A 49 year old man with confusion, hypothermia and shock requiring urgent resuscitation has blood results which showSevere HAGMA

uncompensated, or additional respiratory acidosis

Delta ratio of 2.0 – likely HAGMA without metabolic alkalosis

Elevated glucose

elevated ketones

osmolality 316

mild hyponatraemia

severe total body K depletion

renal failure

likely severe DKA BUT if lactate is 3.8 and ketones are 6.9 what accounts for the rest of the anion gap?

toxic alcohol

metformin

What if I told you his measured osmolality was 357?