Why is the anion gap important to calculate and follow the treatment of DKA
Diabetic Ketoacidosis
A complication of diabetes that results from increased levels of ketones in the blood.
How to calculate anion gap DKA?
· Just so, why is anion gap high in DKA? High anion gap The anion gap is affected by changes in unmeasured ions. In uncontrolled diabetes, there is an increase in ketoacids due to metabolism of ketones. Raised levels of acid bind to bicarbonate to form carbon dioxide through the Henderson-Hasselbalch equation resulting in metabolic acidosis.
What are the symptoms of high anion gap?
· Why is anion gap important? It is important because an increased anion gap usually is caused by an increase in unmeasured anions, and that most commonly occurs when there is an increase in unmeasured organic acids, that is, an acidosis3, 4). Acids (eg, lactate and pyruvate) are protons donors and must be buffered by bicarbonate.
What causes an anion gap?
· Anion gap of >20 usually supports the diagnosis of DKA in these patients. 2 Treatment The therapeutic goals of DKA management include optimization of 1) volume status; 2) hyperglycemia and ketoacidosis; 3) electrolyte …
What happens if you have a low anion gap?
· In DKA, the high anion gap is attributed largely to excessive production of blood ketone bodies, and serum β-hydroxybutyrate quantification is recommended for the diagnosis and monitoring of DKA (2).
What does anion gap have to do with DKA?
In mild DKA, anion gap is greater than 10 and in moderate or severe DKA the anion gap is greater than 12. These figures differentiate DKA from HHS where blood glucose is greater than 600 mg/dL but pH is greater than 7.3 and serum bicarbonate greater than 15 mEq/L.
Why is anion gap important with diabetes?
The abnormal anion gap was created by the insufficiency of bicarbonate used for the buffering of the electrolytes variability occasioned by derangement in glucose metabolism and distorted hormonal secretion. Hence metabolic acidosis is strongly linked with diabetics as a result of distorted anion gap.
Why do we measure anion gap?
Why do we use the anion gap? It is important because an increased anion gap usually is caused by an increase in unmeasured anions, and that most commonly occurs when there is an increase in unmeasured organic acids, that is, an acidosis3, 4).
What are the therapeutic goals of DKA?
The therapeutic goals of DKA management include optimization of 1) volume status; 2) hyperglycemia and ketoacidosis; 3) electrolyte abnormalities; and 4) potential precipitating factors. The majority of patients with DKA present to the emergency room. Therefore, emergency physicians should initiate the management of hyperglycemic crisis while a physical examination is performed, basic metabolic parameters are obtained, and final diagnosis is made. Several important steps should be followed in the early stages of DKA management: 1 collect blood for metabolic profile before initiation of intravenous fluids; 2 infuse 1 L of 0.9% sodium chloride over 1 hour after drawing initial blood samples; 3 ensure potassium level of >3.3 mEq/L before initiation of insulin therapy (supplement potassium intravenously if needed); 4 initiate insulin therapy only when steps 1–3 are executed.
Why is bicarbonate not indicated in mild and moderate forms of DKA?
Bicarbonate therapy is not indicated in mild and moderate forms of DKA because metabolic acidosis will correct with insulin therapy.3, 8The use of bicarbonate in severe DKA is controversial due to a lack of prospective randomized studies.
Is ketoacidosis a type 1 or 2 diabetes?
Diabetic ketoacidosis (DKA) is a rare yet potentially fatal hyperglycemic crisis that can occur in patients with both type 1 and 2 diabetes mellitus. Due to its increasing incidence and economic impact related to the treatment and associated morbidity, effective management and prevention is key. Elements of management include making ...
How many hospitalizations for diabetic ketoacidosis in 2009?
In 2009, there were 140,000 hospitalizations for diabetic ketoacidosis (DKA) with an average length of stay of 3.4 days.1The direct and indirect annual cost of DKA hospitalizations is 2.4 billion US dollars.
Can DKA cause hypokalemia?
A “normal” plasma potassium concentration still indicates that total body potassium stores are severely diminished, and the institution of insulin therapy and correction of hyperglycemia will result in hypokalemia.
What is the name of the regimen that contains both long-acting and short-acting insulin?
The regimen containing both long-acting and short-acting insulin is called a basal-bolus insulin regimen; it provides physiological replacement of insulin. If a patient used insulin prior to admission, the same dose can be restarted in the hospital.
What is a dka?
