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

The same patient in Lab Case 148

Severe 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?

What if I told you his measured osmolality was 357?

How would you treat him?