Ann Fr Anesth Reanim. 2007 May;26(5):423-33. Epub 2007 Apr 25.
[What is the contribution of Stewart's concept in acid-base disorders analysis?].
[Article in French]
Quintard H1, Hubert S, Ichai C.
To explain the different approaches for interpreting acid-base disorders; to develop the Stewart model which offers some advantages for the pathophysiologicalunderstanding and the clinical interpretation of acid-base imbalances.
Record of french and english references from Medline data base. The keywords were: acid-base balance, hyperchloremic acidosis, metabolic acidosis, strong ion difference, strong ion gap.
Data were selected including prospective and retrospective studies, reviews, and case reports.
DATA SYNTHESIS:Acid-base disorders are commonly analysed by using the traditional Henderson-Hasselbalch approach which attributes the variations in plasma pH to the modifications in plasma bicarbonates or PaCO2. However, this approach seems to be inadequate because bicarbonates and PaCO2 are completely dependent. Moreover, it does not consider the role of weak acids such as albuminate, in the determination ofplasma pH value. According to the Stewart concept, plasma pH results from the degree of plasma water dissociation which is determined by 3 independent variables: 1) strong ion difference (SID) which is the difference between all the strong plasma cations and anions; 2) quantity of plasma weak acids; 3) PaCO2. Thus, metabolic acid-base disorders are always induced by a variation in SID (decreased inacidosis) or in weak acids (increased in acidosis), whereas respiratory disorders remains the consequence of a change in PaCO2. These pathophysiological considerations are important to analyse complex acid-base imbalances in critically ill patients. For example, due to a decrease in weak acids, hypoalbuminemia increases SID which may counter-balance a decrease in pH and an elevated anion gap.Thus if using only traditional tools, hypoalbuminemia may mask a metabolic acidosis, because of a normal pH and a normal anion gap. In this case, the association of metabolic acidosis and alkalosis is only expressed by respectively a decreased SID and a decreased weak acids concentration. This concept allows to establish the relationship between hyperchloremic acidosis and infusion of solutes whichcontain large concentration of chloride such as NaCl 0.9%. Finally, the Stewart concept permits to understand that sodium bicarbonate as well as sodium lactate induces plasma alkalinization. In fact, sodium remains in plasma, whereas anion (lactate or bicarbonate) are metabolized leading to an increase in plasma SID.
Due to its simplicity, the traditional Henderson-Hasselbalchapproach of acid-base disorders, remains commonly used. However, it gives an inadequate pathophysiological analysis which may conduct to a false diagnosis, especially with complex acid-base imbalances. Despite its apparent complexity, the Stewart concept permits to understand precisely the mechanisms of acid-base disorders. It has to become the most appropriate approach to analyse complexacid-base abnormalities.
Ann P. Anesth Reanim. 2007 Mayo; 26 (5): 423-33. Epub DE 2007 25 Abr.
[¿Cuál es el aporte de concepto de Stewart en el análisis de los trastornos ácido-base?].
[Artículo en francés]
Quintard H1, Hubert S, Ichai C.
Información del autor
Para explicar los diferentes enfoques para la interpretación de los trastornos ácido-base; para desarrollar el modelo de Stewart,que ofrece algunas ventajas para la comprensión fisiopatológica y la interpretación clínica de los desequilibrios ácido-base.
FUENTE DE DATOS:
Registro de referencias francesas e inglesas de la base de datos Medline. Las palabras clave fueron: equilibrio ácido-base, la acidosis hiperclorémica, acidosis metabólica, diferencia de iones fuertes, diferencia de iones fuertes.
EXTRACCIÓN DE DATOS:
Leer documento completo
Regístrate para leer el documento completo.