Diabetic Ketoacidosis (dka) Diabetic ketoacidosis is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. Hyperglycemia causes an osmotic diuresis with significant fluid and electrolyte loss. DKA occurs mostly in type 1 diabetes mellitus (DM).
What is the anion gap?
The anion gap (AG) is a calculated parameter derived from measured serum/plasma electrolyte concentrations. The clinical value of this calculated parameter is the main focus of this article. Both increased and reduced anion gap have clinical significance, but the deviation from normal that has most clinical significance is increased anion gap associated with metabolic acidosis. This reflects the main clinical utility of the anion gap, which is to help in elucidating disturbances of acid-base balance. The article begins with a discussion of the concept of the anion gap, how it is calculated and issues surrounding the anion gap reference interval. CONCEPT OF THE ANION GAP - ITS DEFINITION AND CALCULATION Blood plasma is an aqueous (water) solution containing a plethora of chemical species including some that have a net electrical charge, the result of dissociation of salts and acids in the aqueous medium. Those that have a net positive charge are called cations and those with a net negative charge are called anions; collectively these electrically charged species are called ions. The law of electrochemical neutrality demands that, in common with all solutions, blood serum/plasma is electrochemically neutral so that the sum of the concentration of cations always equals the sum of the concentration of anions [1]. This immutable law is reflected in FIGURE 1, a graphic display of the concentration of the major ions normally present in plasma/serum. It is clear from this that quantitatively the most significant cation in plasma is sodium (Na+), and the most significant anions are chloride (Cl-) and bicarbonate HCO3-. The concentration of these three plasma constituents (sodium, chloride and bicarbonate) along with the cation potassium (K+) are routinely measured in the clinica Continue reading >>
Is an anion gap of less than 11 mEq/L normal?
However, there are always unmeasurable anions, so an anion gap of less than 11 mEq/L using any of the equations listed in Description is considered normal. 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).
What is the anion gap in chemistry?
OVERVIEW Anion Gap = Na+ – (Cl- + HCO3-) The Anion Gap (AG) is a derived variable primarily used for the evaluation of metabol ic acidosis to determine the presence of unmeasured anions The normal anion gap depends on serum phosphate and serum albumin concentrations An elevated anion gap strongly suggests the presence of a metabolic acidosis The normal anion gap varies with different assays, but is typically 4 to 12mmol/L (if measured by ion selective electrode; 8 to 16 if measured by older technique of flame photometry) If AG > 30 mmol/L then metabolic acidosis invariably present If AG 20-29mmol/L then 1/3 will not have a metabolic acidosis K can be added to Na+, but in practice offers little advantage ALBUMIN AND PHOSPHATE the normal anion gap depends on serum phosphate and serum albumin the normal AG = 0.2 x [albumin] (g/L) + 1.5 x [phosphate] (mmol/L) albumin is the major unmeasured anion and contributes almost the whole of the value of the anion gap. every 1g/L decrease in albumin will decrease anion gap by 0.25 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 ICU patients where lower albumin levels are common HIGH ANION GAP METABOLIC ACIDOSIS (HAGMA) HAGMA results from accumulation of organic acids or impaired H+ excretion Causes (LTKR) Lactate Toxins Ketones Renal Causes (CATMUDPILES) CO, CN Alcoholic ketoacidosis and starvation ketoacidosis Toluene Metformin, Methanol Uremia DKA Pyroglutamic acidosis, paracetamol, phenformin, propylene glycol, paraladehyde Iron, Isoniazid Lactic acidosis Ethylene glycol Salicylates Effects of albumin Anion gap may be underesitmated in hypoalbuminaemia, because if albumin decreased by 1g/L then the anion gap decreases by 0.25 Continue reading >>
What is the pH of diabetic ketoacidosis?
Approach Considerations Diabetic ketoacidosis is typically characterized by hyperglycemia over 250 mg/dL, a bicarbonate level less than 18 mEq/L, and a pH less than 7.30, with ketonemia and ketonuria. While definitions vary, mild DKA can be categorized by a pH level of 7.25-7.3 and a serum bicarbonate level between 15-18 mEq/L; moderate DKA can be categorized by a pH between 7.0-7.24 and a serum bicarbonate level of 10 to less than 15 mEq/L; and severe DKA has a pH less than 7.0 and bicarbonate less than 10 mEq/L. [17] In mild DKA, anion gap is greater than 10 and in moderate or severe DKA the anion gap is greater than 12. These figures differentiate DKA from HHS where blood glucose is greater than 600 mg/dL but pH is greater than 7.3 and serum bicarbonate greater than 15 mEq/L. Laboratory studies for diabetic ketoacidosis (DKA) should be scheduled as follows: Repeat laboratory tests are critical, including potassium, glucose, electrolytes, and, if necessary, phosphorus. Initial workup should include aggressive volume, glucose, and electrolyte management. It is important to be aware that high serum glucose levels may lead to dilutional hyponatremia; high triglyceride levels may lead to factitious low glucose levels; and high levels of ketone bodies may lead to factitious elevation of creatinine levels. Continue reading >>
Can high glucose levels cause hyponatremia?
