title: Correction of the anion gap for albumin in order to detect occult tissue anions in shock.
abstract: BACKGROUND
  It is believed that hypoalbuminaemia confounds interpretation of the anion gap (AG) unless corrected for serum albumin in critically ill children with shock.
  
  
  OBJECTIVE
  To compare the ability of the AG and the albumin corrected anion gap (CAG) to detect the presence of occult tissue anions.
  
  
  METHODS
  Prospective observational study in children with shock in a 22 bed multidisciplinary paediatric intensive care unit of a university childrenrsquo;s hospital. Blood was sampled at admission and at 24 hours, for acid-base parameters, serum albumin, and electrolytes. Occult tissue anions (lactate + truly "unmeasured" anions) were calculated from the strong ion gap. The anion gap ((Na + K) - (Cl + bicarbonate)) was corrected for serum albumin using the equation of Figge: AG + (0.25 x (44 - albumin)). Occult tissue anions (TA) predicted by the anion gap were calculated by (anion gap - 15 mEq/l). Optimal cut off values of anion gap were compared by means of receiver operating characteristic (ROC) curves. Ninety three sets of data from 55 children (median age 7 months, median weight 4.9 kg) were analysed. Data are expressed as mean (SD), and mean bias (limits of agreement).
  
  
  RESULTS
  The incidence of hypoalbuminaemia was 76% (n = 42/55). Mean serum albumin was 25 g/l (SD 8). Mean AG was 15.0 mEq/l (SD 6.1), compared to the CAG of 19.9 mEq/l (SD 6.6). Mean TA was 10.2 mmol/l (SD 6.3). The AG underestimated TA with mean bias 10.2 mmol/l (4.1-16.1), compared to the CAG, mean bias 5.3 mmol/l (0.4-10.2). A clinically significant increase of TA >5 mmol/l was present in 83% (n = 77/93) of samples, of which the AG detected 48% (n = 36/77), and the CAG 87% (n = 67/77). Post hoc ROC analysis revealed optimal cut off values for detection of TA >5 mmol/l to be AG >10 mEq/l, and CAG >15.5 mEq/l.
  
  
  CONCLUSIONS
  Hypoalbuminaemia is common in critically ill children with shock, and is associated with a low observed anion gap that may fail to detect clinically significant amounts of lactate and other occult tissue anions. We suggest that the albumin corrected anion gap should be calculated to screen for occult tissue anions in these children.
authors.affiliation: Paediatric Intensive Care Unit, School of Child & Adolescent Health, University of Cape Town, and Red Cross War Memorial Childrenrsquo, South Africa. hatheril@ich.uct.ac.za
authors.forename: M
authors.initials: M
authors.lastname: Hatherill
authors.forename: Z
authors.initials: Z
authors.lastname: Waggie
authors.forename: L
authors.initials: L
authors.lastname: Purves
authors.forename: L
authors.initials: L
authors.lastname: Reynolds
authors.forename: A
authors.initials: A
authors.lastname: Argent
mesh_terms: D000136:Acid-Base Equilibrium; D000137:Acid-Base Imbalance / Q000209:etiology / Q000378:metabolism*; D000418:Albumins / Q000378:metabolism*; D002648:Child; D006801:Humans; D034141:Hypoalbuminemia / Q000378:metabolism*; D007773:Lactates / Q000032:analysis; D008107:Liver Diseases / Q000150:complications; D011446:Prospective Studies; D011502:Protein-Energy Malnutrition / Q000150:complications; D012709:Serum Albumin / Q000032:analysis; D012769:Shock / Q000209:etiology / Q000378:metabolism*
chemical_list: D000418:Albumins; D007773:Lactates; D012709:Serum Albumin