Open Access Research article

An evaluation of the osmole gap as a screening test for toxic alcohol poisoning

Larry D Lynd12*, Kathryn J Richardson2, Roy A Purssell345, Riyad B Abu-Laban36, Jeffery R Brubacher345, Katherine J Lepik4 and Marco LA Sivilotti7

Author affiliations

1 Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada

2 Centre for Health Evaluation and Outcomes Sciences, Providence Health Care, Vancouver, Canada

3 Department of Emergency Medicine, Vancouver General Hospital, Vancouver, Canada

4 British Columbia Drug and Poison Information Centre, Provincial Health Services Authority of BC, Vancouver, Canada

5 Division of Emergency Medicine, Dept. of Surgery, Faculty of Medicine, University of British Columbia; Vancouver; Canada

6 Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada

7 Departments of Emergency Medicine and of Pharmacology & Toxicology, Queen's University, Kingston, Canada; and Ontario Poison Centre, Toronto, Canada

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Citation and License

BMC Emergency Medicine 2008, 8:5  doi:10.1186/1471-227X-8-5

Published: 28 April 2008



The osmole gap is used routinely as a screening test for the presence of exogenous osmotically active substances, such as the toxic alcohols ethylene glycol and methanol, particularly when the ability to measure serum concentrations of the substances is not available. The objectives of this study were: 1) to measure the diagnostic accuracy of the osmole gap for screening for ethylene glycol and methanol exposure, and 2) to identify whether a recently proposed modification of the ethanol coefficient affects the diagnostic accuracy.


Electronic laboratory records from two tertiary-care hospitals were searched to identify all patients for whom a serum ethylene glycol and methanol measurement was ordered between January 1, 1996 and March 31, 2002. Cases were eligible for analysis if serum sodium, blood urea nitrogen, glucose, ethanol, ethylene glycol, methanol, and osmolality were measured simultaneously. Serum molarity was calculated using the Smithline and Gardner equation and ethanol coefficients of 1 and 1.25 mOsm/mM. The diagnostic accuracy of the osmole gap was evaluated for identifying patients with toxic alcohol levels above the recommended threshold for antidotal therapy and hemodialysis using receiver-operator characteristic curves, likelihood ratios, and positive and negative predictive values.


One hundred and thirty-one patients were included in the analysis, 20 of whom had ethylene glycol or methanol serum concentrations above the threshold for antidotal therapy. The use of an ethanol coefficient of 1.25 mOsm/mM yielded higher specificities and positive predictive values, without affecting sensitivity and negative predictive values. Employing an osmole gap threshold of 10 for the identification of patients requiring antidotal therapy resulted in a sensitivity of 0.9 and 0.85, and a specificity of 0.22 and 0. 5, with equations 1 and 2 respectively. The sensitivity increased to 1 for both equations for the identification of patients requiring dialysis.


In this sample, an osmole gap threshold of 10 has a sensitivity and negative predictive value of 1 for identifying patients for whom hemodialysis is recommended, independent of the ethanol coefficient applied. In patients potentially requiring antidotal therapy, applying an ethanol coefficient of 1.25 resulted in a higher specificity and positive predictive value without compromising the sensitivity.