One night that I was on call, I received an interesting patient from the ED.
The patient was confused but walked into the ER and was able to give at least a partial history. They did some initial chemistries and called me with the following results:
This is the kind of lab that grabs your attention.
With that glucose the first thought should be, “Is this DKA?”
Beta-hydroxybutyrate: 6 mmol/L
I try to account for the anion gap. So I look at all the anions I measure and see how well they explain the gap. And if I can’t account for the majority of the gap I have difficulty sleeping. This patient’s gap was 51, 12 is normal which leaves 39 to account for. Only 6 can be accounted for with beta-hydroxybutyrate.
“Is there a lactic acidosis?”
That still leaves 17 mmol/L of unexplained anions.
Next step, look for an osmolar gap.
Measured osmolality 348
Ethanol level 0
Fomepizole not needed in PG toxicity. IMO, propofol, PG, & paracetamol (APAP) should replace phenformin in MUDPILES. https://t.co/B3PTX2cjOc
— Bryan D. Hayes (@PharmERToxGuy) August 10, 2015