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Excess Anion Gap

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181. Approach to the Genitourinary Patient - History

of HCO 3 in evaluation of Cl levels and urine anion gap for and K levels in determining the cause of or Levels of calcium, magnesium, uric acid, oxalate, citrate, and cystine in evaluation of calculi Eosinophils, cells that stain bright red or pink-white with Wright or Hansel staining, most commonly indicate one of the following: Acute interstitial nephritis Rapidly progressive glomerulonephritis Acute prostatitis Cytology is used for the following: To screen for cancer in high-risk populations (eg (...) kidney function. Its plasma concentration is independent of sex, age, and body weight. Testing is not always available, and values are not standardized across laboratories. Serum electrolytes (eg, Na, K, HCO 3 ) may become abnormal and the anion gap (Na – [Cl + HCO 3 ]) may increase in and . Serum electrolytes should be monitored periodically. CBC may detect anemia in chronic kidney disease or, rarely, polycythemia in or . Anemia is often multifactorial (mainly due to erythropoietin deficiency

2013 Merck Manual (19th Edition)

182. Approach to the Genitourinary Patient - Evaluation of the Renal Patient

or acute interstitial nephritis. Other useful measurements include the following: Fractional excretion of HCO 3 in evaluation of Cl levels and urine anion gap for and K levels in determining the cause of or Levels of calcium, magnesium, uric acid, oxalate, citrate, and cystine in evaluation of calculi Eosinophils, cells that stain bright red or pink-white with Wright or Hansel staining, most commonly indicate one of the following: Acute interstitial nephritis Rapidly progressive glomerulonephritis (...) inhibitor that is produced by all nucleated cells and filtered by the kidneys, can also be used to evaluate kidney function. Its plasma concentration is independent of sex, age, and body weight. Testing is not always available, and values are not standardized across laboratories. Serum electrolytes (eg, Na, K, HCO 3 ) may become abnormal and the anion gap (Na – [Cl + HCO 3 ]) may increase in and . Serum electrolytes should be monitored periodically. CBC may detect anemia in chronic kidney disease

2013 Merck Manual (19th Edition)

183. Diabetic Ketoacidosis (DKA)

mostly in type 1 diabetes mellitus (DM). It causes nausea, vomiting, and abdominal pain and can progress to cerebral edema, coma, and death. 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. (See also and .) Diabetic ketoacidosis (DKA) is most common among patients with type 1 diabetes mellitus and develops when insulin levels are insufficient (...) Pa co 2 at presentation appear to be at greatest risk. Delays in correction of hyponatremia and the use of bicarbonate during DKA treatment are additional risk factors. Diagnosis Arterial pH Serum ketones Calculation of anion gap In patients suspected of having diabetic ketoacidosis, serum electrolytes, BUN and creatinine, glucose, ketones, and osmolarity should be measured. Urine should be tested for ketones. Patients who appear significantly ill and those with positive ketones should have

2013 Merck Manual (19th Edition)

184. Metabolic Acidosis

of Respiratory Acidosis SOCIAL MEDIA Add to Any Platform Loading Topic Resources Metabolic acidosis is primary reduction in bicarbonate (HCO 3 − ), typically with compensatory reduction in carbon dioxide partial pressure (P co 2 ); pH may be markedly low or slightly subnormal. Metabolic acidoses are categorized as high or normal anion gap based on the presence or absence of unmeasured anions in serum. Causes include accumulation of ketones and lactic acid, renal failure, and drug or toxin ingestion (high (...) anion gap) and GI or renal HCO 3 − loss (normal anion gap). Symptoms and signs in severe cases include nausea and vomiting, lethargy, and hyperpnea. Diagnosis is clinical and with ABG and serum electrolyte measurement. The cause is treated; IV sodium bicarbonate may be indicated when pH is very low. (See also and .) Overview of Metabolic Acidosis VIDEO Etiology Metabolic acidosis is acid accumulation due to Increased acid production or acid ingestion Decreased acid excretion GI or renal HCO 3 − loss

2013 Merck Manual (19th Edition)

185. Multiple Myeloma

anemia with formation of rouleau, which are clusters of 3 to 12 RBCs that occur in stacks. WBC and platelet counts are usually normal. ESR usually is > 100 mm/h; BUN, serum creatinine, LDH, and serum uric acid may be elevated. Anion gap is sometimes low. Hypercalcemia is present at diagnosis in about 10% of patients. Protein electrophoresis is done on a serum sample and on a urine sample concentrated from a 24-h collection to quantify the amount of urinary M-protein. Serum electrophoresis identifies (...) , and rarely absent entirely) and lytic bone lesions, light-chain proteinuria, or excessive plasma cells in bone marrow. A bone marrow biopsy is usually needed. Specific treatment most often includes some combination of conventional chemotherapy, corticosteroids, and one or more of the newer agents such as bortezomib , carfilzomib , ixazomib, lenalidomide , thalidomide , pomalidomide , daratumumab , or elotuzumab . High-dose melphalan followed by autologous peripheral blood stem cell transplantation may

