Professional Documents
Culture Documents
Dr Iyan Darmawan
Story DA, Bellomo R. Strong ions, weak acids and base excess: a simplified Fencl–
Stewart approach to clinical acid–base disorders British Journal of Anaesthesia,
2004, Vol. 92, No. 1 54-60
Fencle-Stewart
Case 1
pH 7.2/ pCO2 25/ BE -4/ HCO3- 10
Na+160 ;Cl- 102 ;K+ 5 ;Alb 3.7
– BE -4
– SID effect, mEq/l = A + B
• A. Free Water effect on Na+
= 0.3 x ([160] – 140)=6
• B. Corrected Cl- effect
= 102 – ([C102-] x 140/[160])=12.75
– ATOT effect, mEq/l
= 0.123 x 7.2 - 0.6310 x (42 - [37])=1.273
UA effect = BE ef – SID ef – ATot ef=
-4 -(6 +12.75+ 1.273)=-24.023
Fencle-Stewart
160
SID i
SID effect 19.75
142 (alkalinisasi)
HCO3-
UA UA effect
-24.023
Albumin effect Alb Alb
1.273
Na (alkalinisasi)
Na
Case 2:
7.48 / 45 / +10 / 34
Na 150; Cl 102; Alb 4
(a) Free water effect:
0.3 x (150-140) = 3
(b) Chloride effect
102-(102 x 140/150) = 6.8
(c) Albumin effect
(0.123 x 7.48 - 0.631) (42-[40]) = 0.578
UA effect = 10 – [(3) + (6.8) + (0.5)] mEq/L = - 0.3
Fencle-Stewart
140 HCO3-
Alb Alb
Case 3:
7.48 / 45 / + 9 / 34
Na 140; Cl 93; Alb 4.2
HCO3-
Alb
102
Alb
93
Na+ Cl-
Fencle-Stewart
Case 4:
7.35 / 35 / -4 / 15
Na 140; Cl 102; Alb 2.0
Na+ Cl-
Hipoalbuminemia
pH 7.36/pCO2 46/ BE 0.96/HCO3 26
Na+ 137; Cl- 112, Alb 20 g/L; Hb 8 g /dl
Mg++ 1
Ca++ 2.2
K+ 3.5 HCO3-
25 26 SIDe
3.5 Weak acid
(Alb- 20,P- 1)
=31.5
3.2
When these patients have a normal pH and a+normal SBE and HCO3- concentration, it would seem most
Na
appropriate to consider this to be physiologic compensation for a decreased ATOT rather than classifying
137
this condition as a complex acid–base disorder with a mixed metabolic acidosis/
Cl - hypoalbuminemic alkalosis
Stewart's designation of a 'normal' SID of approximately 40 mmol/l was based on a 'normal' CO2 and ATOT
112
The 'normal' SID for a patient with an albumin of 2g/dl would be much lower (eg approximately 32 mmol/l).
KATION ANION
SIDa = (137 + 3.5 + 2.2 +1) – 112 = 31.7 SIDe= 26 + 0.2x[20] + 1.5 x [1]
Fencle-Stewart
140
SIDe 30.84
Acidifying effect
Alkalizing effect of UA = - 8.56 of lactate -
Alb
hypoalb + 6.7 8.56
hipoalbumin
102
Na+ Cl-
J.A. KELLUM
Directly measures the amount o f UA
JA Kellum
Approach:
1. To calculate ATOT,you have to determine Pi (in mEq/L) from PO4 and albumin
converted to mEq/L by the following formulas.
Pi = (PO4 x10/30.97)x(0.309xpH-0.469)
= (0.85 x 10/30.97) x 0.309 x 7.55 -0.469) = ~ 0.5 mEq/L
Na+ 159
121
Decrease in SID ~10 was due to high UA. Plasma water deficit (Na 159 mEq/L) icrease SID. Low SID
acidosis was masked by hypoalbuminemia. BE miss detection of acidosis with high UA tand interpret
the acid-base status merely as mild metabolic alkalosis.HCO3 high normal.
JA Kellum
Approach:
1. To calculate ATOT,you have to determine Pi (in mEq/L) from PO4 and albumin
converted to mEq/L by the following formulas.
Pi = (PO4 x10/30.97)x(0.309xpH-0.469)
= (4 x 10/30.97) x 0.309 x 7.32 -0.469) = ~ 2.3 mEq/L
Na+ 131
86
SID decreased by ~ 12 mEq/L (owing to water excess and high UA and Pi. This
acidosis was masked by alkalosis due to Cl deficit and hypoalbuminemia; HCO3 onlu
slightly decreased. Base deficit was only - 4 mEq/L Here, the severity of acidosis had