Management of Severe High Anion Gap Metabolic Acidosis

Diagnostic Approach

The American Diabetes Association recommends obtaining plasma glucose, serum and urine ketones to evaluate for diabetic ketoacidosis, with a strength of evidence level of A 2, 3, 1
The American Diabetes Association suggests obtaining blood urea nitrogen, creatinine, and complete metabolic panel to assess renal function and electrolyte balance, with a strength of evidence level of B 2, 3
Arterial blood gas (or venous pH) is recommended for monitoring, with a strength of evidence level of C 4, 3
Serum osmolality and calculation of osmolar gap are suggested to evaluate for toxic alcohol ingestion, with a strength of evidence level of B 2, 3
Lactate level is recommended to assess for lactic acidosis, with a strength of evidence level of C 1
Urinalysis looking for calcium oxalate crystals is suggested to evaluate for ethylene glycol poisoning, with a strength of evidence level of B 3
Toxicology screen including methanol, ethylene glycol, and salicylate levels is recommended, with a strength of evidence level of B 3

The American College of Critical Care Medicine recommends initiating hemodialysis immediately if toxic alcohol ingestion is suspected, with a strength of evidence level of A 5, 1
The American College of Critical Care Medicine suggests administering fomepizole to block alcohol dehydrogenase, with a strength of evidence level of B 1
The American Diabetes Association recommends beginning aggressive fluid resuscitation with isotonic saline for diabetic ketoacidosis, with a strength of evidence level of A 2, 4, 3
The American Diabetes Association suggests starting continuous intravenous regular insulin infusion for diabetic ketoacidosis, with a strength of evidence level of A 4
The American Diabetes Association recommends monitoring potassium closely and replacing aggressively as insulin drives potassium intracellularly, with a strength of evidence level of B 4, 3

The American Diabetes Association suggests that bicarbonate administration may be beneficial for pH <6.9, with a strength of evidence level of B 4
The American Diabetes Association recommends that bicarbonate is not necessary for pH >7.0, with a strength of evidence level of B 4

The American Diabetes Association recommends rechecking electrolytes, glucose, and venous pH every 2-4 hours, with a strength of evidence level of B 4, 3
The American Diabetes Association suggests monitoring for resolution of diabetic ketoacidosis, with a strength of evidence level of B 4
The American Diabetes Association recommends avoiding overly rapid correction of bicarbonate levels, with a strength of evidence level of C
The American Diabetes Association suggests watching for complications such as hypokalemia, hypophosphatemia, and cerebral edema, with a strength of evidence level of B 4