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by "Grog" (Alan W. Grogono), Professor Emeritus, Tulane Univ ersity Department of Anesthesiology
[H+] [OH-]
Stewart's Dependent Variables:
[HCO3 -] [CO3 2-]Stewart listed a total of six ion concentrations as dependent: [H+],
[HA] [A-] [OH-], [HCO3-], [CO3--2], [HA], [A-] (weak acids and ions). In-vivo
and clinically, therefore, these are not subject to independent
alteration. Their concentrations are governed by concentrations of
other ions and molecules.
Calculation:
Stewart showed that using the above equations, the concentration of each of the
dependent variables was uniquely and independently determined by the three
independent variables: PCO2, [ATOT], [SID]. The equations he derived were complex and
involved 4th order polynomials. Not surprisingly, Stewart used a computer to derive the
effects of the three Independent Variables:
[SID]:
The Strong Ion Difference is the difference between the sums of concentrations of
the strong cations and strong ions:
[SID] = [Na+] + [K+] + [Ca2+] + [MG2+] - [CL-] - [Other Strong Anions].
[ATOT]:
[ATOT] is the total plasma concentration of the weak non-volatile acids, inorganic
phosphate, serum proteins, and albumin:
[ATOT] = [PiTOT] + [PrTOT] + albumin.
PCO2 :
At the molecular level, it is clearly the concentration of CO2, not the partial
pressure, which governs its effect on other molecules and ions. In practice,
however, our warm-blood status means solubility scarcely varies and we can use
PCO2 to measure carbon dioxide's effects.
Clinical Considerations:
Changes in acid-base status are either respiratory or non-repiratory, i.e., metabolic:
Respiratory:
The effects of changes on PCO2 are well understood and produce the expected
alterations in [H+]:
CO2 + H2O <> H2CO3 <> HCO3- + H+
Metabolic (Non-Respiratory):
Metabolic disturbances, obviously, cannot be viewed as a consequence of
bicarbonate concentration because bicarbonate is merely a dependent variable.
The two possible sources of metabolic, i.e., non-respiratory, disturbances are
either [SID] or [ATOT].
With normal protein levels, [SID] is about 40mEq/L. Any departure from this
normal value is roughly equivalent to the standard base excess (SBE), i.e., if the
measured [SID] were 45 mEq/L, the BE would be about 5 mEq/L, and a
measured [SID] of 32 mEq/L would approximate to a BE = -8 mEq/L. Because
[SID] does not allow for hemoglobin, there is often a discrepancy.
Changing [SID]:
[SID] can be changed by two principal methods:
1) Concentration:
Dehydration or over-hydration alters the concentration of the strong ions and
therefore increases, or decreases, any difference. The body's normal state is on
the alkaline side of neutral. Therefore, dehydration concentrates the alkalinity
(contraction alkalosis) and increases [SID]; whereas, over-hydration dilutes this
alkaline state towards neutral (dilutional acidosis) and decreases [SID].
2) Strong Ion Changes:
If the sodium concentration is normal, alterations in the concentration of other
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7/19/13 Acid-Base Tutorial - Strong Ion Difference
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