[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

Ureteral Diversions

Carbonic anhydrase inhibitors

1-Renal Failure
P04S04-

2-Ketoacidosis AcAc B-OHB

3-Salicylate Poison

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

5-Lactic Acidosis

Glucose
Alkalosis
NADH

NAD

2 Pyruvate

2Lactate + 47 Kal
Liver Dis.

Oxidation Gluconeogenesis
Anoxia Endotoxin Thiamine

Anoxia

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
NADH

AcAc
NAD

Fomepizole

NADH

NAD

Lactate Glycolic Acid Formic Acid

ß-OHB

Glyoxylic Acid

Thiamine Pyridoxine

Non-Toxic Metabolites

Oxalic Acid