High-Anion Gap Metabolic Acidosis (“HAGMA”)
- Note how the labs were significant for an acidemia (pH < 7.35) with an anion gap of 21. Respiratory compensation is appropriate, as calculated using Winter’s Formula
- Differential diagnosis includes ketonemia, uremia, lactic acidemia, or ingestion of substances such as ethylene glycol, propylene glycol, methanol, salicylates, tylenol, or toluene
- Also note how the osmolar gap is 15, suggesting ethylene glycol, propylene glycol, or methanol ingestion
Further Workup
- UA was negative for ketones, blood, or crystals; serum β-hydroxybutyrate negative
- BUN/Creatinine within normal limits
- Lactic acid within normal limits
- Salicylate and toluene levels negative
- Volatile acid screen was positive for ethylene glycol at 23 mg/dL
Management
- Fomepizole was initiated
- Because of severe acidemia, Nephrology was consulted and hemodialysis was initiated to remove ethylene glycol from the body
- His acidemia resolved after dialysis, his mental status improved in the following days off of sedation, and he was successfully extubated, at which time he admitted to “Antifreeze” ingestion in a suicide attempt
- He was discharged home after a Psychiatry consult and initiation of SSRI therapy with close outpatient follow-up
- For more, see Metabolic Acidosis
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