The anion gap is commonly used as a screening test for the presence of lactic acidosis. Analysis of the distribution of anion gaps for 56 adult surgical ICU patients with peak blood lactate levels >2.5 mmol/L showed the anion gap to be an insensitive screen for elevated lactate in a critically ill, hospitalized population. All patients (11/11) with a peak lactate >10 mmol/L had an anion gap >16 mmol/L; however, 50% (6/12) of patients with lactates between 5.0 and 9.9 mmol/L and 79% (26/33) of those with lactates between 2.5 and 4.9 mmol/L had anion gaps < 16 mmol/L. Hyperlactatemia was associated with considerable mortality at all levels: 100% among patients with lactate levels >10 mmol/L, 75% between 5.0 and 9.9 mmol/L, and 36.4% between 2.5 and 4.9 mmol/L. Acidosis (pH < 7.30) did not significantly alter mortality by lactate level. The observation that, for 57% of patients in this study, an elevated lactate level was not accompanied by an elevated anion gap suggests that hyperlactatemia should be included in the differential diagnosis of nonanion gap acidosis.
From the Departments of Surgery, Anesthesiology, and Community Medicine, The Mount Sinai Medical Center, New York, NY.