Distribution ratios of ethanol and water between whole blood, plasma, serum, and erythrocytes: Recommendations for interpreting clinical laboratory results in a legal context

This article reviews the scientific literature dealing with the distribution of ethanol and water between whole blood (WB), plasma, serum, and erythrocytes (red-blood cells). Knowledge of the ethanol distribution ratio is important when analytical results derived from hospital clinical laboratories are interpreted in a forensic context, such as during the prosecution of traffic offenders. Statutory blood-alcohol concentration (BAC) limits for driving are defined as the concentration of ethanol in WB and not in plasma, serum or red-blood cells. These bio-fluids differ in their water content and thereby the concentrations of ethanol. Plasma and serum contain ~90%-92% w/w water, WB ~78%-80% w/w and erythrocytes ~64%-66% w/w. The mean plasma/WB and serum/WB distribution ratios of ethanol are therefore expected to be ~1.15:1 (91/79 = 1.15), which is in good agreement with values determined empirically. However, in individual cases, the actual distribution ratio will depend on the person's age, gender, and biochemical and hematological properties of the blood specimen, such as its hematocrit. For legal purposes, we recommend that the concentration of ethanol in plasma or serum determined at hospital laboratories is divided by a factor of 1.2, which would provide a conservative estimate of the co-existing BAC and the chance of overestimating the true value is only 1 in 2000 (0.05%).