The anion gap does not accurately screen for lactic acidosis in emergency department patients.
BACKGROUND
Lactic acidosis portends a poor prognosis in trauma, sepsis, and other shock states and is useful for triaging and resuscitating emergency department (ED) patients. The authors sought to determine whether the AG is a reliable screen for lactic acidosis when applied specifically in the ED setting.


METHODS
The authors performed a retrospective cohort study over a seven month period. Subjects were all ED patients that had a serum lactate obtained. Sensitivity analyses of the AG for detecting presence of lactic acidosis were calculated for the traditional AG normal value (AG <12) and for the lower AG normal value when using newer ion selective electrode assays (AG <6).


RESULTS
Serum lactate levels were ordered in the ED on 440 occasions. 137 samples were excluded by protocol. Using an AG cutoff of 12, the sensitivity for detecting lactic acidosis was 58.2%, specificity was 81.0%, and the negative predictive value was 89.7%. Using the AG cutoff of 6, the sensitivity was 93.2%, the specificity was 17.3%, and the negative predictive value was 91.8%.


CONCLUSIONS
The traditional definition of AG >12 was insensitive for the presence of lactic acidosis. Using the revised AG of >6 is more sensitive but non-specific for lactic acidosis. The authors conclude that employing the AG as a screen for LA may be inappropriate in ED patients. Instead, they recommend ordering a serum lactate immediately upon suspicion of a shock state. A prospective study to confirm these findings is needed.
US Army, Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center, San Antonio, TX 78234, USA.
B D
BD
Adams
T A
TA
Bonzani
C J
CJ
Hunter
D000140:Acidosis, Lactic / Q000175:diagnosis*; D000328:Adult; D000368:Aged; D000838:Anions / Q000032:analysis*; D015331:Cohort Studies; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D019344:Lactic Acid / Q000097:blood*; D008297:Male; D008875:Middle Aged; D012372:ROC Curve; D012189:Retrospective Studies; D012680:Sensitivity and Specificity
D000838:Anions; D019344:Lactic Acid