Anion Gap

6 Oktober 2015
H2O + CO2 H2CO3 HCO3 - + H+
Adult values for PaO2 and oxygen saturation

PaO2 (kPa) SaO2 (%)

Normal (range) 13(10.7) 97 (95-100)
Hypoxaemia <10.7 <95
Mild hypoxaemia 8-10.5 90-94
Moderate hypoxaemia 5.3-7.9 75-89
Severe hypoxaemia <5.3 <75
In metabolic acidosis, the compensatory response is a
respiratory alkalosis with an expected reduction in PaCO2,
with a response time of between 12 and 24 hours.
The equation used for the calculation was:
In metabolic alkalosis, the compensatory response is a
respiratory acidosis with an expected increase in PaCO2, with
an irregular response time.
The equation used for the calculation was:
In respiratory acidosis, the compensatory response is a
metabolic alkalosis with an expected increase in bicarbonate,
with a response time expected according to the details of the
case:
- in an acute condition, the response appears within minutes
- in a chronic condition, the response appears within two to
four days.
- The equations used in this calculation were:

Acute condition:

Chronic condition:
In respiratory alkalosis, the compensatory response is a
metabolic acidosis with an expected reduction in bicarbonate,
with a response time expected in the according to the details
of the case:
- in an acute condition, the response appears within minutes
- in a chronic condition, the response appears within two to
four days. The equations used in this calculation were:

Acute condition:

Chronic condition:
- The anion gap is the difference between primary measured
cations (sodium Na+ and potassium K+) and the primary
measured anions (chloride Cl- and bicarbonate HCO3-) in
serum.
- This test is most commonly performed in patients who
present with altered mental status, unknown exposures,
acute renal failure, and acute illnesses.

Serum anion gap = (Na + K) - (Cl + HCO3)

Commonly, a simpler formula is used, as sodium is the most

dominant cation in the equation below (see also the Anion Gap
calculator).

Serum anion gap = Na - (Cl + HCO3)

The reference range is slightly higher with this alternative
formula.
The [K+] is low relative to the other three ions and it typically
does not change much so omitting it from the equation doesnt
have much clinical significance.

normal reference values ranged from 8 to 16 mEq/L plasma

when not including [K+] and from 10 to 20 mEq/L plasma
when including [K+]. Some specific sources use and 816
mEq/L.

The concentrations are expressed in units of

milliequivalents/liter (mEq/L) or in millimoles/litre (mmol/L).
In an inorganic metabolic acidosis (eg due HCl infusion), the
infused Cl- replaces HCO3 and the anion gap remains normal.

In an organic acidosis, the lost bicarbonate is replaced by the

acid anion which is not normally measured. This means that
the AG is increased.
- For the urine anion gap, the most prominently unmeasured
anion is ammonia.
- Healthy subjects typically have a gap of 0 to slightly normal
(< 10 mEq/L).
- A urine anion gap of more than 20 mEq/L is seen in
metabolic acidosis when the kidneys are unable to excrete
ammonia (such as in renal tubular acidosis).
- If the urine anion gap is zero or negative but the serum AG is
positive, the source is most likely gastrointestinal (diarrhea or
vomiting).
The anion gap (see the Anion Gap calculator) can be defined
as low, normal, or high. Laboratory error always needs to be
ruled out first if the clinical picture does not correlate with the
findings.

Certain errors in collection can interfere with the ions of

measured electrolytes that are used to calculate the anion
gap. This can include timing, dilution, renal disease, and small
sample size. For example, delays in processing the collected
sample results in continued leukocyte cellular metabolism,
which then causes an increase in bicarbonate levels.
A decreased anion gap (< 6 mEq/L) may suggest the following:

Hypoalbuminemia
Plasma cell dyscrasia
Monoclonal protein
Bromide intoxication
Normal variant
- Albumin is the major unmeasured anion and contributes
almost the whole of the value of the anion gap.
- Every one gram decrease in albumin will decrease anion gap
by 2.5 to 3 mmoles.
- A normally high anion gap acidosis in a patient with
hypoalbuminaemia may appear as a normal anion gap
acidosis. This is particularly relevant in Intensive Care
patients where lower albumin levels are common.
- A lactic acidosis in a hypoalbuminaemic ICU patient will
commonly be associated with a normal anion gap.
A normal anion gap (6-12 mEq/L) may indicate the following:

