+

[H ] (nEq/L) = 24 X (CO2 / HCO3—)

Anion Gap
 

Gap

Measured AG – Normal AG (12)

 

  Gap

Gap + HC03- =

>24=Metabolic Alkalosis
<24=Metabolic Acidosis
 Diarrhea Isotonic saline
infusion

Early Renal
insufficiency Renal tubular acidosis

Carbonic anhydrase
Ureteral Diversions inhibitors
 1-Renal Failure 2-Ketoacidosis
P04- AcAc
S04-
B-OHB

4-Alcohols
Methanol (Formic Acid),
3-Salicylate Poison Ethylene Glycol (oxalate stones)
Ethanol

5-Lactic Acidosis
 Glucose
Alkalosis
NADH NAD

2 Pyruvate 2Lactate + 47 Kal

Liver Dis.

Oxidation
Gluconeogenesis
Anoxia
Anoxia
Endotoxin
Thiamine
673 Kal 652 Kal Glucose
• SIRS
• SIRS + infection = Sepsis
• SIRS + infection + organ
dysfunction = Severe sepsis
• SIRS + infection + organ
dysfunction + hypotension =
septic shock

• MODS
• MOF
• Circulatory Shock
• Sepsis
• Thiamine deficiency
• Drugs
• Metformin
• Epinephrine
• Nitroprusside
• propofol

• Propylene Glycol (increase water solubility for I.V.):

• Lorazepam
• Diazepam
• Esmolol
• NTG
• Phenytoin

• Intracellular alkalosis
• Hepatic insufficiency
• Acute asthma
 +
H2O + CO2 H + HCO3—
• Intracellular alkalosis
• Increase CO2 =
Acidosis
• Hypernatremia
• Severe ill patients
• PH < 7.1
• More than ½ HCO3 deficit

• If no improvement D/C
+ NADH + NAD
DKA = 1 : 3
AKA = 1 : 8
 Hyperglycemia > 250
Anion Gap
Serum HCO3 < 20
Urine or Blood Ketones
 NPO
 INSULIN ( Bolus + Infusion)
 IVF
 Hyperkalemia / Hypokalemia
 ? NaHCO3
 Ethylene Glycol Methanol
Pyruvate AcAc

NADH NAD Fomepizole NADH NAD

Lactate ß-OHB
Glycolic Acid Formic Acid

Glyoxylic Acid Thiamine Non-Toxic

Pyridoxine Metabolites

Oxalic Acid