Non-Anion Gap Metabolic Acidosis (NAGMA) has a broad differential diagnosis. Often the cause is obvious, but otherwise this leads to a rat's nest of various forms of renal tubular acidosis (RTA). Fortunately, appropriate treatment generally doesn't require immediate diagnosis of the specific cause of the NAGMA. So have no fear – give the evaluation an honest college try, but don't delay treatment (the latter being simpler and more important)
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Josh is the creator of PulmCrit.org. He is an associate professor of Pulmonary and Critical Care Medicine at the University of Vermont.
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The administration of bicarbonate to “treat” NAGMA is a controversial topic and I would argue is not standard of care. If you do it remember not to do it at the expense of fluid overload, hypernatremia, hypocalcemia, or hypokalemia. If you wouldn’t otherwise be giving your patient crystalloid/volume then you’re almost certainly not justified in giving them bicarb for their NAGMA, as the evidence for harm from volume overload far outweighs the evidence of benefit from “fixing” their NAGMA (which is basically just less bone demineralization and nephrolithiasis when chronically administers to CKD pts and whatever you take away from… Read more »
Hello,
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Keep up the great work!!
Learned a lot! Thanks for this amazing piece!
The link for “Previously the urinary anion gap has been used for this purpose, but it has numerous limitations (24403272). ” I believe is wrong as it opens “Occupational dust exposure and head and neck squamous cell carcinoma risk in a population-based case-control study conducted in the greater Boston area.” – Just FYI.
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In the NAGMA treatment scheme, you suggested isotonic bicarbonate as the main treatment option for patients with hyponatremia and hypovolemia. In parentheses, you also stated that it can be added in hypertonic bicarbonate, what exactly do you mean here? So, to correct the patient’s severe acidosis and/or hyponatremia, do we need to run the hypertonic bicarbonate infusion with an infusion line separate from the isotonic bicarbonate? Or should we first of all (before sending isotonic bicarbonate), correct severe acidosis and/or hyponatremia with hypertonic bicarbonate, and then run isotonic bicarbonate as a maintenance fluid? Or something else?
thanks in advance.
This was a well-structured post that addressed a lot of the questions I had. Your explanations were clear, and I now feel more confident about applying these strategies. Thanks for the helpful guide!
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