Metabolic Acidosis-Elevated Anion Gap (Anion Gap Metabolic Acidosis, AGMA)





Etiology (GOLDMARK Mnemonic)


Serum Chemistry

  • Serum Bicarbonate: decreased

Serum Anion Gap (see Serum Anion Gap)

  • Elevated

Arterial Blood Gas (ABG) (see Arterial Blood Gas)

  • Decreased Serum Bicarbonate with Respiratory Compensation: assessment of the appropriateness of respiratory compensation can be determined using standard rules of expected compensation (see Acid-Base Physiology, [[Acid-Base Physiology]])

Serum Osmolality (see Serum Osmolality)

  • Serum Osmolal Gap: variable (depending on the etiology)

Clinical Manifestations

Pharmacologic Manifestations

Enhanced Effect of Neuromuscular Junction Antagonists (see Neuromuscular Junction Antagonists)

  • Physiology: acidosis potentiates the effect of neuromuscular junction antagonists
  • Agents

Renal Manifestations

  • Anion Gap Metabolic Acidosis (AGMA)


  • Treat Underlying Disorder


  • The delta gap: an approach to mixed acid-base disorders. Ann Emerg Med. 1990;19:1310–1313 [MEDLINE]
  • Management of life-threatening acid-base disorders. First of two parts. N Engl J Med 1998; 338:26-34 [MEDLINE]
  • Management of life-threatening acid-base disorders. Second of two parts. N Engl J Med. 1998 Jan 8;338(2):107-11 [MEDLINE]
  • Systematic review of current guidelines, and their evidence base, on risk of lactic acidosis after administration of contrast medium for patients receiving metformin. Radiology Jan 2010; 254:261-269
  • Treatment of acute metabolic acidosis: a pathophysiologic approach. Nat Rev Nephrol. 2012 Oct;8(10):589-601. doi: 10.1038/nrneph.2012.186. Epub 2012 Sep 4 [MEDLINE]
  • Lactic acidosis. N Engl J Med. 2014 Dec 11;371(24):2309-19. doi: 10.1056/NEJMra1309483 [MEDLINE]
  • Diagnostic Challenge in a Patient with Severe Anion Gap Metabolic Acidosis. Case Rep Crit Care. 2015;2015:272914. doi: 10.1155/2015/272914. Epub 2015 May 31 [MEDLINE]