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dc.contributor.authorGlasmacher, Stella Andrea
dc.contributor.authorStones, William
dc.identifier.citationGlasmacher , S A & Stones , W 2016 , ' Anion gap as a prognostic tool for risk stratification in critically ill patients – a systematic review and meta-analysis ' , BMC Anesthesiology , vol. 16 , 68 .
dc.identifier.otherPURE: 244033966
dc.identifier.otherPURE UUID: e1ed5a47-c46d-434f-9805-ca82e5c3c4ca
dc.identifier.otherScopus: 84984612095
dc.identifier.otherWOS: 000382199100001
dc.description.abstractBackground Lactate concentration is a robust predictor of mortality but in many low resource settings facilities for its analysis are not available. Anion gap (AG), calculated from clinical chemistry results, is a marker of metabolic acidosis and may be more easily obtained in such settings. In this systematic review and meta-analysis we investigated whether the AG predicts mortality in adult patients admitted to critical care settings. Methods We searched Medline, Embase, Web of Science, Scopus, The Cochrane Library and regional electronic databases from inception until May 2016. Studies conducted in any clinical setting that related AG to in-hospital mortality, in-intensive care unit mortality, 31-day mortality or comparable outcome measures were eligible for inclusion. Methodological quality of included studies was assessed using the Quality in Prognostic Studies tool. Descriptive meta-analysis was performed and the I2 test was used to quantify heterogeneity. Subgroup analysis was undertaken to identify potential sources of heterogeneity between studies. Results Nineteen studies reporting findings in 12,497 patients were included. Overall, quality of studies was poor and most studies were rated as being at moderate or high risk of attrition bias and confounding. There was substantial diversity between studies with regards to clinical setting, age and mortality rates of patient cohorts. High statistical heterogeneity was found in the meta-analyses of area under the ROC curve (I2=99%) and mean difference (I2=97%) for the observed AG. Three studies reported good discriminatory power of the AG to predict mortality and were responsible for a large proportion of statistical heterogeneity. The remaining 16 studies reported poor to moderate ability of the AG to predict mortality. Subgroup analysis suggested that intravenous fluids affect the ability of the AG to predict mortality. Conclusion Based on the limited quality of available evidence, a single AG measurement cannot be recommended for risk stratification in critically ill patients. The probable influence of intravenous fluids on AG levels renders the AG an impractical tool in clinical practice. Future research should focus on increasing the availability of lactate monitoring in low resource settings.
dc.relation.ispartofBMC Anesthesiologyen
dc.rights© 2016 The Author(s). Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.en
dc.subjectR Medicineen
dc.titleAnion gap as a prognostic tool for risk stratification in critically ill patients – a systematic review and meta-analysisen
dc.typeJournal articleen
dc.description.versionPublisher PDFen
dc.contributor.institutionUniversity of St Andrews.School of Medicineen
dc.contributor.institutionUniversity of St Andrews.Global Health Implementation Groupen
dc.description.statusPeer revieweden

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