2013 Merck Manual (19th Edition)

186. Hypertensive Emergencies

titrated in increments of 0.5 mcg/kg to a maximum of 8 to 10 mcg/kg/min; maximum dose is given for ≤ 10 min to minimize risk of cyanide toxicity. The drug is rapidly broken down into cyanide and nitric oxide (the active moiety). Cyanide is detoxified to thiocyanate. However, administration of > 2 mcg/kg/min can lead to cyanide accumulation with toxicity to the CNS and heart; manifestations include agitation, seizures, cardiac instability, and an anion gap metabolic acidosis. Prolonged administration (...) (if BP is reduced too rapidly), thiocyanate and cyanide toxicity Most hypertensive emergencies Should be used cautiously in patients with high intracranial pressure or azotemia Phentolamine 5–15 mg IV Tachycardia, flushing, headache Catecholamine excess *Hypotension may occur with all drugs. † A special delivery system (eg, infusion pump for nitroprusside , nonpolyvinyl chloride tubing for nitroglycerin ) is required. Oral drugs are not indicated because onset is variable and the drugs are difficult

2013 Merck Manual (19th Edition)

187. Renal Tubular Acidosis

of electrolyte derangements, or progress to chronic kidney disease. Diagnosis is based on characteristic changes in urine pH and electrolytes in response to provocative testing. Treatment corrects pH and electrolyte imbalances using alkaline agents, electrolytes, and, rarely, drugs. RTA defines a class of disorders in which excretion of hydrogen ions or reabsorption of filtered bicarbonate is impaired, leading to a chronic with a normal anion gap. Hyperchloremia is usually present, and secondary derangements (...) ) may occur in type 2 and sometimes in type 1 RTA. Type 4 RTA is usually asymptomatic with only mild acidosis, but or paralysis may develop if hyperkalemia is severe. Diagnosis Suspected in patients with metabolic acidosis with normal anion gap or with unexplained hyperkalemia Serum and urine pH, electrolyte levels, and osmolalities Often, testing after stimulation (eg, with ammonium chloride, bicarbonate, or a loop diuretic) RTA is suspected in any patient with unexplained (low plasma bicarbonate

2013 Merck Manual (19th Edition)

188. Iron Poisoning

binding capacity is often inaccurate and not helpful in diagnosing serious poisoning and is not recommended. The most accurate approach is to serially measure levels of serum iron, HCO 3 , and pH (with calculation of the anion gap); these findings are then evaluated together, and results are correlated with the patient’s clinical status. For example, toxicity is suggested by increasing iron levels, metabolic acidosis, worsening symptoms, or, more typically, some combination of these findings. Clinical (...) like candy. Prenatal multivitamins are the source of iron in most lethal ingestions among children. Children’s chewable multivitamins with iron usually have such small amounts that toxicity rarely occurs. Pathophysiology Iron is toxic to the GI system, cardiovascular system, and CNS. Specific mechanisms are unclear, but excess free iron is inserted into enzymatic processes and interferes with oxidative phosphorylation, causing metabolic acidosis. Iron also catalyzes free radical formation, acts

2013 Merck Manual (19th Edition)

189. Specific Poisons

, coma, paralysis, negative anion gap Discontinuation of drug, hydration and NaCl IV to promote diuresis, furosemide 10 mg IV q 6 h For severe poisoning, hemodialysis Bromine Highly corrosive With exposure to liquid or vapor, skin and mucous membrane burns Aggressive decontamination, supportive care Bupropion HCl Respiratory depression, ataxia, seizures Charcoal, benzodiazepines, supportive care Butyl nitrate See Nitrites — Cadmium Cadmium oxide fumes (eg, from welding) Ingestion: Severe gastric (...) Diethylene glycol Most automotive antifreeze Ingestion: Inebriation but no alcohol odor on breath, nausea, vomiting Later, carpopedal spasm, lumbar pain, oxalate crystalluria, oliguria progressing to anuria and acute renal failure, respiratory distress, seizures, coma Eye contact: Iridocyclitis Ingestion: Respiratory support, correction of electrolyte imbalance (anion gap), consideration of correcting acidemia, ethanol (see treatment of methyl alcohol) or fomepizole 15 mg/kg IV (loading dose) followed

