## Patient Encounter 3 Calculate the Plasma Osmolality

A 50-year-old homeless man is brought to the emergency department staggering and smelling like beer. Rapid respiration, tachycardia, and a BP of 90/60 mm Hg were noted. The sodium is 142 mEq/L (142 mmol/L), potassium 3.6 mEq/L (3.6 mmol/L), chloride 100 mEq/L (100 mmol/L), bicarbonate 12 mEq/L (12 mmol/L), glucose 180 mg/dL (9.99 mmol/L), and BUN 28 mg/dL (9.99 mol/L). The measured osmolarity is 360 mOsm/L.

Calculate the osmolality.

Calculate the osmolar gap.

What is the likely cause of an increased gap in this patient?

Many of the electrolyte disturbances discussed in the remainder of this chapter represent medical emergencies that call for aggressive interventions including the use of concentrated electrolytes. However, these solutions are a frequent source of medical errors with significant potential for patient harm. As such, the 2005 National Patient Safety Goals published by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommends that concentrated electrolyte solutions (KCl, potassium phosphate, and NaCl greater than 0.9%) be removed from patient care areas. In addition, JCAHO recommends standardizing and limiting the number of drug concentrations available in each institution so as to further reduce the risk of medication errors and improve outcomes.14

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