title: Hunting down a double gap metabolic acidosis.
abstract: Double gap metabolic acidosis occurs in the setting of unmeasured active osmoles in the serum (osmolal gap) and anion gap (AG) metabolic acidosis. We describe a 67-year-old woman with acute respiratory failure on mechanical ventilator from pneumonia and anuric acute on chronic renal failure (urea nitrogen 21.4 mmol/L, creatinine 530.4 micromol/L) requiring haemodialysis (HD). On hospital day 5, she was found to have progressive metabolic acidosis (serum pH 7.16, PCO(2) 4.38 kPa, HCO(3)(-) 12.1 mmol/L and AG 21 mmol/L). There was no evidence of hypoxaemia, hypoperfusion or haemodynamic instability. Normal serum ketone and L-lactate but high serum osmolal gap (89.4 mmol/kg) was detected. A search for toxic alcohols revealed a high serum propylene glycol (PG 32.9 mmol/L), a stabilizing solvent for intravenous formulations of lorazepam, which was being used as sedation for mechanical ventilation. Unexpectedly, serum L- and D-lactate as metabolites of PG were not elevated. Although extended HD for eight hours completely removed serum PG and the osmolal gap, the predialysis high AG metabolic acidosis persisted, potentially related to hypercatabolism and anuric renal failure. PG should be in the differential diagnosis of the disorders with high osmolar gap and may not always be associated with L- or D-lactic acidosis.
authors.affiliation: Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
authors.forename: Ming-Tso
authors.initials: MT
authors.lastname: Yan
authors.forename: Tom
authors.initials: T
authors.lastname: Chau
authors.forename: Chih-Jen
authors.initials: CJ
authors.lastname: Cheng
authors.forename: Shih-Hua
authors.initials: SH
authors.lastname: Lin
mesh_terms: D000138:Acidosis / Q000097:blood / Q000175:diagnosis* / Q000209:etiology*; D000368:Aged; D000437:Alcoholism / Q000150:complications; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000097:blood / Q000628:therapy; D008140:Lorazepam / Q000009:adverse effects; D053717:Pneumonia, Ventilator-Associated / Q000097:blood / Q000175:diagnosis; D019946:Propylene Glycol / Q000097:blood; D006435:Renal Dialysis
chemical_list: D019946:Propylene Glycol; D008140:Lorazepam