Anion Gap

Two weeks ago we talked about anion gap acidosis and how we can use nmemonics like GOLDMARK to help us remember the causes. Sometimes, we run into the situation where the anion gap is normal, but our patient is still in metabolic acidosis. This is most commonly due to excessive excretion from diarrhea, but could also be from renal failure, medications like acetazolamide, a potent chloride sparing diuretic, or even normal saline. Normal saline has a high amount of chloride and excessive fluid administration can lead to a surplus of chloride in the body. Regardless of the reason for the excess chloride, this causes bicarbonate to be displaced from the other direction and therefore creating a non anion gap metabolic acidosis (NAGMA). What is your approach to dealing with metabolic acidosis and it causes?