Loss of bicarbonate (ie, diarrhea)

Recovery from diabetic ketoacidosis
Ileostomy fluid loss
Carbonic anhydrase inhibitors (acetazolamide, dorzolamide,
topiramate)
Renal tubular acidosis
Arginine and lysine in parenteral nutrition
Normal variant
An elevated anion gap (>12 mEq/L; mud pilers) may
indicate the following:

Milk-alkali syndrome
Uremia
Diabetic ketoacidosis
Propylene glycol
Isoniazid intoxication
Lactic acidosis
Ethanol ethylene glycol
Rhabdomyolysis/renal failure
Salicylates
The newest mnemonic was proposed in The Lancet reflecting
current causes of anion gap metabolic acidosis:

G glycols (ethylene glycol & propylene glycol)

O oxoproline, a metabolite of paracetamol
L L-lactate, the chemical responsible for lactic acidosis
D D-lactate
M methanol
A aspirin
R renal failure
K ketoacidosis, ketones generated from starvation, alcohol,
and diabetic ketoacidosis
An increased AG is associated with renal failure, ketoacidosis,
lactic acidosis, and ingestion of certain toxins.

A normal AG acidosis is characterized by a lowered

bicarbonate concentration, which is counterbalanced by an
equivalent increase in plasma chloride concentration. For this
reason, it is also known as hyperchloremic metabolic acidosis.
Methanol ingestion results in an elevated osmolar gap, so in
cases of stupor of unknown cause, testing for an osmolar gap
should be routine.

- The osmolar gap can be calculated using a set formula.

- To find the osmolar gap, take the measured plasma
osmolality and subtract the calculated osmolality.
- Calculated osmolality requires a serum glucose
measurement and is derived as follows:

Calculated osmolality (mOsm/kg) = 2(Na+) + (glucose/18) +

(blood urea nitrogen [BUN]/2.8)
The osmol gap is typically calculated as:

OG = measured serum osmolality calculated osmolality

- Calculated osmolality = 2 x [Na mmol/L] + [glucose mmol/L]

+ [urea mmol/L] + 1.25 x [Ethanol mmol/L]

- In non-SI laboratory units: Calculated osmolality = 2 x [Na

mmol/L] + [glucose mg/dL] / 18 + [BUN mg/dL] / 2.8 +
[Ethanol/3.7] (NB: divisor 18 respectively 2.8 to convert
mg/dL into mmol/L)

A normal osmol gap is < 10 mOsm/kg

Osmol gaps are used as a screening tool to identify toxins

Causes of an elevated osmol gap are numerous

Generally there are 4 main causes:

- alcohols
- sugars
- lipids
- proteins
 Anion Gap
uthor: Cory Wilczynski, MD; Chief Editor: Eric B Staros, MD more

Updated: Mar 13, 2014

Thank You
MODULE II: CHEMICAL APPROACH

With this module it was possible to determine the quantity of acid or base necessary to correct the blood pH.
The module corresponds to the calculation of base excess. It is based on the Van Slyke equation and allows
for the calculation of base excess, standard base excess and corrected base excess with the concentration of
albumin and phosphate [9] in accordance with equations 9, 10, and 11. The equation for the calculation of
base excess (BE) is applied in in vitro conditions and is as follows:

BE = (HCO3-- 24.4 + (2.3 Hb + 7.7)

(pH - 7.4)) * (1 - 0.023 Hb) (9)
Where HCO3- and hemoglobin (Hb) are expressed in mmol/L.
In accordance with Kellum [20], the following equation of standard base excess (SBE) provides greater
precision than BE in vivo:

(10)
However, these equations assume a normal ATOT . When the concentration of albumin and phosphate
decrease, as happens in the some case of some critically ill patients, the following corrected equation is used:

SBEc = (HCO3-- 24.4) + ((8.3 Alb 0.15)

+ (0.29 PO4-0.32)) (pH - 7.4) (11)
Where albumin (Alb) is expressed en g/dL and phosphate (PO4-) in mg/dL. The user has the option to
calculate all the equations in the same module. Equations 10 and 11 are adequate, preferably with the value of
SBEc; however, for this case, as can be seen, it is necessary to use the concentrations of albumin and PO4-.