It is important to be aware that high serum glucose levels may lead to dilutional hyponatremia; high triglyceride levels may lead to factitious low glucose levels; and high levels of ketone bodies may lead to factitious elevation of creatinine levels. Continue reading >>. Diabetic Ketoacidosis.
What is the diagnosis of DKA?
DKA is diagnosed by detection of hyperketonemia and anion gap metabolic acidosis in the presence of hyperglycemia. Treatment involves volume expansion, insulin replacement, and prevention of hypokalemia.
Does phosphate drop with DKA?
Phosphate may drop in patients with severe DKA, and this will need to be replaced if the phosphate is < 1 mg/dL. [ 8,13] Also pay attention to the serum magnesium. Magnesium on the higher level of normal may assist in prevention of arrhythmias (> 2.2 mg/dL).
What is mild DKA?
Mild DKA is defined by a serum bicarbonate just below 18 or pH slightly less than 7.
Is DKA a ketoacidosis?
While DKA is associated with hyperglycemia, acidosis, and low bicarbonate, patients can have normal glucose (euglycemic DKA) and normal pH and normal bicarbonate (ketoacidosis with metabolic alkalosis from fluid depletion and vomiting). [ 1-6] Interestingly, the Canadian DKA guidelines state that “there are no definitive criteria for diagnosis ...
Do you need IV fluids for mild DKA?
However, this may not be always needed. Patients with mild DKA typically only need some IV fluids and insulin ; they may even be appropriate for discharge directly from the ED with follow up. Mild DKA is defined by a serum bicarbonate just below 18 or pH slightly less than 7.
Does bicarbonate cause acidosis?
Bicarbonate administration can instead worsen intracellular acidosis, and it can further drop serum potassium levels. [ 20,42] The best means of addressing low serum bicarbonate is to increase the insulin infusion, or bolus 10 units IV. This may require additional potassium and glucose to match the increased insulin.
What is euglycemic DKA?
Euglycemic DKA is DKA with glucose < 250 mg/dL, which occurs in up to 10% of patients with DKA. [ 2,3,44] Causes include SGLT2 inhibitors, decreased hepatic glucose production (starvation, pregnancy), and partial treatment with insulin before the patient presents to the ED.
Can you use insulin for DKA?
Subcutaneous insulin can be used in those with mild to moderate DKA. Intubating a patient with DKA is fraught with danger. Attempt high flow nasal cannula first. While bicarbonate is not necessary for all patients with DKA, it may help with resolving NAGMA. Euglycemic DKA exists.
What is the anion gap in a metabolic acidosis?
The anion gap helps differentiate hyperchloremic metabolic acidosis (normal AG) from high AG metabolic acidosis. In hyperchloremic metabolic acidosis, there is an increase in plasma chloride equivalent to the fall in plasma bicarbonate, so that the sum of these two anions remains unchanged.
Why is the anion gap important?
The anion gap is clinically useful in the differential diagnosis of acid-base disorders. The anion gap is due to the presence of anions that are not measured in a standard plasma analysis , such as the negative charges associated with proteins. It is calculated as
What causes an increased anion gap?
An increased anion gap can come from an increase in the unmeasured anions (hyperalbuminemia, lactic acidosis, ketoacidosis) or a decrease in the unmeasured cations (hypocalcemia, hypokalemia, hypomagnesemia). If the decrease in HCO 3− is offset by an increase in Cl −, there is a hyperchloremic acidosis but a normal anion gap.
What is an anion gap?
The anion gap is elevated in processes that result in an increase in the plasma concentration of anions that are not routinely measured in conventional chemistry panels , including lactate, phosphates, sulfates, and other organic anions (such as the degradation products of commonly ingested alcohols).
Why is it important to calculate the anion gap?
