured urine cation NH4+ - served as determinate between renal and extrarenal bicarbonate loss in the state of hyperchloremic acidosis.ResultsDuring the first week of ICU stay 43 of the patients presented with hyperchloremic acidosis on one or more days represented as pronounced negative BEChloride. In 31 patients hyperchloremic acidosis was associated with RTA characterized by a UOG ≤150 mosmol/kg in combination with preserved renal function. However, in 26 of the 31 patients with RTA metabolic acidosis was neutralized by other acid-base disturbances leading to a normal arterial pH.ConclusionsRTA is highly prevalent in critically ill patients with hyperchloremic acidosis, whereas it is often neutralized by the simultaneous occurrence of other acid-base disturbances.Trial registrationClinicaltrials.gov NCT02392091. Registered 17 March 2015