2013 Merck Manual (19th Edition)

190. Chemical Warfare Agents

discoloration or darkening of coins carried by the patient should lead to a heightened suspicion of hydrogen-sulfide poisoning. Diagnosis Clinical evaluation Severely affected patients must be treated before testing is available, so diagnosis is mainly clinical. Laboratory findings include a decreased arteriovenous oxygen difference (due to higher-than-usual venous oxygen content) and high-anion-gap acidemia with increased lactate. Triage All unconscious patients with a pulse are potentially salvageable (...) sulfide, interfere with mitochondrial energy transport, blocking cellular respiration. They are distributed in the blood (and are thus termed blood agents in military references) and thus affect most tissues. Vesicants damage the dermoepidermal junction, causing pain and typically blistering. Many can affect the lungs if inhaled. Nerve agents inhibit the enzyme acetylcholinesterase, causing excess cholinergic stimulation and cholinergic crisis (eg, diarrhea, urination, miosis, bronchorrhea

2013 Merck Manual (19th Edition)

191. Diet-induced metabolic acidosis. (Abstract)

Diet-induced metabolic acidosis. The modern Western-type diet is deficient in fruits and vegetables and contains excessive animal products, generating the accumulation of non-metabolizable anions and a lifespan state of overlooked metabolic acidosis, whose magnitude increases progressively with aging due to the physiological decline in kidney function. In response to this state of diet-derived metabolic acidosis, the kidney implements compensating mechanisms aimed to restore the acid-base (...) studies confirm an association between insulin resistance and metabolic acidosis markers, including low serum bicarbonate, high serum anion gap, hypocitraturia, and low urine pH.Copyright © 2011 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

2011 Clinical nutrition (Edinburgh, Scotland)

192. Defining metabolic acidosis in patients with septic shock using Stewart approach. (Abstract)

Defining metabolic acidosis in patients with septic shock using Stewart approach. The aim of this study was to define the nature of metabolic acidosis in patients with septic shock on admission to intensive care unit (ICU) using Stewart method. We also aimed to compare the ability of standard base excess (SBE), anion gap (AG), and corrected AG for albumin and lactate (AGcorr) to accurately predict the presence of unmeasured anions (UA).Thirty consecutive patients with septic shock were (...) prospectively included on ICU admission. Stewart equations modified by Figge were used to calculate the strong ion difference and the strong ion gap (SIG).Most patients had multiple underlying mechanisms explaining the metabolic acidosis. Unmeasured anions and hyperchloremia were present in 70% of the patients. Increased UA were present in 23% of patients with normal values of SBE and [HCO3-]. In these patients, plasma [Cl-] was significantly lower compared with patients with low SBE and increased UA (103

2011 American Journal of Emergency Medicine

193. Physiological Demands of a Simulated BMX Competition. Full Text available with Trip Pro

Physiological Demands of a Simulated BMX Competition. The aim of this study was to investigate the physiological demands of Supercross BMX in elite athletes. Firstly athletes underwent an incremental cycling test to determine maximal oxygen uptake (VO2max) and power at ventilatory thresholds. In a second phase, athletes performed alone a simulated competition, consisting of 6 cycling races separated by 30 min of passive recovery on an actual BMX track. Oxygen uptake, blood lactate, anion gap (...) and base excess (BE) were measured. Results indicated that a simulated BMX performed by elite athletes induces a high solicitation of both aerobic (mean peak VO2 (VO2peak): 94.3±1.2% VO2max) and anaerobic glycolysis (mean blood lactate: 14.5±4. 5 mmol x L(-1) during every race. Furthermore, the repetition of the 6 cycling races separated by 30 min of recovery led to a significant impairment of the acid-base balance from the third to the sixth race (mean decrease in BE: -18.8±7.5%, p<0.05

2012 International Journal of Sports Medicine

194. Ethylene glycol poisoning

glycol concentration and the osmolal gap making this test less useful. Additionally, the presence of other alcohols such as , , or or conditions such as or , , or kidney failure may also produce an elevated osmolal gap leading to a false diagnosis. Other laboratory abnormalities may suggest poisoning, especially the presence of a metabolic acidosis, particularly if it is characterized by a large . Large anion gap acidosis is usually present during the initial stage of poisoning. However, acidosis has (...) follow a three-step progression, although poisoned individuals will not always develop each stage. Stage 1 (30 minutes to 12 hours) consists of and and looks similar to alcohol poisoning. Poisoned individuals may appear to be , , , , , and have , , , , and . Irritation to the stomach may cause and . Also seen are excessive thirst and urination. Over time, the body ethylene glycol into other toxins. Stage 2 (12 to 36 hours) where signs of "alcohol" poisoning appear to resolve, underlying severe

2012 Wikipedia

195. Electrolyte

Electrolyte Electrolyte - Wikipedia Electrolyte From Wikipedia, the free encyclopedia For the R.E.M. song, see . An electrolyte is a substance that produces an when dissolved in a , such as water. The dissolved electrolyte separates into and , which disperse uniformly through the solvent. Electrically, such a solution is neutral. If an is applied to such a solution, the cations of the solution are drawn to the electrode that has an abundance of electrons, while the anions are drawn (...) to the electrode that has a deficit of electrons. The movement of anions and cations in opposite directions within the solution amounts to a current. This includes most soluble , , and . Some gases, such as , under conditions of high temperature or low pressure can also function as electrolytes. Electrolyte solutions can also result from the dissolution of some biological (e.g., , ) and (e.g., ), termed " ", which contain charged . A substance that dissociates into ions in solution acquires the capacity