Calculating the anion gap is critical when assessing a patient's acid-base status because an elevated anion gap may alert the physician to the presence of a metabolic acidosis that might not be apparent on first glance of the arterial blood gas values.
Is plasma anion gap normal?
In contrast, the plasma anion gap is normal in other types of multiple myeloma, which is due to the differences in the isoelectric points of IgA and IgG paraproteins ( 54 ). IgG paraproteins have isoelectric points that are higher than physiologic pH and are positively charged.
Why can't anion gap be used as a surrogate for lactic acidosis?
The anion gap cannot be used as a surrogate in the diagnosis of lactic acidosis because the association between hyperlactatemia and the anion gap is poor.78 Furthermore, correcting the anion gap for hypoalbuminemia does not appear to improve detection of hyperlactatemia. 78 The lack of tight correlation between lactate concentration and the anion gap may be due to the fact that metabolic acidosis in critically ill patients is commonly multifactorial; hyperchloremia and/or an increase in unidentified anions often accompanies hyperlactatemia. 79 Gunnerson et al., 80 comparing lactate acidosis with nonlactate metabolic acidosis in 548 critically ill patients, noted that patients with lactic acidosis had the highest mortality rate (56%), whereas mortality was lower in those with strong ion gap (unmeasured anion) acidosis (39%) and hyperchloremic acidosis (29%). The identity of these unmeasured anions (i.e., anions other than lactate, ketoanions, anions from renal failure or toxins) is not completely understood. Forni et al. 81 proposed that these anions were negatively charged intermediates of the Krebs cycle. However, other investigators have provided data suggesting that strong ion gap acidosis is probably multifactorial in nature. 82
Why is it important to know the anion gap?
It is important because an increased anion gap usually is caused by an increase in unmeasured anions, and that most commonly occurs when there is an increase in unmeasured organic acids, that is, an acidosis3, 4). Acids (eg, lactate and pyruvate) are protons donors and must be buffered by bicarbonate.
Can a low anion gap mask acidosis?
Third, a low anion gap can mask an underlying high anion gap acidosis and potentially delay intervention. While an increase in the anion gap is almost always caused by retained unmeasured anions, a decrease in the anion gap can be generated by multiple mechanisms. Conclusion.
When were ion-selective electrodes used?
Since the 1980s , ion-selective electrodes for specific ionic species were used for the measurement of serum electrolytes. The difference between the ionic concentration in the electrode (known) and the sample creates an electrical potential (measured) and the sample ionic concentration can be calculated.
Does IgG have a positive charge?
In addition to displacement of sodium-containing water from serum by large amounts of non-sodium-containing paraproteins, some paraproteins (eg, IgG in multiple myeloma) can have a net positive charge at physiological pH. This leads to an increase in unmeasured cations and a low anion gap7, 8).
What is the anion gap?
The anion gap can be used to distinguish probable cause of metabolic acidosis (high anion gap versus normal anion gap metabolic acidosis), which will aid the provider in determining a diagnosis and suitable treatment. Albumin is the major unmeasured anion and contributes almost the whole of the value of the anion gap.
Is albumin an anion gap?
Albumin is the major unmeasured anion and contributes almost the whole of the value of the anion gap. An actual high anion gap acidosis in a patient with hypoalbuminaemia may appear as a normal anion gap acidosis.
What is the normal level of anion gap?
The normal level of anion gap is between 8 and 12 milliequivalents per liter of blood. An elevated anion gap reflects an increase in "unmeasured" anions--usually organic acids--that are not normally included in standard determinations of other anions, such as chloride and bicarbonate.
Why does lactic acidosis cause increased anion gap?
This may also occur because of reduced inorganic acid excretion, such as that seen in chronic renal failure.
What is the pH of a diabetic ketoacidosis?
Diabetic ketoacidosis is a serum glucose level greater than 300 mg per dL, ketones in the serum, and a pH less than 7.3 Se rum sodium is often low secondary to elevated serum glucose. Serum potassium is often elevated secondary to the acidosis.
Why is glucose correction important?
So, glucose correction is actually a secondary goal at that point - it is important as a goal BECAUSE doing so helps to correct that acid imbalance.
What happens to the body when there is no glucose in the blood?
Without glucose in the cells (it's all floating around in the blood), the cells use their alternative form of energy, lactic acid production. This, on top of the intracellular lytes that move back and forth with glucose, causes the body to become quite acidotic. CO2 is an acid.