44th International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT), 28–31 May 2024, Munich, Germany
Year: 2024
Type: article
Study design: Observational Study
Abstract: Objective Many hospitals are unable to determine toxic alcohol concentrations in a clinically relevant timeframe. As a result, clinicians are forced to use surrogate markers such as the osmol gap. Toxic alcohol ingestion is often implicated when the osmol gap is elevated. Based on our experience, many patients with alcoholic ketoacidosis (AKA) also have a very elevated osmol gap. We aimed to characterize the range of osmol gaps in patients with AKA.Methods This was a retrospective study from a single poison center from 2000 to 2023. Records were reviewed to identify cases coded as “methanol”, “ethylene glycol”, or “ethanol with a metabolic acidosis”. An additional search identified records with the word “osm” in the narrative. The case definition of AKA required: (1) documented alcohol use disorder; (2) presence of urine or serum ketones or elevated blood beta-hydroxybutyrate concentration; (3) an anion gap ≥14 mmol/L. Potential AKA cases that failed to fulfil all three criteria were adjudicated by a 2/3 majority of three board certified toxicologists who assessed cases independently. Exclusion criteria included (1) detectable toxic alcohol concentration, (2) hemodialysis and/or multiple doses of fomepizole, (3) no osmol gap documented, (4) other confounding diagnoses for metabolic acidosis including seizures, diabetic ketoacidosis or cardiac arrest. Demographics, pH, anion gap, and osmol gap were extracted.Results Of 1053 patients screened, 55 met diagnostic criteria for AKA (30 by definition and 25 after adjudication). Sixty-two percent were male, their mean age was 50 years. The median osmol gap was 25 [interquartile range 18–35]. The largest anion gap was 57 mmol/L and the lowest pH was 6.8. Forty-four (80%) of the patients with AKA had an osmol gap >10; 37 (67%) had an osmol gap >20; 23 (42%) had an osmol gap >30; and 11 (20%) had an osmol gap >40.Conclusion In this retrospective study, patients with AKA had a median osmol gap of 25, which is greater than previously reported [Citation1]. Furthermore, a majority of these patients had an osmol gap classically associated with toxic alcohol poisoning. As such, AKA should not be excluded from the differential diagnosis of patients with an anion gap metabolic acidosis because the osmol gap is very elevated. AKA is easily treated with inexpensive therapies, and proper identification may prevent costly and invasive treatment directed at toxic alcohol poisoning.
Source: Clinical Toxicology
Authors: Glaser, Nina, Reuser, Michael, Feistkorn, Esther, Begemann, Kathrin
Language: English
Subfield: Emergency Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W4396733317