Closing the gap on unmeasured anions

Many critically ill and injured patients, especially those with metabolic acidosis, have abnormally high levels of unmeasured anions in their blood. At the same time, such patients are prone to hypoalbuminemia, which makes the traditional anion gap calculation inaccurate. Thus, little is known about the epidemiology and clinical consequences of an excess in unmeasured anions in the blood. Indeed, even the etiology of these "missing ions" is often unclear. Unfortunately, more precise means of quantifying unmeasured anions, such as the strong ion gap (SIG), are cumbersome to use clinically. However, a simple means of correcting the anion gap can be used to estimate SIG and may provide additional insight into this common clinical problem.