title: Postmortem identification of hyperglycemia.
abstract: The detection of diabetic coma postmortem requires accurate biochemical analysis. Due to continuous consumption of glucose by surviving cells postmortem, blood glucose levels decrease rapidly. Therefore, vitreous fluid has been used as a substitute in forensic practice, since it has a very low cell count. It has been repeatedly reported that the sum value of vitreous glucose and lactate should be used to estimate the original antemortem blood glucose level, based on the assumption that pre-existing glucose is gradually converted to lactate under anaerobic conditions during agonal phase and the early postmortem period. In this study, we applied a strategy including consistent sampling of vitreous fluid from the centre of both eyes of deceased subjects as soon as possible after arrival at the morgue, and immediate bedside analysis using a blood gas instrument. In total, 3076 cases were included during 2004-2006. We found that, after an initial drop of vitreous glucose during the very early postmortem period, the levels stayed stable for appreciable time postmortem. Analysis of a second sample collected at autopsy 1-3 days later gave similar results (R(2)=0.90). In contrast, the vitreous lactate levels showed a steady increase. This implies that the sum value of glucose and lactate increases with postmortem time, as reflected by vitreous potassium level. In fact, a statistically significant difference in the sum value was seen between subjects with potassium below 10 mmol/L (n=1086) and above 20 mmol/L (n=531), p<.001. In addition, in this large material, we did not identify a single case with circumstantial indication of hyperglycemia that only showed high vitreous lactate. We therefore suggest that vitreous glucose alone should be used to diagnose hyperglycemia postmortem and that the limit of 10 mmol/L should have a good specificity for diabetic coma, which theoretically would equal an original blood glucose value of about 26 mmol/L. As to the methodology, we found that sonication, centrifugation and addition of fluoride to the samples are unnecessary procedures when using a blood gas instrument. The strategy resulted in a doubling of the number of diabetic coma identified at our department compared to preceding period when analysis only was performed on selected cases.
authors.affiliation: Department of Forensic Medicine, Karolinska Institute, Retzius v. 3, SE-171 77 Stockholm, Sweden.
authors.forename: B
authors.initials: B
authors.lastname: Zilg
authors.forename: K
authors.initials: K
authors.lastname: Alkass
authors.forename: S
authors.initials: S
authors.lastname: Berg
authors.forename: H
authors.initials: H
authors.lastname: Druid
mesh_terms: D001784:Blood Gas Analysis; D003926:Diabetic Coma / Q000175:diagnosis; D005260:Female; D049429:Forensic Pathology; D005947:Glucose / Q000032:analysis*; D006801:Humans; D006943:Hyperglycemia / Q000175:diagnosis*; D019344:Lactic Acid / Q000032:analysis; D008297:Male; D008875:Middle Aged; D011180:Postmortem Changes; D011188:Potassium / Q000032:analysis; D012964:Sodium / Q000032:analysis; D013997:Time Factors; D014822:Vitreous Body / Q000737:chemistry*
chemical_list: D019344:Lactic Acid; D012964:Sodium; D005947:Glucose; D011188:Potassium