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Comment & Response |

Toxic Alcohol Calculations and Misinterpretation of Laboratory Results

Peter E. Wu, MD, MSc, FRCPC1,2; Marco L. A. Sivilotti, MD, MSc, FRCPC, FACEP, FACMT3,4
[+] Author Affiliations
1Ontario Poison Centre, Toronto, Ontario, Canada
2Division of Clinical Pharmacology & Toxicology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
3Department of Emergency Medicine, Queen’s University, Kingston, Canada
4Department of Biomedical & Molecular Science, Queen’s University, Kingston, Canada
JAMA Intern Med. 2016;176(8):1227-1228. doi:10.1001/jamainternmed.2016.3714.
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To the Editor We read with interest the Teachable Moment in a recent issue of JAMA Internal Medicine by Himmel and colleagues1 and commend them on sharing this experience of medical error and disclosure. Regarding the clinical aspects of toxic alcohol poisoning, a few points merit discussion.

First, the ethanol concentrations provided are discordant. The molecular mass of ethanol is 46.1 g/mol and to convert mmol/L to mg/dL, multiply by 4.61 (this corrects for the unit change); therefore a level of 8.1 mmol/L converts to 37.3 mg/dL, not 144 mg/dL (31.2 mmol/L). Depending on which is correct, very different interpretations will be drawn. Second, when facing an elevated osmole gap, one must determine if the gap can be accounted for by ethanol alone. The authors do not specify whether the osmole gap of 27 was adjusted for the ethanol. Importantly, ethanol’s contribution to the osmole gap is more than 1 mosm to 1 mmol. In fact, it ranges from 1.21 to 1.25 mosm to 1 mmol.2,3 Practically speaking, a conservative correction of 1.20 (ie, adding a fifth of ethanol) becomes particularly important at high concentrations of ethanol, say over 20 mmol/L, a common source of high osmole gap confusion and unnecessary fomepizole administration.3 Only if the level is 8.1 mmol/L, rather than 31.3 mmol/L, is it justified to test for toxic alcohol levels.

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April 1, 2016
Megan E. Himmel, PhD; Kenneth Lam, MD; Michael Fralick, MD
1University of Toronto Medical School, Toronto, Ontario, Canada
2Internal Medicine Program, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
JAMA Intern Med. 2016;176(4):431-432. doi:10.1001/jamainternmed.2015.8447.
August 1, 2016
Mark K. Su, MD, MPH; Robert S. Hoffman, MD
1Division of Medical Toxicology, The Ronald O. Perelman Department of Emergency Medicine, New York, New York
JAMA Intern Med. 2016;176(8):1228. doi:10.1001/jamainternmed.2016.3717.
August 1, 2016
Giuseppe Lippi, MD; Mario Plebani, MD
1Section of Clinical Biochemistry, University of Verona, Verona, Italy
2Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
JAMA Intern Med. 2016;176(8):1228-1229. doi:10.1001/jamainternmed.2016.3720.
August 1, 2016
Michael Fralick, MD; Kenneth Lam, MD; Megan E. Himmel, PhD
1Internal Medicine Program, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
2Undergraduate Medical Program, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
JAMA Intern Med. 2016;176(8):1229-1230. doi:10.1001/jamainternmed.2016.3729.
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