title: Serum anion gap in the differential diagnosis of metabolic acidosis in critically ill newborns.
abstract: OBJECTIVE
  To determine in critically ill newborn infants (1) the range of the serum anion gap without metabolic acidosis and (2) whether the serum anion gap can be used to distinguish newborns with lactic acidosis from those with hyperchloremic metabolic acidosis.
  
  
  METHODS
  Umbilical arterial blood gases and serum electrolyte and lactate concentrations were measured simultaneously in 210 samples from 63 infants over the first week of life. Metabolic acidosis was defined as a blood base deficit (BD) >4 mmol/L. The anion gap was calculated as [Na(+)] - [C1(-)] - [TCO (2)]. Lactic acidosis was defined as a serum lactate concentration >2 SD above the mean serum lactate concentration in samples without metabolic acidosis.
  
  
  RESULTS
  In 89 blood samples with BD <4 mmol/L, serum lactate concentration decreased with postnatal age (r = 0.51). The upper limit of serum lactate concentration was 3.8 mmol/L at less than 48 hours, 2.4 mmol/L between 48 and 96 hours, and 1.5 mmol/L for infants greater than 96 hours of age. The mean serum anion gap +/- 2 SD in 174 samples without lactic acidosis was 8 +/- 4 mmol/L; in 36 samples with lactic acidosis it was 16 +/- 9 mmol/L (P <.0001). Serum anion gap and lactate concentration were poorly correlated for samples without lactic acidosis (r = 0.04) but highly correlated in those with lactic acidosis (r = 0.81, P <.0001). None of the 85 samples with metabolic acidosis but without lactic acidosis had an anion gap >16 mmol/L; only 4 of 36 samples with lactic acidosis had an anion gap <8 meq/L. However, 25 of 36 samples with lactic acidosis had serum anion gaps of 8 to 16 mmol/L.
  
  
  CONCLUSIONS
  In the presence of metabolic acidosis, a serum anion gap >16 mmol/L is highly predictive of lactic acidosis; a serum anion gap <8 is highly predictive of the absence of lactic acidosis; an anion gap = 8 - 16 mmol/L has no use in the differential diagnosis of metabolic acidosis in the critically ill newborn.
authors.affiliation: Department of Pediatrics and Human Development, Michigan State University, East Lansing, Michigan, USA.
authors.forename: J M
authors.initials: JM
authors.lastname: Lorenz
authors.forename: L I
authors.initials: LI
authors.lastname: Kleinman
authors.forename: K
authors.initials: K
authors.lastname: Markarian
authors.forename: M
authors.initials: M
authors.lastname: Oliver
authors.forename: J
authors.initials: J
authors.lastname: Fernandez
mesh_terms: D000136:Acid-Base Equilibrium; D000138:Acidosis / Q000175:diagnosis*; D000140:Acidosis, Lactic / Q000175:diagnosis; D016638:Critical Illness; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D011237:Predictive Value of Tests