2012 Wikipedia

196. Renal tubular acidosis

a clinical syndrome similar to the other types of RTA described above. It was included in the classification of renal tubular acidoses as it is associated with a mild (normal anion gap) metabolic acidosis due to a physiological reduction in proximal tubular excretion (impaired ammoniagenesis), which is secondary to , and results in a decrease in urine buffering capacity. Its cardinal feature is , and measured urinary acidification is normal, hence it is often called hyperkalemic RTA or tubular (...) -functioning kidneys. Several different types of RTA exist, which all have different syndromes and different causes. The word refers to the tendency for RTA to cause an excess of , which lowers the blood's . When the blood pH is below normal (7.35), this is called . The metabolic acidosis caused by RTA is a . Contents Types [ ] An overview of types 1, 2, and 4 is presented below (type 3 is usually excluded from modern classifications): Type Type 1 Type 2 Type 4 Location Collecting Tubules, distal tubules

2012 Wikipedia

197. Aspirin poisoning Full Text available with Trip Pro

of and levels. assessments will typically find early in the course of the overdose due to hyperstimulation of the respiratory center, and may be the only finding in a mild overdose. An anion-gap occurs later in the course of the overdose especially if it is a moderate to severe overdose, due to the increase in protons (acidic contents) in the blood. The diagnosis of poisoning usually involves measurement of plasma salicylate, the active metabolite of aspirin, by automated spectrophotometric methods. Plasma (...) > 20,000 per year (US) Salicylate poisoning , also known as aspirin poisoning , is the acute or chronic poisoning with a such as . The classic symptoms are , , , and a . Early on these may be subtle while larger doses may result in . Complications can include or , , , or . While usually due to aspirin, other possible causes include and . Excess doses can be either on purpose or accidental. Small amounts of oil of wintergreen can be toxic. Diagnosis is generally based on repeated blood tests measuring

2012 Wikipedia

198. Lead Full Text available with Trip Pro

mixing into four sp 3 orbitals. In lead, the inert pair effect increases the separation between its s- and p-orbitals, and the gap cannot be overcome by the energy that would be released by extra bonds following hybridization. Rather than having a diamond cubic structure, lead forms in which only the p-electrons are delocalized and shared between the Pb 2+ ions. Lead consequently has a structure like the similarly sized metals and . Bulk [ ] Pure lead has a bright, silvery appearance with a hint (...) , such as , dissolve lead in the presence of oxygen. Concentrated will dissolve lead and form . Inorganic compounds [ ] See also: Lead shows two main oxidation states: +4 and +2. The state is common for the carbon group. The divalent state is rare for and , minor for germanium, important (but not prevailing) for tin, and is the more important of the two oxidation states for lead. This is attributable to , specifically the , which manifests itself when there is a large difference in between lead and , , or anions

2012 Wikipedia

199. Acid-Base Disorders in ICU Patients Full Text available with Trip Pro

Acid-Base Disorders in ICU Patients Metabolic acid-base disorders are comnom clinical problems in ICU patients. Arterial blood gas analysis and anion gap (AG) are important laboratory data in approaching acid-base interpretation. When measuring the AG, several factors such as albumin have influence on unmeasured anions and unmeasured cations. If a patient has hypoalbuminemia, the AG should be adjusted according to the albumin level. High AG metabolic acidoses including lactic acidosis (...) , ketoacidosis, and ingestion of toxic alcohols are common in ICU patients. The treatment target of lactic acidosis and ketoacidosis is not the acidosis, but the underlying condition causing acidosis. Gastric acid loss, diuretics, volume depletion, renal compensation for respiratory acidosis, hypokalemia, and mineralocorticoid excess are common causes of metaboic alkalosis. In chloride responsive metaboic alkalosis, volume and potassium repletion are mandatory.

2010 Electrolytes & Blood Pressure : E & BP

200. Prospective assessment of short-term propylene glycol tolerance in neonates. (Abstract)

Prospective assessment of short-term propylene glycol tolerance in neonates. Propylene glycol (PG) is an unintentional frequently administered solvent in neonates despite the fact that PG accumulation potentially results in hyperosmolarity, lactic acidosis and renal/hepatic toxicity.Prospective evaluation of renal (diuresis, creatinaemia, sodium), metabolic (base excess, anion gap, lactate, bicarbonate) and hepatic (alanine transaminase, aspartate aminotransferase, direct bilirubinaemia

2010 Archives of Disease in Childhood

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