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The connection with insulin and DKA will be in how DKA comes about (not enough insulin, so blood sugar elevates, the body homeostatic mechanisms kick in and the patient goes into dka if the situation is not treated) Diabetic ketoacidosis is a triad of hyperglycemia, ketonemia and acidemia,

Anion gap is defined as the difference between measured serum cations and anions. It is calculated by adding the number of chloride and bicarbonate anions together and then subtracting them from the number of sodium and potassium cations in the blood. In other words: (Na+ + K+) - (Cl- + HCO3-) where Na- is sodium, K+ is potassium, Cl- is chloride, and HCO3- is bicarbonate.

Agap = Na + K - Cl -CO2

The anion gap can be normal, high, or low. The normal level of anion gap is between 8 and 12 milliequivalents per liter of blood. An elevated anion gap reflects an increase in "unmeasured" anions--usually organic acids--that are not normally included in standard determinations of other anions, such as chloride and bicarbonate. The gap is increased when K+, Ca++, or Mg++ is decreased, when the concentration of plasma proteins is increased, or when organic anions such as lactate or foreign anions accumulate in blood. The anion gap is decreased when cations are increased or when plasma albumin is decreased.

A high anion gap indicates metabolic acidosis. If the anion gap level is 20 or above, this signals a problem. A low anion gap is rare but may occur with multiple myeloma, hypoalbuminemia, hyponatremia, or hypomagnesemia.

The anion gap can be used to distinguish probable cause of metabolic acidosis (high anion gap versus normal anion gap metabolic acidosis), which will aid the provider in determining a diagnosis and suitable treatment. Albumin is the major unmeasured anion and contributes almost the whole of the value of the anion gap. An actual high anion gap acidosis in a patient with hypoalbuminaemia may appear as a normal anion gap acidosis.

Metabolic acidosis with increased anion gap may be caused by an accumulation of organic acids, such as lactic acidosis, ketoacidosis, toxic ingestions (ethylene glycol, salicylates, methanol, paraldehyde), and acute renal failure. This may also occur because of reduced inorganic acid excretion, such as that seen in chronic renal failure. Metabolic acidosis accompanied by normal anion gap may be caused by GI bicarb loss (diarrhea, ileostomy, colostomy), renal tubular acidosis, interstitial renal disease, ureterosigmoid loop, ureteroileal conduit, and ingestion of acetazolamide or ammonium chloride.

Diabetic ketoacidosis is a serum glucose level greater than 300 mg per dL, ketones in the serum, and a pH less than 7.3 Serum sodium is often low secondary to elevated serum glucose. Serum potassium is often elevated secondary to the acidosis. Diabetic ketoacidosis is treated with insulin, fluids and correction of the electrolyte disturbances.

Anion gap (AG or AGAP) is a value calculated using the results of an electrolyte panel. It is used to help distinguish between anion-gap and non-anion-gap metabolic acidosis. Acidosis refers to an excess of acid in the body; this can disturb many cell functions and should be recognized as quickly as possible, when present. AG is frequently used in the hospital and/or emergency room setting to help diagnose and monitor acutely ill patients. If anion-gap metabolic acidosis is identified, the AG may be used to help monitor the effectiveness of treatment and the underlying condition.

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